Prof. U. C. SAMALMD, FICC, FACC, FIACM, FIAE, FISE, FISC, FAPVSEx- Prof. Cardiology & Ex-HOD Medicine Patna Medical College, Patna, BiharPast President, Indian College of CardiologyPermanent & Chief Trustee, ICC-Heart Failure FoundationNational Executive Member, Cardiological Society of IndiaPresident, CSI Bihar 1

HEART FAILURE

Heart failure -- Epidemiology

Prevalence • > 2% - 3% overall; 10% - 20% at > 70 yrs• European society of cardiology countries : > 15 milion patients with heart failure and increasing

Burden • Primary cause of 5% of hospital admissions• Present in 10% of hospitalized patients• 2% of national health expenditure [60% - 70% of cost due to heart failure hospitalization]• 40% of patients admitted to hospital with heart failure are dead or readmitted within 1 yr

Mcmurray J J Et Al Eur Heart J 2013; 33 [14]: 1787-1847

Dickstein K Et Al Eur Heart J 2006; 29: 2388-2442

Total Population of India - 1.16 Billion (2009 Est)

• diuretics• ultrafiltration

Vasodilators • nitroglycerin• nesiritide• nitroprusside

INOTROPES • dobutamine• dopamine• levosimendan• nitroprusside

Fluid retention or redistribution ?

“dry out” “warm up & “dry out”

Assessment of hemodynamic profile : therapeutic implications

Adapted from Stevenson L W, Eur Heart j

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Clinical classification of the mode of heart failure (Forrester classification).

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H-I to H-IV refer to hemodynamic severity, with reference figures for CI and pulmonary capillary pressures shown on the vertical and horizontal axes, respectively. C-I to C-IV refer to clinical severity. CI, cardiac index. Adapted, with permission, from Forrester JS,Diamond GA, Swan HJ. Correlative classification of clinical and hemodynamic function after acute myocardial infarction. Am J Cardiol 1977;39:137-45.

Normal

Hypovolemic shock

Pulmonary edema

Cardiogenic shock

Diagnosis of HF in untreated patients with symptoms suggestive of HF using natriuretic peptides

Clinical examinationECG, Chest X-rayEchocardiography

Natriuretic peptides

BNP < 100pg/mlNT-proBNP <

400pg/ml

BNP < 100-400 pg/mlNT-proBNP 400-2000

pg/ml

BNP > 400 pg/mlNT-proBNP > 2000

pg/ml

Chronic HF likely Uncertain diagnosis Chronic HF likely

NeurohormonesNorepinephrine

ReninAngiotensin II

CopeptinEndothelin

Vascular systemHomocysteine

Adhesion molecules(ICAM, P-selectin)

EndothelinAdiponectin

C-type natriuretic peptide

InflammationC-reactive protein

sST2Tumor necrosis

factorFAS (APO-1)

GDF-15Pentraxin 3AdipokinesCytokines

ProcalcitoninOsteoprotegerin

Myocardial stressNatriureticpeptides

Mid-regional pro-adrenomedullin

NeuregulinsST2

Myocardial injuryCardiac troponins

High sensitivity cardiac troponinsMyosin light-chain kinase 1Heart-type fatty acid binding

proteinPentraxin 3

Matrix and cellularremodelingGalectin-3

sST2GDF-15MMPsTIMPs

Collagen propeptidesOsteopontin

Cardio-renal syndromeCreatinineCystatin C

NGALß-Trace protein

Oxidative stressOxidized LDL

MyeloperoxidaseUrinary biopyrrins

Urinary and plasma isoprostanes

Plasma malondialdehyde

HF as a systemic illness.

8Nature Review Cardiology

Vol.9 June 12 pg 349

Stages, Phenotypes and Treatment of HF

2013 ACCF/AHA Guideline for the Management of Heart Failure

Stages, Phenotypes and Treatment of HF

2013 ACCF/AHA Guideline for the Management of Heart Failure

Stages, Phenotypes and Treatment of HF

STAGE AAt high risk for HF but without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or symptoms of HF

THERAPYGoals· Control symptoms· Improve HRQOL· Prevent hospitalization· Prevent mortality

Strategies· Identification of comorbidities

Treatment· Diuresis to relieve symptoms

of congestion· Follow guideline driven

indications for comorbidities, e.g., HTN, AF, CAD, DM

· Revascularization or valvular surgery as appropriate

STAGE CStructural heart disease

with prior or current symptoms of HF

THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality

Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists

Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin

In selected patients· CRT· ICD· Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPYGoals· Prevent HF symptoms· Prevent further cardiac

remodeling

Drugs· ACEI or ARB as

appropriate · Beta blockers as

appropriate

In selected patients· ICD· Revascularization or

valvular surgery as appropriate

e.g., Patients with:· Known structural heart disease and· HF signs and symptoms

HFpEF HFrEF

THERAPYGoals· Heart healthy lifestyle· Prevent vascular,

coronary disease· Prevent LV structural

abnormalities

Drugs· ACEI or ARB in

appropriate patients for vascular disease or DM

· Statins as appropriate

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure

e.g., Patients with:· Marked HF symptoms at

rest · Recurrent hospitalizations

despite GDMT

e.g., Patients with:· Previous MI· LV remodeling including

LVH and low EF· Asymptomatic valvular

disease

e.g., Patients with:· HTN· Atherosclerotic disease· DM· Obesity· Metabolic syndrome orPatients· Using cardiotoxins· With family history of

cardiomyopathy

Development of symptoms of HF

Structural heart disease

2013 ACCF/AHA Guideline for the Management of Heart Failure

Cumulative benefits of medical therapy on mortality. Adapted, with permission, from Fonarow GC, et al.Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J2011;161:1024-30.

Cumulative benefits of medical therapy on mortality. Adapted, with permission, from Fonarow GC, et al.Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J

2011;161:1024-30.

Heart Failure Therapies

Beta-blocker Beta-blocker + ACEI/ARB

Beta-blocker + ACEI/ARB +

ICD

Beta-blocker + ACEI/ARB +

ICD + HF education

Beta-blocker + ACEI/ARB + ICD + HF education+ anticoagulation

for HF

Beta-blocker + ACEI/ARB + ICD +

HF education+ anticoagulation

for HF+CRT

-39%[-28% to -49%]

P < 0.0001

-63%[-54% to -71%]

P < 0.0001 -76%[-68% to -81%]

P < 0.0001

-81%[-75% to -86%]

P < 0.0001

-83%[-77% to -88%]

P < 0.0001

-81%[-72% to -87%]

P < 0.0001

Chan

ge in

odd

s of

24-

mon

th m

orta

lty [%

]

Number needed to treat for mortality

15

Guideline recommended therapy

Relative risk reduction in mortality

Number needed to treat for mortality

Number needed to treat for mortality [ standardized to 36 mths]

Relative risk reduction in HF hospitalisations

ACEI / ARB 17% 22 over 42 mths 26 31%

Beta blocker 34% 28 over 12 mths 9 41%

Aldosterone antagonist

30% 9 over 24 months 6 35%

Hydralazine / nitrate

43% 25 over 10 mths 7 33%

CRT 36% 12 over 24 mths 8 52%

ICD 23% 14 over 60 mths 23 NA

Reproduced with permission from Fonarow GC et al Am Heart j 2011; 161: 1024-30

Number needed to treat for mortality

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“HF-CBS-SRS”Quantitative results in~ 15 minutes! EDTA Whole Blood , No Centrifugation

Anywhere, anytime, in time

Point of Care System for rapid, accurate results• Easy• Portable• Reliable Results in about minutes

Fluorescence Sandwich immunoassay

Test Normal RangeCKMB ng/mL (0.0 - 4.3)

MYO ng/mL (0.0 – 107)TNI ng/mL (0.00 - 0.40)BNP pg/mL (0.00 - 100)

DDIM ng/mL (0.0 - 400)

NGAL* ng/mL (0-149)

PANEL OF SOB TRIAGE/ AMI/ AKI

15

6 Biomarkers 750 +750 bucks

* Galectin3/BNP+NGAL being uploaded to the test platform

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SOB TRIAGE METER PLATFORM

Parameters Normal Range

Price(Rs.) Timing

CKMB 0.0-4.3SOB

PANEL

Rs. 750

10-15 MinMYO 0.0-107

TNI 0.00-0.40

BNP 0.00-100

DDIM 0.1-400

NAGAL 0-149 Rs. 850 15 Min

Triage® Meter: Three Simple Steps

1. Add whole blood to Test Device

2. Insert Test Device into Meter

3. Read results

Intelligent Nephelometry TechnologySmart Card CalibrationEconomic 10 Parameter Assay Panelser- friendly 3 Step Assay ProcedureNo Sample dilution

Test Normal Range

ASO I/mL (50 - 1000)

CRP mg/L (0.5 - 320)

RF I/mL (10-120)

HbA1c % (3-13%)

IgE I/mL (1-1000)

MICROALBMIN mg/L (5-200)

Lp(a) Mg/dl (1-100)

CYSTATIN C mg/L (0.0-10)

FERRITIN I/mL (1-1000)

D-DIMER ng/mL

REPORT OF MISPA PANELREPORT OF MISPA PANELREPORT OF MISPA PANEL

REPORT OF MISPA PANEL SERUM/ URINE

REPORT OF MISPA PANEL“HF-CBS-SRS” MeasuresACR

&Routine rine Parameters

• 95% Correlation with conventional immunoturbidimetric test• Analyze spot rine sample• Works on batteries or power cable• Provides Printed report

“15/23 Minutes Exercise”

10 Biomarkers 1000 Bucks

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Agappe Mispa carries ISO 13485:2003 and CE marking; GMP and FDA compliant ISO 9001: 2008 certified

1st Ht Consult

Parameters Pack size Test Range Normal Range Price TimingASO 30 Test 50-1000 IU/ml 0-200 IU/ml 62 5 Min

CRP 30 Test 0.5-250 mg/L 0.000-6.000mg/L 51 5Min

RF 30 TEST 10-120 IU/ml 0.000-20.000/IU/ml 46 6 min

CYSTATIN C 30 TEST 0.1-10 mg/L 0.000-1.149 mg/L 161 6 min

HbA1C 30 TEST 3-13% 4.000-6.000 % 160 7 min

D-DIMER 30 TEST 0-400 ng/mL 0.000-400 ng/ml 160 7 min

IgE 30 TEST 0-1000 IU/mL 0.000-400 IU/mL 180 6 min

FERRITIN 30 TEST 0-1000 ng/mL 0.000-230 ng/mL 200 6 min

Lp(a) 30 TEST 1-100 mg/dL 0-30 mg/dL 180 7 min

MICROALBUMIN 30 TEST 5-200 mg/L 0.000-25.000 mg/L 101 5 min

Intelligent Double Chanel Nephlometry Technology

Possible future strategies for biomarker-guided therapies in chronic HF. 2013-14 Optimism :

Ahmad T et al Nat. Rev. Cardiol.9,347-359(2012)

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“Poly Client Challenge”

• Poly co-morbidities• Poly – pharmacy• Poly - side effects• Poly – healthcare providers• Poly - clinics• Poly-labs / investigation

• POLY – CONFUCSION…….END RESULT

HF----

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