Modern Management of heart Failure

1. Modern Management of heart Failure Dr Amanda Varnava Consultant Cardiologist Watford & St Mary’s Hospitals

2. Background • What is HF? • How to diagnose? • 4 stages of HF and Rx of these stages • Specific therapies • Prognosis • SCD and prevention • HF with normal systolic function • Who manages care?

3. Background • Huge health costs $27 billion pa in US • Primarily a disease of the elderly • Incidence of 10/100 in those over 65yrs

5. What is heart failure? • Impaired ventricular filling and / or contraction Symptoms Signs Dyspnoea Impaired ext tolerance Fatigue Fluid overload 3rd Heart sound

7. Assessment • ECG • BNP • Echo • Non invasive testing for ischaemia • Angiogram

8. BNP assessment

9. 3 questions we need addressed with echo • Is EF preserved? • Is LV structure and wall movement normal? • Are there other structural abnormalities? • Valvar disease • Atrial dilation • PA hypertension

10. Stages of Heart Failure At risk Frank Heart Failure Evidence of structural disease, but no symptoms At risk, but no evidence of structural disease or symptoms Structural disease with symptoms Refractory symptoms NYHA IV despite max Rx • Dyspnoea • Fatigue •  Ex Tol • HT • CAD • Obesity • FH CM • Cardiotoxins • ETOH • MI • Valvular disease • LVH Palliative care Or TX LVADs Stem cell Tx ACEIn  Blockers Spironolactone ±CRT ACEIn/ARB 1º Prevention

11. Primary prevention HT • Lifetime risk of HT is 75% • Optimal Rx of HT cuts in 1/2 the risk of HF DM • Females 3 x > likely to develop HF • ACEIn CAD • All MI pts should start on ACEIn and  • If HF > Add epeleronone

12. Management of asymptomatic pts Drugs • ACEIn delay onset of symptoms and improve mortality • No specific trials with ARBs • No trials with s, but ACC guidance suggests use esp in CAD Devices • MADIT II ICD trial supports use, but no’s huge thus not current practice

13. Symptomatic patients • As with asymptomatic • In addition diuretics for fluid overload • Aldosterone antagonists Also • Na restriction • Withdraw NSAIDS, Ca antag • Exercise • Close F/U

14. Refractory symptoms • Increased awareness of palliative care Where appropriate consider • Cardiac TX • LVADs • Stem cell Tx

15. Heart Failure Therapies

17. ACEIns • Inhibit RAS at multiple sites • Start low, go slow • Probably class effect • Side effects related to kinin production (cough ion 5-10%) and angioedema (1%) > common in Chinese and Blacks

18. Angiotensin Receptor Blockers • Developed because of RAS “escape” with ACEIn and side effects • However, less well studied and some benefits may relate to kinin production • Thus alternative, not 1st line • Data is equivocal for ACEIn + ARB

19.  Blockers • Inhibit advrse effects of sympathetic NS • Trials with carvedilol, bisoprolol and LA metoprolol • Not class effect • Rx as soon as HF diagnosed • If pts on low dose ACEIn greater benefit to add’n of  than  ACEIn

20. Aldosterone antagonists • Compensate for RAS escape with ACEIn • RALES study provided 30%mortality in NYHA III/IV • EPESUS study showed 20% mortality post MI with HF signs (eplerenone) • Thus in mod-severe HF or HF post MI

21. Nitrate and Hydralazine • Less well tolerated • Trials show inferior to ACEIn • Subgroup analysis showed benefit in black pts when added to standard Rx

22. Digoxin • No prognostic benefit • Can improve quality of life • Use in pts with persistent symptoms despite standard Rx • Caution post MI / ongoing ischaemia

23. Cardiac resynchronisation therapy (CRT) • Third of pts in NYHA III/IV have QRS>120ms (+electrical dysynchrony) • Associated with suboptimal LV filling, prolonged MR and paradoxical septal motion • Pacing both ventricles improves contractility and reduces MR

24. CRT cont’d • When added to optimal drug Rx improves QOL, Ex Tol and hopitalisation • Recent trials have also shown 20-30% mortality • However, many pts do not benefit thus other discriminators echo TDI used to select pts • Thus pts with persitent symptoms, wide QRS and echo dysynchrony

25. Prognosis • Likelihood of survival can be reliably predicted for populations, but not individuals (death may be endstage HF or sudden) • Old prognostic models do not apply due to new drug Rx and devices • Annual mortality of 7% in those on 

26. Sudden cardiac death • Proportion with SCD is greater in those with less severe LVSD • ICD trials show risk reduction 23-30% in pts with EF<35% However, • Not within 1st 30 days post MI, no benefit within 1st year and most trials did not inc large no’s of elderly

27. Heart failure with normal systolic function

28. Management of diastolic dysfunction • Few trials • Resolve fluid overload • Some data on ACEIn / ARBs • Treat underlying condition

29. Who should manage care? Once diagnosed and appropriate investigations completed • Nurse led clinics GP or specialist run service? • 1° care manage most pts • If remain symptomatic or are complex then refer to specialists