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Acute Decompensated Heart Failure in Hospitalized Patients

The 1 st Kuwait-North American Update in Internal Medicine. Acute Decompensated Heart Failure in Hospitalized Patients. Michael M. Givertz, M.D. Medical Director, Heart Transplant/Mechanical Circulatory Support Brigham and Women ’ s Hospital Associate Professor of Medicine

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Acute Decompensated Heart Failure in Hospitalized Patients

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  1. The 1st Kuwait-North American Update in Internal Medicine Acute Decompensated Heart Failure in Hospitalized Patients Michael M. Givertz, M.D. Medical Director, Heart Transplant/Mechanical Circulatory Support Brigham and Women’s Hospital Associate Professor of Medicine Harvard Medical School Boston, MA

  2. Heart Failure is a Progressive Disease

  3. The Course of Heart Failure Goodlin et al., J Am Coll Cardiol 2009;54:386

  4. Trends in ADHF Morbidity/Mortality Chen et al., JAMA 2011;306:1669

  5. Markers of Advanced Disease and Poor Prognosis • Severe (objective) exercise intolerance • ACE inhibitor or β-blocker intolerance • High-dose diuretics • RV failure, 2 pulmonary hypertension • Hyponatremia, anemia, hyperuricemia • Chronic kidney disease (CKD) • Cardiac cachexia

  6. Muscle Wasting in Heart Failure

  7. Repeat Hospitalizations and Death 6-12 months Setoguchi et al., Am Heart J 2007;154:260

  8. ADHF: Who are They? • Older (mean age 70s) • ≈50% women • 40-50% preserved EF • Over 85% with chronic HF • Multiple co-morbidities • Hypertension • Diabetes • Chronic kidney disease

  9. Shortness of Breath is the Main Reason for HF Hospitalization

  10. Congestion(Not Low Output) is the Main Finding in Hospitalized Patients 1Fonarow et al. Rev Cardiovasc Med 2003;4 Suppl 7:S21 2VMAC Investigators. JAMA 2002;287:1531

  11. PASP PADP HR Congestion is Often Unrecognized and Precedes Hospitalization Adamson et al., J Am Coll Cardiol 2003;41:565 Yu et al., Circulation 2005;112:841

  12. CardioMEMS: Pressure Measurement System Dear Michael M. Givertz, MD A new reading has come in for your patient, 31-003 C-Z which violated the alert threshold set up for "Mean Pressure above 20.0 mmHg". The reading was taken on 25 Jan 04:06 EST. Systolic: 89 Diastolic: 51 Mean: 66 Heart Rate: 91 Pressure waveform is attached. Thank you, CardioMEMS Alert System

  13. CHAMPION Study: HF Hospitalizations p < 0.001, based on Negative Binomial Regression HF Hospitalizations, no.

  14. Guidelines N=25 Class I N=18 Class II N=5 Class III N=2 Evidence A N=1 IIa N=4 IIb N=1 Evidence B N=2 Evidence B N=3 Evidence B N=1 Evidence C N=1 Evidence C N=14 Evidence C N=3 ACC/AHA Guidelines for ADHF Consensus opinion 72%, “Evidence” 28%

  15. Class I, Level of Evidence A • Concentrations of BNP1 or NT-proBNP2 should be measured in patients being evaluated for dyspnea in which the contribution of HF is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test. Unfortunately, the routine use of serial natriuretic peptide measurements to monitor hemodynamics has not been shown to be helpful in improving the outcomes of the hospitalized patient with HF (ACC/AHA) 1Maisel et al., N Engl J Med 2002;347:161 (BNP Study) 2Januzzi et al., Am J Cardiol 2005;95:948 (PRIDE Study)

  16. Diuretics for ADHF and Fluid Overload • Treatment with IV loop diuretics should begin in the ED without delay, as early intervention may be associated with better outcomes (Level of evidence B). • If patients are already receiving loop diuretics, initial IV dose should equal or exceed chronic oral dose (Level of evidence C). • When a patient with congestion fails to respond to IV diuretics, consider increased dose of loop diuretic, addition of second diuretic, continuous infusion of loop diuretic (Level of evidence C)

  17. DOSE Study Felker et al., N Engl J Med 2011;364:797

  18. DOSE Study • 308 patients with ADHF • Randomized 2x2 to low vs. high-dose furosemide and IV bolus vs. continuous infusion • No differences at 72 hours in: • Global symptom assessment (1° efficacy endpoint) • Change in renal function (1° safety endpoint) Felker et al., N Engl J Med 2011;364:797

  19. Death, Rehospitalization, or ED Visit Felker et al., N Engl J Med 2011;364:797

  20. Secondary Endpoints: Low vs. High Dose Strategy

  21. Cardiorenal Syndrome:Worsening Renal Function During Treatment of ADHF Increase in creatinine ≥ 0.3 mg/dl Occurs in 15-30% of admissions Risk factors: Older age HTN, DM Baseline renal dysfunction May be associated with adverse outcomes during the hospitalization and post-discharge Gottlieb et al., J Card Fail 2002;8:136 Forman et al., J Am Coll Cardiol 2004;43:61

  22. Transient vs. Persistent Worsening Renal Function +1.17 +0.60 N = 467 with ADHF, WRF in 115 (24%) Aronson et al., J Card Fail 2010;16:541

  23. Ultrafiltration: An Attractive Alternative to Diuretics • More effective way to restore sodium balance1 • removal of isotonic vs. hypotonic saline • No effect on serum electrolytes • Rapid and predictable fluid removal • Does not stimulate neurohormones • May restore diuretic responsiveness and improve long-term outcomes2 1Jessup and Costanzo, J Am Coll Cardiol 2009;53:597 2Agostoni et al., J Am Coll Cardiol 1993;21:424

  24. Minimally Invasive Ultrafiltration FDA approved, portable device Non-ICU, routine nursing PICC or central line UNLOAD (sponsor-initiated) Greater weight loss at 48 hours compared to IV diuretics (5 vs. 3.1 kg; p < 0.001) Decreased HF hospitalization at 90 days Costanzo et al., J Am Coll Cardiol 2007;49:675

  25. CARRESS Study N = 188 with ADHF, Cre ↑ ≥ 0.3, persistent congestion Randomized to UF vs. stepped pharmacologic care Bart et al., N Engl J Med 2012;367:2296

  26. CARRESS Study: Primary Endpoint Cre ↑ 0.23 Cre ↓ 0.04 Bart et al., N Engl J Med 2012;367:2296

  27. CARRESS: Adverse Events • More patients in UF group (72%) had SAEs compared to stepped pharmacologic care (57%) • Renal failure • Bleeding • IV catheter-related • No difference in 60-day mortality or rate of death or HF rehospitalization Bart et al., N Engl J Med 2012;367:2296

  28. Options for Diuretic Resistant Patients • Vasodilators • IV Nitroprusside, nitroglycerin • Hydralazine/nitrates • Positive inotropes • Dobutamine • Milrinone • Dopamine (renal-dose vs. higher doses) • Mechanical circulatory support

  29. Dobutamine: Interpatient Variability Colucci et al., Circulation 1986;73:III175

  30. Tolerance to (Not All) Inotropes N = 20, severe chronic HF, CI 1.63 L/min/m2 Mager et al., Am Heart J 1991;121:1974

  31. Is There Really a Role for Low-Dose Dopamine? N = 380 with ADHF and estimated GFR 15-60 ml/min Randomized to dopamine 2 mcg/kg/min vs. placebo Chen et al., JAMA 2013:310:2533

  32. ROSE Study No effect on symptoms, 60-day readmission or 180-day mortality More tachycardia Chen et al., JAMA 2013:310:2533

  33. Worst Prognosis with Inotrope Dependence Community-based Clinical trial Hershberger, J Card Fail 2003;9:180 Rogers, J Am Coll Cardiol 2007;50:741

  34. ADHF is a Good Time to Address Risks and Co-Morbidities • Arrhythmias or conduction disease • consider ICD for primary prevention • AF: consider amiodarone/CV, ablation • LBBB: consider CRT* • Risk of thromboembolism: need for anticoagulation or anti-platelet therapy • Anemia, diabetes, obesity, sleep apnea • Advanced directives *should NOT be used as a “bail-out”

  35. Dying with HF is Rarely Unexpected • N = 160 • Mean age 60, 74% male • Mean duration of HF: 5 years • 40% died in hospital, 10% with hospice • Within 6 months of death: • 93% NYHA class III or IV • 74% hospitalized at least once • mean Na 128, Cre 3.1, Hct 30 Teuteberg et al, J Card Fail 2006;12:47

  36. Comprehensive Discharge Instructions Six key aspects of care • Diet • Medications (adherence and uptitration) • Activity level • Follow-up appointments • Daily weights • What to do if HF worsens?

  37. Thank you for your attention

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