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Learning Objectives
At the conclusion of this workshop, participants will be able to: 1. Review changes and updates for optimal management of chronic and acute heart failure; updating 2006 recommendations to 2012 context and environment; 2. Discuss exercise for heart failure patients - where to begin, what to do and where to end; and 3. Identify opportunities and challenges of surgery for patients with an ischemic etiology for heart failure.
Classification of AHF
high BP, +/- preserved LV systolic fxn; increased sympathetic tone with HR, vasoconstriction; may be euvolaemic or only mildly hypervolemic, and frequently with signs of pulmonary or systemic congestion
usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion.
Severe respiratory distress, RR, orthopnea, rales. O2 sats <90% RA prior to O2 Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT).
Usually sys BP <90 mmHg or drop in MAP >30 mmHg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly
low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures
ESC 2008
Harrisons Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501
CASE 1
74 year old female 2 months worsening SOB/orthopnea Presented to ED after Chinese food Past Hx unclear, no meds Physical exam HR 98, BP 142/82, RR 28, temp 36.0C JVP elevated, crackles, pulses 2+, legs warm and LEE+
CASE 1
No right answer
Our Case ?
? 2
1
1 1 1
CASE 1
74 year old female CXR = increased pulmonary markings c/w edema, no evidence of COPD Labs = troponin I 0.20
BNP 728 pg/ml Creatinine 130
Our Case 4
2 2
1
1 1 1
CCS 2012
We recommend the use of a validated diagnostic scoring system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence). e.g. PRIDE score, Boston criteria This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation.
Heart Failure Guidelines
CCS 2012
We recommend that in the clinical scenario when the clinical diagnosis of AHF is of intermediate pre-test probability, NP level be obtained to rule-out (BNP <100 pg/ml; NT-proBNP <300 pg/ml) or rule-in (BNP >500 pg/ml; NT-proBNP >900 pg/ml if age 50-75 years, NT-proBNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF (Strong Recommendation, Moderate Quality Evidence)
Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin.
CASE 2
52 year old male with history of HF
Presented to ED after the Edmonton Oilers won the Stanley Cup
SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36.0c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0.15
1
Dry and Warm Increasing Perfusion/ Cardiac Output
2
Wet and Warm
3
Dry and Cold
4
Wet and Cold
0%
1
0%
2
0%
3
0%
4
1
Dry and Warm Increasing Perfusion/ Cardiac Output
2
Wet and Warm
3
Dry and Cold
4
Wet and Cold
Admit or discharge?
Treatment options?
CASE 2
52 year old male with history of HF
Presented to ED after the Edmonton Oilers won the Stanley Cup
SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36.0c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0.15
48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose e.g. Home dose = 40 mg BID Bolus = 80 (low) 200 (high) 72 hours Co-primary endpoints 60 days Clinical endpoints Heart Failure Guidelines Felker, NEJM 2011
Efficacy:
Patient Global Assessment by visual analog scale over 72 hours using area under the curve
Safety:
Change in creatinine from baseline to 72 hours
DOSE-AHF Conclusions
There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either: bolus vs. infusion or low vs. high No clinical differencesbut
High was associated with favorable trends:
Symptom relief (global assessment and dyspnea) Weight loss and net volume loss Proportion free from signs of congestion Reduction in NT-proBNP
We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).
Patient
New-onset HF or no maintenance diuretic therapy
Initial IV dose
Furosemide 20-40 mg 2-3 times daily Furosemide bolus equivalent to oral dose Furosemide 20-80 mg 2-3 times daily Furosemide bolus equivalent to oral dose
Maintenance dose
Lowest diuretic dose that allows for clinical stability is the ideal dose
*Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details. Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.
Conflict Disclosures
Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical
None of the drugs, devices, or treatment modalities mentioned in this presentation are non approved indications.
You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next? 1. 2. 3. 4. Angiotensin receptor blocker ICD CRT CRT + ICD (CRT-D)
1820 pts, mostly NYHA II, CRT+ICD vs ICD alone Low risk population, annual mortality ~3% 40% reduction in HF events in CRT-ICD group
Heart Failure Guidelines
363 (40.3%)
297 (33.2%)
0.75 (0.640.87)
0.75 (0.620.91) 0.68 (0.560.83)
<0.001
0.003 <0.001
Practical tips
QRS> 150 ms based on a subgroup analysis of MADIT-CRT and RAFT studies
Most LBBB are >150 msec
Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010
Recommendation
Routine CRT implantation is not currently recommended for patients with heart failure and narrow QRS (<120 ms)
Practical tips
Patients enrolled in CRT studies who show benefit have a QRS duration >150ms, on average. The benefit in patients with QRS 120ms to 150ms is less clear Echocardiography derived parameters of dyssynchrony cannot be recommended on a routine basis since clinical utility has not been established
Heart Failure Guidelines
Practical tip
The use of CRT may prevent worsening in patients with LV systolic dysfunction who require permanent pacing and who are expected to have a high burden of ventricular pacing
Case 1. 34 year old female with NYHA FC II HF with LVEF 29% BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0 On BB, ACE, diuretic target doses. Which drug should you start next?
A. B. C. D.
ARB Aldo Inhibitor Neither Does not matter, going for device anyway
Case 2. 64 year old female with NYHA FC I HF with LVEF 29% BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2 On BB, ACE, CCB, diuretic target doses. Which drug should you start next?
A. B. C. D.
Case 3. 84 year old female with NYHA FC IIIb HF with LVEF 29% BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7 On BB, ACE, Digoxin, diuretic optimal doses. Which drug should you start next?
A. B. C. D.
Pfeffer MA et al. Lancet 2003;363:759-66. Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.
24.2 18.3
Candesartan
7.8
3.1
4.5
4.1 0.7
3.4
Increased potassium
p=0.0003
p<0.0001
2006 Recommendation
Patients with LVEF 30% and severe symptoms despite optimized other therapies (Class I, Level B)
Or with AHF with an LVEF less than 30% following acute myocardial infarction (Class IIa, level B)
69
Eplerenone (N=1364) 68.7 (7.7) 22.7% 70 124 17/75 10 30 34 1.14 (0.30) 71.2 (21.9) 32 4.3 (0.4)
Placebo (N=1373) 68.6 (7.6) 21.9% 68 12417/7510 32 29 1.16 (0.31) 70.4 (21.7) 35 4.3 (0.4)
40
Placebo
30
356 (25.9)
Eplerenone
Placebo
253 (18.4)
Eplerenone
20
20
249 (18.3)
10
164 (12.0)
10
0 0 1 2 3
1373 1364
848 925
512 562
199 232
1373 1364
848 925
512 562
199 232
213 (15.5)
171 (12.5)
71
Eplerenone
Placebo
16.3%
16.6%
188 (13.8%)
222 (16.2%)*
39.1 13.8
40.8 12.9
* p = 0.09
Recommendation 2011
We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged > 55 years with LV systolic dysfunction (LVEF < 30%, or if LVEF is 30% and 35% with QRS duration >130 ms), and recent hospitalization for CVD or elevated BNP/NT-proBNP levels, who are on standard HF therapy
(Strong Recommendation, High-Quality Evidence)
CHF Clinics Increased use of EBM versus Community- the First 1933 Patients
EB Therapy First visit from Community (n= 1155) Previously seen in clinic (n= 778) P value
62 (16) 30 (14) 79 25 49 49 15
63 (14) 31 (14) 81 60 66 58 30
Measurement
LVEF Improve by > 20% Improve by >10% ACE use ACE or ARB Beta blocker use Aldo Antagonist
Eur Heart J 2011;32 (suppl 1)
p< 0.001 p< 0.001 p< 0.001 p< 0.001 p< 0.001 p< 0.001 P< 0.001
79
Suggested addition.
Most of the time, the Aldosterone Antagonist is the way to go Monitoring is the most important aspect of Rx Triple therapy is discouraged outside special circumstances
All patients with stable New York Heart Association (NYHA) class I-III should be considered for enrolment in a tailored exercise training program, in order to improve exercise tolerance and quality of life.
A. True B. False
Based on the results of prior studies of exercise training, the Canadian Cardiovascular Society has adopted recommendations that physical activity be considered for stable patients with systolic dysfunction. Canadian Cardiovascular Society consensus conference
recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006;22(1):2345.
The technician was unaware of how to prepare a patient with a defibrillator for a treadmill test and the attending physician should have supervised more closely in preparation for the test.
A written protocol was made to ensure that this would not happen again. The patient was satisfied with the procedure. She began training again about 1 year later and still sees her cardiologist in that same hospital. Current EF is 45% (July 2012 echocardiogram)
Initial supervision ensures safety of the prescribed program and may help patients understand their limits. For patients who prefer home-based exercise, after a minimum of 6-8 supervised sessions, exercise training may continue with a home-based program.
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