heart failure for the family medicine physician
TRANSCRIPT
Heart Failure For the Family
Medicine PhysicianCT Academy of Family Physicians Annual Symposium
Sara R Tabtabai MD
October 17, 2019
Outline
• Heart failure classification
• Evaluation
• Prevention and treatment
• Specific cardiomyopathies
Case Presentation
• A 62 year old male presents with complaint of
shortness of breath for the past 4 weeks
– Also reports ankle edema
– History of coronary artery disease and atrial fibrillation
Case Continued
• Echocardiogram performed, left ventricular ejection
fraction 35%
Epidemiology
• Lifetime risk of developing HF is 20% for Americans
> 40 yrs
• >650,000 new HF cases diagnosed annually
• Increased number of cases as the population ages
Classification
• Based on etiology: Primary vs. secondary
• Based on ejection fraction: HF reduced EF, HF
preserved EF
Classification
Circulation. 2006;113:1807-1816.
Classification
Am Fam Physician. 2017 Nov 15;96(10):640-646.
Definitions of HFrEF and HFpEF
Yancy et al. 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary
HF Prevalence by Age and SexNational Health and Nutrition Examination Survey: 2007-2010
Recent Trends in Heart Failure-related Mortality:
United States, 2000-2014
NCHS Data Brief No 231 Dec 2015
Recent Trends in Heart Failure-related Mortality:
United States, 2000-2014
NCHS Data Brief No 231 Dec 2015
Pathophysiology
Adapted from HFSA board review course
Heart Failure Evaluation
Recommended Evaluation of the
Patient Presenting with Heart Failure
Evaluation of the Patient Presenting
with Heart Failure
2-Minute Hemodynamic Assessment
AHA Scientific Council Statement, Circulation 2000
The Goal of Therapy
Adapted from Dr. Stevenson
Biomarkers in the Evaluation of HF
Han-Na Kim, and James L. Januzzi, Jr Circulation.
2011;123:2015-2019
Biomarkers in the Evaluation of HF
• BNP and NT-proBNP useful to support clinical
judgement for:
– Diagnosis or exclusion of HF
– Chronic ambulatory HF
– Acute decompensated HF
– Unclear etiology of dyspnea – negative predictive value
– Useful to rule out HF if < 100
Biomarkers in the Evaluation of HF
Recommended Evaluation of the
Patient Presenting with Heart Failure
Recommended Evaluation of the
Patient Presenting with Heart Failure
Recommended Components of Follow-
up Visits
Prevention and Treatment
Prevention
Lifestyle Interventions
• Most evidence for benefit in established heart
failure:
– Exercise training
• Most evidence for prevention:
– Achieving and maintaining high levels of fitness and
maintenance of normal body weight
Revised Staging System for HF
Stages of HF and Treatment
Treatment of Stage C Heart Failure
Aldosterone Receptor Antagonists
• Landmark RALES trial (Randomized AldactoneEvaluation Study)– 30% reduction all-cause mortality, reduced risk SCD and HF
hospitalizations with spironolactone in patients with chronic HFrEF and LVEF < 35%
– Eplerenone shown to reduced all-cause deaths, CV deaths, or HF hospitalizations
• Inappropriate use of aldosterone receptor antagonists potentially harmful– Life-threatening hyperkalemia or renal insufficiency when serum
creatinine greater than• 2.5mg/dL in men
• 2.0mg/dL in women
• And/or serum potassium greater than 5.0 mEq/L
Aldosterone Receptor Antagonists
Benefit of Medical Therapy
Medications to Avoid:
• Thiazolidinediones– Increase insulin sensitivity by activating nuclear peroxisome proliferator-activated
receptor gamma, which also regulates sodium reabsorption in the collecting ducts of the kidney
– Increased incident of HF events, including those without prior history of HF
• NSAIDs– Inhibit synthesis of renal prostaglandins which mediate vasodilation in kidneys
– Can cause sodium and water retention and blunt the effects of diuretics
– Increased M&M with either nonselective or selective NSAIDs
• Calcium channel blockers – Myocardial depressant activity
– Amlodipine generally well tolerated, neutral effects on M&M
Indications for Cardiac Resynchronization
Therapy
CRT
Stage D Heart Failure
ARNI should NOT be administered with
ACE inhibitors or within 36 hrs of last
dose of ACE inhibitor
ARNI should NOT be administered to
patients with a history of angioedema
2017 Updates:
Drug Therapy for Stage C HFrEF
2017 Updates:
Drug Therapy for Stage C HFrEF
Case Presentation
• An 82 year old female presents with complaint of
decreased functional capacity
Secular Trends in Survival among Patients with Heart
Failure and Preserved or Reduced Ejection Fraction
Owan TE et al. N Engl J Med 2006;355:251-259.
Improved
survival in
HFrEF over time
No improvement
in survival in
HFpEF over
time
Cause of Death in Patients with
HFpEF
Redfield, M MD. Braunwald’s Heart Disease 9th Ed.
Non-
cardiovascular
death
Pathophysiology• Ventricular diastolic dysfunction
– Impaired relaxation, increased diastolic stiffness
– Present at rest or induced by stress
• EF normal at rest
– Does not increase appropriately with stress
• Endothelial dysfunction, arterial stiffening, and increased ventricular
systolic stiffness
– Heightened sensitivity to changes in load
Rapid onset pulmonary edema with increases in load
Excessive hypotension with decreases in load
Redfield, M MD. NEJM 2016
How Do We Make the Diagnosis of
HFpEF?
Circulation 2018
Heart Failure with Preserved EF
HFpEF• ‘Trials using comparable and efficacious agents for HFrEF have
generally been disappointing when used in patients with HFpEF’
– Most recommended therapies for HFpEF are directed at symptoms,
comorbidities, and risk factors that may worsen cardiovascular disease
• Blood pressure control – ACE and ARB first-line
• Diuretics – relief from volume overload
• Management of atrial fibrillation
• Use of ARBs Class IIb – decreased hospitalizations
Pharmacologic Treatments for
HFpEF
• Blood pressure control → ACE and ARB first-line
• Diuretics → relief from volume overload
• Management of coronary artery disease and atrial fibrillation
• Use of ARBs Class IIb → decreased hospitalizations
Proven Therapies for HFpEF
ESC HF Guidelines 2016
Don’t miss ‘non-HFpEF’ causes of
HFpEF
Adapted from Borlaug, B. HFSA Review Course 2016
Updates on Comorbidities
• Anemia and HF– Treatment with IV iron repletion - improved functional status and QoL
– Ongoing studies for efficacy of oral repletion
– Erythropoietin-stimulating agents should not be used
• Hypertension– Stage A HF – optimal blood pressure target less than 130/80 mmHg
(SPRINT trial)
• Sleep apnea– Sleep study is reasonable
– Distinguish between central and obstructive sleep apnea
– CPAP can be helpful for obstructive sleep apnea (improve sleep quality and daytime sleepiness)
– Central sleep apnea – adaptive servo-ventilation causes harm
Specific Cardiomyopathies
Hypertrophic Cardiomyopathy
• Common autosomal dominant
• 1:500 of general population for phenotype recognized by
echocardiography
• Most common cause of sudden cardiac death in the
young
Arrhythmogenic Right Ventricular
Dysplasia
• Typically present from teens to 40s
• Prevalence 1:5000
• Male : Female 3:1
• 4 phases of disease– Concealed – asymptomatic but increased risk of SCD
– Overt – symptomatic arrhythmias
– Signs and symptoms RV failure
– Biventricular heart failure and arrhythmias
Left Ventricular Noncompaction
• May present with palpitations, heart failure
• Evidence for genetic predisposition
• Increased risk for LV dysfunction, arrhythmia, and
thrombotic stroke
• Implications for family screening, consideration for ICD,
anticoagulation
Evidence for Genetic Testing
Thank you!
Treatment of Stage A Heart Failure
• Hypertension and lipid disorders should be
controlled in accordance with contemporary
guidelines
• Other conditions that may lead to or contribute to
HF: obesity, DM, tobacco use, cardiotoxic agents,
should be controlled or avoided
Treatment of Stage B Heart Failure
Treatment of Stage C Heart Failure
ANY Updates for HFpEF?
TOPCAT Trial
Substudy
analysis
focused on
the Americas
ANY Updates for HFpEF?
Routine use of phosphodiesterase-5
inhibitors to increase activity or QoL is
ineffective
NEAT HFpEF and RELAX – negative
RCTs