chronic heart failure latest guidance 2013 heart... · 2015-11-14 · acute mi chronic chd all...
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Chronic Heart FailureLatest Guidance 2013
Dr Geraint H. JenkinsConsultant CardiologistConsultant Cardiologist
Regional Cardiac Centre, Swansea
Heart Failure Epidemiologyp gy• Heart failure is common
– prevalence 2-4%prevalence 2 4%– incidence 1% per year
• True incidence and prevalence unknown• True incidence and prevalence unknown• 10,000 new cases per year in SW Wales• 30,000 patients requiring ongoing treatment• 3,000 new cases per year in Swanseap y• 2,800 discharges in ABMULHB in 2011• Mortality 60% in first year after an admission• Mortality 60% in first year after an admission• Outlook much better with modern treatment
Admission to Hammersmith Hospital pwith Heart Failure 1999-2000
100
80
60
Freq
uenc
y 60
40F 40
2020
0
Std. Dev = 12.68 Mean = 75
N = 473.00
Age (years)
1009080706050403020100
Inpatient Stay in Heart Failure
Digestive
GU
Injury & po isoning
Bladder cancer
Nervous sytem
Respiratory
Cancer
Colorectal cancer
Lung cancer
Breast cancer
iag
no
sis
Ch i CHD
Heart failure
Stroke
Diabetes
Ma
in d
CHD
Angina
Acute M I
Chronic CHD
All
Circulatory
0 5 10 15 20 25 30Number of inpatient days
Causes of Heart Failure
• Coronary artery disease• Hypertension• Valvular heart disease• Valvular heart disease• Dilated cardiomyopathy• Tachycardia / Bradycardia
Oth• Other
Chest X-Ray
LVRVV
LARA
Dilated Cardiomyopathyy p y
Amyloid Cardiomyopathy
ACC/AHA Staging of Heart FailureStage Patient Description
A High risk for • Coronary artery diseasegdeveloping heart failure (HF)
y y• Hypertension• Diabetes mellitus• Family history of cardiomyopathyy y y p y
B Asymptomatic HF
• Previous myocardial infarction• Left ventricular systolic dysfunction• Asymptomatic valvular diseasey p
C Symptomatic HF • Known structural heart disease• Shortness of breath and fatigue• Reduced exercise tolerance
D Refractory end-stage HF
• Marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalised or cannot be safely discharged from hospital without specialised interventions)
Quality of life in Heart FailureQuality of life in Heart FailureNYHA Definition Diagnosed functional class HF cases
%
Class I No limitation: ordinary physical exercise does not cause dyspnoea. 0
Class II (s) Slight limitation of physical activity: dyspnoea on walking more than 200 yards or on stairs; M d t li it ti f h i l ti it d lki l
69
Class II (m) Moderate limitation of physical activity: dyspnoea walking less than 200 yards.
Class III Marked limitation of physical activity: comfortable at rest but dyspnoea washing and dressing or walking from room to room
15dyspnoea washing and dressing, or walking from room to room.
Class IV Severe limitation of physical activity: dyspnoea at rest with 16Class IV Severe limitation of physical activity: dyspnoea at rest, with increased symptoms with any level of physical activity.
16
Symptoms v. severity of disease
Conditions that may mimic heart failure
• Lung diseaseOb i
• HypoalbuminaemiaR l h i di• Obesity
• Venous insufficiency i l li b
• Renal or hepatic disease• Pulmonary embolism
i d/ iin lower limbs• Drug induced ankle
d
• Depression and/or anxiety disordersS ioedema
• Drug induced fluid i
• Severe anaemia• Thyroid disease
Bil t l l tretention • Bilateral renal artery stenosis
(or coexist with heart failure)
Diagnosing Heart Failure
in the Community
Based on NICE 2010
Principles of Heart Failure ManagementConfirm presence of clinical heart failure– Confirm presence of clinical heart failure
– Institute simple treatmentIdentify cause e g aortic stenosis echo and other tests– Identify cause e.g. aortic stenosis – echo and other tests
– Identify• precipitating factors e g new AF UTI LRTI anaemia• precipitating factors e.g new AF, UTI, LRTI, anaemia• Exacerbating factors e.g. salt intake, medication• Concomitant disease e.g. COPD, renal failureg ,
– Simple medical therapy – Diuretic, B-Blocker, ACE, MRA
– Optimal medical therapyp py– Definitive treatment – drugs, surgery, devices– Assess and re-asses symptom severityy p y– Estimation of prognosis
Aims of treatment
• Improve symptoms• Improve prognosis• Cure (in a few)• Cure (in a few)• Treatment directed at cause• Almost all drug trials are in patients with
heart failure due to LV dysfunctionheart failure due to LV dysfunction• Treat overall patient not the test
Non-Pharmacological Management
• Low salt intakeW i h d i
• Daily weightEd i• Weight reduction
• Exercise• Education• Self-management• Nurse advice
Pharmacological Management
Prognosis Symptoms• ACE Inhibitors
B Bl k• Diuretics
Di i• B-Blockers• Mineralcorticoid
• Digoxin• Hydralazine / Nitrates
Receptor Antagonists• AIIRB
• Ivabradine
Device / Surgical Management
Devices Surgery
• Simple Pacemakers • Valve repair / replacement• Biventricular
Pacemakersreplacement
• Revascularisation• Defibrillators• Balloon pumps
• Volume reduction surgeryp p
• LV assist devices • Transplantation
ESC Guidelines for Management of Chronic Heart Failure
2012
Maximal doses of B-blockersand ACE Inhibitors are important
Triple Therapy forTriple Therapy for most patients – ACE, B-Blocker and MRA
ACE Inhibitors
Trials of ACEI in Heart FailureTrials of ACEI in Heart Failure(20-25% reduction in mortality)
Patients Mean NYHA LVEF Effects on(n) Follow-
upClass (%) all-cause mortality
HF
CONSENSUS 253 188 days IV N/A All-cause mortality:At 6 months↓ 40%(p=0.002)
SOLVD-T t t
2569 3.4yrs II–III ≤35 All-cause mortality:↓ 16% (p<0 0036)Treatment ↓ 16% (p<0.0036)
SOLVD-Prevention
4228 3.1yrs N/A ≤35 All-cause mortality↓8% (p=0.30)
P t MI HFPost-MI HF
SAVE 2231 3.5yrs N/A ≤40 All-cause mortality:↓ 19%(p=0.019)
AIRE 2006 1 25 I III N/A All liAIRE 2006 1.25yrs I–III N/A All-cause mortality: ↓ 27%(p=0.002)
TRACE 1749 2-4.2yrs N/A ≤ 35 All-cause mortality:↓ 22%(p=0.001)(p )
Avoid stopping ACEI because of cough
B-Blockers
i l f bl k d i ilTrials of B-blockade in Heart Failure(30-35% reduction in mortality)
n MeanFollow-up
NYHAClass
LVEF(%)
Effects onall-cause mortality
HF
CIBIS 641 1.9yrs III-IV <40 All-cause mortality:↓ 20% (p=0.22)
CIBIS-II 2647 1.3yrs III-IV ≤35 All-cause mortality:↓ 34% (p<0.0001)
MERIT-HF 3991 1yr II–IV ≤40 All-cause mortality: ↓ 34% (p=0 0062)↓ 34% (p 0.0062)
US Carvedilol HF Study
1094 6.5mths II–IV ≤35 All-cause mortality:↓ 65% (p<0.001)
COMET 3029 4.9yrs II-IV <35 All-cause mortality: y y↓ 17%(p=0.0017)
Post-MI HF
CAPRICORN 1959 1.25yrs N/A <40 All-cause mortality:CAPRICORN 1959 1.25yrs N/A <40 All cause mortality:↓23%(p=0.03)
B Blockade in Heart FailureB-Blockade in Heart Failure
Heart 2001
Ald t R tAldosterone Receptor AntagonistsAntagonists
(ARA or MRA)( )
Spironolactone in Heart FailureRALES: All-Cause Mortality
0.90
0.95
1.00
Risk reduction 30%95% CI (18%-40%)
0 001
of su
rviv
al
0.75
0.80
0.85 p < 0.001
Aldosterone receptor antagonist + ACE inhibitor + loop diuretic ± digitalis
Prob
abili
ty
0.60
0.65
0.70ACE inhibitor + loop diuretic ± digitalis
Placebo + ACE inhibitor + loop diuretic ± digitalis
0.45
0.50
0.55loop diuretic ± digitalis
Months0 3 6 9 12 15 18 21 24 27 30 33 36
54Pitt B et al, N Engl J Med 1999; 341: 709-717
EPLERENONE
• Selective Aldosterone Receptor Antagonist(SARA)
• Short half life 3-5 hoursShort half life 3 5 hours• No sex steroid side effects of Spironolactone• Ephesus study shows clear benefit in heart
failure post MIfailure post MI• Expensive
EPHESUS
Primary Endpoint: All-Cause Mortality222018
Cumulative PlaceboEplerenone
161412
Incidence (%)Eplerenone12
1086
RR = 0.85 (95% CI, 0.75-0.96) P = 0.008
02
64
Months Since Randomisation002993237091213180124182830298330643313Placebo
03633302724211815129630
0001103367281260185724632896304431253319Eplerenone
Pitt B et al. N Eng J Med 2003; 348: 1309-1321
EPHESUS
Sudden Cardiac Death10
98
All Patients
Cumulative
8765
Placebo
Cumulative Incidence
(%)
543
RR = 0 79 (95% CI 0 64
Eplerenone
210
RR = 0.79 (95% CI, 0.64-0.97)P = 0.03
Months Since Randomisation
0 3 6 9 12 15 18 21 24 27 30 33 36
Pitt B et al. N Eng J Med 2003; 348: 1309-1321
Emphasis HF - Summary
• Age >55yrs, • NYHA Class II heart failure• EF <30%• EF <30%• B-Blocker, ACE and/or ARB• Cardiovascular admission within 6/12
• Reduced hospitalisation / death co-endpoint p pby 37% overall, 54% in diabetics
Angiotension II R t Bl kReceptor Blockers
Angiotensin II Receptor Blockers• Usually used in ACE intolerant patients• May be small additional benefit on top ofMay be small additional benefit on top of
ACE, B-blocker and SpironolactoneV lH FT– ValHeFT
– CHARM• Alternative• Added• Preserved• Low
– VALIANT
Ivabradine
• Inhibits If current in Sinoatrial node• Slows heart rate in sinus rhythm• Higher heart rate is associated with higher• Higher heart rate is associated with higher
mortality in heart failure
Shift StudyShift Study• Class II-IV Heart Failure• LV EF <35%• Heart Rate >70• Heart Rate >70• Sinus rhythm• Hospitalised with heart failure in preceding
12 months12 months• 90% on B-blockers, 91% on ACEI, 83%
Diuretics, 59% ARA
Shift StudyShift Study
Shift Death or HospitalisationShift – Death or Hospitalisation for HFfor HF
4.2% absolute reduction
Shift – Hospitalisation for HF
Shift Outcomes
Maximal Heart Failure Management%
)100
Maximal Heart Failure Managemental
ity (%
8080
100
Feels better
mor
ta
6060
80 Feels better
1 ye
ar
3926 22
40
1 2615
2220 (?)
0Diuretic Add
C
Add AddSpironolactone
AddIvabradine
AddCRT
£19.11 £14.99 £19.66 £552.33 £8000 +FU
£10.04
ACEI B-blocker Spironolactone Ivabradine CRT
Four most effective drugs £63.80 per annum (BNF March 2013, drug cost only)
Optimal Drug Doses in LV Systolic Dysfunction
Cardiac Resynchronisation Therapyy py• 30% of heart failure patients have incoordinate LV
i i ( d ll l h )activation (and usually also have LBBB)– Adverse effect on LV ejection– Adverse haemodynamic effects– Associated with Increased mortality
• Cardiac resynchronisation in patients with poor LV, LBBB and NYHA III-IV heart failure– Improves symptoms and exercise tolerance– Reduces hospitalisation for heart failurep– Reduces mortality when combined with ICD
LBBB
Cardiac Resynchronisation
NICE 2007
59% of all heart failure59% of all heart failure admissions
37076 patients admitted pwith heart failure of which 4170 were readmissions
Mandatory in Wales since April 2012
National Heart Failure Audit 2012National Heart Failure Audit 2012
2011
National Heart Failure AuditNational Heart Failure Audit 20122012
Inpatient Care Cardiology Ward Medical Ward Other Ward% of Total 48 41 11% of Total 48 41 11Length of Stay (d) 12.7 13.1 14.7Inpatient Mortality % 7.8 13.2 17.4
Cardiology patients were younger and more malesgy p y gCardiology patients were more likely to be on prognostic drugs
Mortality reduction on cardiology wards remains significant when confounding factors are taken into accountare taken into account
National Heart Failure Audit 2012National Heart Failure Audit 2012
National Heart Failure Audit 2012National Heart Failure Audit 2012
National Heart Failure Audit 2012
National Heart Failure Audit 2012
Issues
• Lack of– Echo services– Clinical expertise– Cardiologists– Heart Failure Nurses
• Pressure to reduce length of stay• Every patient with heart failure should be• Every patient with heart failure should be
seen by a cardiologist ( or GPwSI)
New Swansea Service
• British Heart Foundation & LHB Funding– 7 Community Heart Failure Nurses– Heart Failure Nurse CoordinatorHeart Failure Nurse Coordinator– 1 Hospital based Heart Failure Nurse
H t F il A dit T– Heart Failure Audit Team
• Training of Nurses• Development of Referral Pathways• Development of Referral Pathways
Refer to Tertiary Cardiologist if:YoungV l l diValvular diseaseAcute coronary syndromesCo-existing anginaDifficulty optimising treatment in secondary careDifficulty optimising treatment in secondary careCandidate for conventional pacingS i i l d h i h LBBBSymptomatic on maximum tolerated therapy with LBBBTransplant or device candidate
Take Home Message
• Low threshold for considering heart failure• BNP screening if not clear• Echocardiography for all heart failure patients• Echocardiography for all heart failure patients• Basic triple therapy for all LVSD (ACE, BB, MRA)
• All patients should see a cardiologistC di l f ll i t d ith• Cardiology follow up associated with improved outcome.