Controversies in Heart Failure Management

1. Controversies in Heart Failure Management M.Birhan YILMAZ, MD, FESC Cumhuriyet University School of Medicine Department of Cardiology, Sivas, TURKEY

3. HeartFailure • 2% of the population, • >10% over 70 years • - no “healing”,irreversible • high mortality, • frequent rehospitalizations • Extremely costly (in terms of hospitalization • andcurrentlydevicerelated)

4. Potentialareas of controversy • Diagnosis • Life style • Device related • HR reduction • Anticoagulation • Revascularization • Inotrope • AHF

5. Increased sensitivity at a cost of compromised specificity

6. Diagnostic Controversy The diagnosis of HF-PEF remains a particular challenge, and theoptimum approach incorporating symptoms, signs, imaging, biomarkers,and other investigations is uncertain. *Differentdiseaseor a differentphase of the samediseasespectrum *Diastolicstress test

7. ‘Artificial’ recommendations confessed ESC decided that the guidelines for HF probably had been artificially giving recommendations for lifestyle advice really on the basis of no good evidence. The exceptions, both class IA recommendations: "Regular aerobic exercise is encouraged in patients with heart failure to improve functional capacity and symptoms," and patients are advised to enroll in a "multidisciplinary-care management program" to lower the risk of heart-failure hospitalization.

8. How much of salt?

9. Heart Failure Therapy Moderate CHF Severe CHF Post-MI LV dysfunction Mild CHF SOLVD Treatment (enalapril) CONSENSUS (enalapril) AIRE/SAVE (ramipril/captopril) CHARM/Val-HeFT (candesartan/valsartan) US Carvedilol/MERIT/CIBIS (carvedilol/metoprolol/bisoprolol) COPERNICUS (carvedilol) CAPRICORN (carvedilol) RALES (spironolactone) EPHESUS (eplerenone) EMPHASIS-HF (eplerenone) MADIT, MUSTT (ICD) SCD-HeFT, MADIT-II (ICD) MIRACLE, COMPANION, MUSTIC (CRT +/- ICD) CARE-HF

10. Solved Controversy

11. Device Related Controversies

12. Randomized Controlled Trials on Resynchronization therapy • MIRACLE • MUSTIC SR • MUSTIC AF • PATH CHF • MIRACLE ICD • CONTAC CD COMPANION • PATH CHF II • MIRACLE ICD II • CARE HF • RAFT CRT Improves NYHA Class, Quality of life score, Exercise Capacity, LV function, Reverse remodeling, Hospitalization, Mortality

13. CRT in patient with Atrial fibrillation • 1/3 of the patients with HF are in AF • 1/5 of the patients receiving CRT in Europe • Older, more co-morbidities, worse prognosis

14. HF and AFPrevalence by NYHA class

15. Why does AF matter when selecting for CRT? • Loss of AF synchrony • AV optimization not possible • Excessive intrinsic ventricular rate • High pacing rates needed to provide biventricular capture, if possible at all!

16. How to improve CRT benefit on AF patients • Complete ventricular capture (>95% pacing)- is mandatory in order to maximize clinical benefit and improve the prognosis • Pharmacological therapy to slow ventricular rate • Ablation of AVN • Pulmonary vein isolation

17. CRT-P versus CRT-D • CRT-D is associated with more device-related complications (up to 10%)

18. Inappropriate shocks

19. CRT and reverse remodeling

20. CRT –ON doesn’t increase VT/VF episodes Remodeling is associated with less VT/VF episodes Remodeling and arrhythmias REVERSE

21. CRT-P versus CRT-D • The group of patients that benefit most is the one with QRS ≥ 150 ms • Anyone who undergoes CRT for the most part is also indicated for an ICD if you look at the crossover. • So, why use a CRT-P?

22. Why use a CRT-P? • People may like, at least in Europe, to see or pursue a therapy that is less expensive, compared with CRT-D, but that provided the same quality of life as CRT-D • Choice of a patient – “If I die suddenly, I die suddenly, but I really don't like the shortness of breath." • Remember the 10% ofcomplications, inappropriate shocks

23. Electricity in HF -charged with sex discrimination • CRT benefit favors women: MADIT-CRT • Women with ICD get fewer shocks • Women have better heart-failure survival than men

24. MADIT-CRT -CRT benefit favors women • 69% plunge in rate of death or heart failure in women (p<0.001) far exceeded the 28% reduction (p<0.01) in men. • associated with consistently greater echocardiographicevidence of reverse cardiac remodeling in women than in men

25. Women have better heart-failure survival than men MAGGIC study Women with heart failure have better survival than man, irrespective of age, etiology and EF (patient data from 31 studies in 41 949patients ).

26. CRT controversy Patients with NYHA Class III or ambulatory IV Patients with NYHA Class II

27. Device with Huge Controversy

28. Does lowering heart rate improve clinical outcomes in chronic HF? • Systematic reviews have demonstrated that a major contributor to the benefits of -blocker therapy may be their rate-lowering effect – but they are generally underused or underdosed! • When ivabradine does become available, the results of SHIFT will likely support the use of ivabradine in patients with moderate to severe HF on optimum medical therapy including -blockade with LVEF 35% and resting heart rate 70 bpm.

29. HR reduction controversy

30. Anticoagulate in Heart Failure - Do We Have an Answer? • Warfarin vs Aspirin in Reduced Cardiac Ejection Fraction (WARCEF trial) No significant difference seen in the primary end point between groups -no difference in death rates between groups, -intracerebral hemorrhage was very infrequent in both groups -highly significant reduction in ischemic stroke among those on warfarin vs aspirin. -Major hemorrhage was significantly higher with warfarin (GIT bleeding), -no significant differences in intracerebral or intracranial hemorrhage

31. Anticoagulation in HF • ASPIRIN - safer to use, easier to use, patients tolerate it pretty well, there are no food interactions, and it's inexpensive • Newer oral anticoagulants now becoming available—dabigatran and rivaroxaban, which are already approved, and apixaban, which is expected to be approved soon—might reopen this question. • However, it is important to keep in mind that eGFR<30 ml/kg/min is a frequent exclusion (though it is common in HF)

32. Thrombo-embolism prophylaxis in patients with HF and AF shouldbe based on CHA2DS2-VASc score Most patients with systolic HF will have a risk score consistentwith a firm indication for (score ≥2), or preference for, an oralanticoagulant (score ≥ 1), although bleeding risk must also be considered • Some new anticoagulant drugs such as the oral direct thrombininhibitors and oral factor Xa inhibitors are contraindicated insevere renal impairment (creatinine clearance ,30 mL/min).

33. Rate or Rhythm Control in HF-AF • In patients with chronic HF, a rhythm-control strategy including • pharmacological or electrical cardioversion has not been demonstrated • to be superior to a rate-control strategy in reducing mortality or morbidity.

34. RevascularizationControversy in HF

35. STICH viabilityarmfailedtoshowanybenefit of viabilitytesting (?)

36. Inotrope Controversy • Dobutamine, Dopamine, Adrenaline, Levosimendan, Omecamtiv mecarbil (cardiac myosin activator) etc…. • Several studies with controversial or neutral results (even detrimental)

37. Controversies for VADs VADs and biventricular assist devices (bi-VADS) received a class I level B recommendation for use as a bridge to heart transplantation, but a class IIa level B "should be considered" endorsement as destination therapyin 'highly-selected patients'

38. Acute HF Land of Controversies