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Heart Failure Definition

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Heart Failure Definition Powered By Docstoc
					Heart Failure in 2012


Patricia P. Chang, MD MHS FACC
        Associate Professor, Medicine
 Director, Heart Failure & Transplant Program




                February 25, 2012
             Disclosures
• No relationships to disclose
• I will discuss products that are
  investigational or used off-label
                    Case
• 55 yo BW presented to PCP with palpitations,
  ECG “abnormal”
  – Stress thallium (2003): no ischemia, LVEF 20%.
  – Exercises on treadmill 2 miles, 33 minutes, 3-4
    d/week. No SOB, cp. Frequently naps during the
    day. Exam unremarkable except BMI 33.
  – PMH: carpal tunnel syndrome. No HTN, DM, h/o
    diet-controlled hyperlipidemia
  – FH: Father died MI age 67. No other CVD/HF/SCD
• Presents to HF Clinic for further E/M
• ACC/AHA Stage B, NYHA Class I
• Further w/u? Treatment? Prognosis?
                         Topics
•   Epidemiology
•   Evaluation: etiology, testing
•   Common comorbidities
•   Therapies and timing

Disclaimer: More focus on Systolic HF vs HF with preserved EF
                   Topics
•   Epidemiology
•   Evaluation: etiology, testing
•   Common comorbidities
•   Therapies and timing
                               HF Estimates
     • HF affects 5.7 Million: 3.1 M men, 2.6 M
       women (self-report, age ≥20yo, NHANES-2008)
     • Lifetime risk 20% (≥40yo, Framingham[FHS])
     • Hospitalizations > 1 M / year
     • Prevalence and Incidence of HF
       increases with age
           – 670,000 new cases age ≥45yo (FHS)
           – 56,000 deaths; 1 in 9 deaths (NCHS)
     • ≥50% diagnosed w/ HF die within 5 yrs
         (Olmsted)
Roger V et al. Heart Disease and Stroke Statistics—2011 Update. Circulation 2011;123(4):e18-e209.
“Diastolic” vs Systolic HF




Aurigemma GP, Gaasch WH. NEJM 2004;351:1097-105.
                 Systolic HF vs HFpEF
4596 HF patients, Mayo Clinic




                                Owan TE et al, NEJM 2006; 355(3):254
Survival by HF type




      Owan TE et al, NEJM 2006; 355(3):254
           Survival by Gender
• Olmstead County: N=4537 HF patients
  (1979-2000) by ICD-9-CM codes (98% (+) Framingham criteria)


         MEN                                   WOMEN




          Rogers VL et al, JAMA 2004;292:344
         Survival by Race & Gender
                                                 Study




Loehr L, Rosamond W, Chang PP, et al. Am J Cardiol 2008;101(7):1016-1022
 SHF Survival by Etiology & Gender
5 RCTs (N=11642 [2851 F]): PRAISE, PRAISE-2, MERIT-HF, VEST, PROMISE




                            Etiology may be more important




                                                         Nonischemic

                                Ischemic



                                     Frazier CG et al, JACC 2007;49(13):1450-8.
                   Topics
•   Epidemiology
•   Evaluation: etiology, testing
•   Common comorbidities
•   Therapies and timing
          Practice Guidelines
• ACC/AHA: 1995, 2001, 2005, 2009
 my.americanheart.org
Heart Failure: Stage vs Class




 Hunt SA et al. ACC/AHA Guidelines 2005 & 2001; Circulation 2001;104:2996.
 Farrell MH, Foody JM, Krumholz HM. JAMA 2002;287:890
      Practice Guidelines
• HFSA: 1999, 2006, 2010   www.hfsa.org




• ESC: 2001, 2005, 2008 (2010)
     Etiology of Systolic HF
• Coronary artery disease
       (“ischemic cardiomyopathy”)            2/3
• Hypertension
       (“hypertensive cardiomyopathy”)
• Valvular disease (“valvular CM”)
• Infectious (e.g., viral myocarditis, Chagas)
• Cardiotoxins (e.g., alcohol, chemotherapy)
• Infiltrative (e.g., amyloidosis, sarcoidosis,
  hemochromatosis, Wilson’s)
• Peripartum CM
• Stress-induced CM
• Genetic (Familial)
• Idiopathic (Dilated) CM
       Evaluation of New HF
                (after a good H&P)

• Cardiac function/structure
  – ECHO (Cardiac MRI, MUGA)
• Etiology
  – R/O CAD: cath vs stress vs CT
  – Serologies: TSH, ANA, Ferritin, HIV,
    SPEP/UPEP
  – Cardiac MRI
  – Family Hx: Genetic testing?
Genomic Locations of Genetic Variants
Associated with the Risk of MI and HF




  O'Donnell CJ, Nabel EG. N Engl J Med 2011;365:2098-2109
Representative Genomewide Association
  Studies (GWAS) of Common CVDs




      O'Donnell CJ, Nabel EG. N Engl J Med 2011;365:2098-2109
             Familial DCM

• New Idiopathic DCM dx = Familial in 20-35%
  (when 1st degree family members screened)
• Point mutations in 31 autosomal and 2 X-
  linked genes
  – But only account only for 30-35% genetic causes




                   Hershberger RE, Siegfried JD, JACC 2011;57(16):1641-9
         Genetic Testing
• Genetics Clinic at UNC (Meadowmont)
• Familion “send out” (www.familion.com)
                   Topics
•   Epidemiology
•   Evaluation: etiology, testing
•   Common comorbidities
•   Therapies and timing
            Comorbidities
• Affect sxs, Rx, prognosis
• Cardiovascular
  – CHD & CHD risk factors: HTN, DM,
    metabolic syndrome, obesity
  – Valvular disease
  – Arrhythmias
  – Other atherosclerotic disease: PAD, stroke
• Noncardiac comorbidities
  – Too many to list… but will highlight:
     • Anemia
     • Sleep apnea
                              Anemia
• ~25% in HF population
  – Etiology: hemodilution, Fe or Epo deficiency,
    CKD
• 1-g/dL Hgb reduction associated with a
  20% increase in risk of death
  Tang WH et al, JACC 2008;51:569-576; Anand I et al, Circulation 2004;110:149-154

• Treatment is relatively easy
  – Iron supplementation
  – IV iron (short-term)
  – Erythropoiesis-stimulating agents (short term)
 Obstructive Sleep Apnea (OSA)
  • Similar sxs as HF
  • Common (12-53%) but under-diagnosed
  • Thus undertreated

                                                           Mild to No OSA




                                                           Untreated OSA




Wang H et al, JACC 2007;49(15):1625-31.   Kasai T, Bradley TD, JACC 2011;57(2):119-27 [REVIEW]
                   Topics
•   Epidemiology
•   Evaluation: etiology, testing
•   Common comorbidities
•   Therapies and timing
               Standard HF Therapy
                      (Systolic HF > HFpEF)
• Guidelines
   – ACC/AHA: 1995, 2001, 2005, 2009
   – HFSA: 1999, 2006, 2010
• Medications
   – Diuretics, ACE inhibitors* &/or Angiotensin receptor blockers* &/ or
     Hydralazine/Nitrates*, Beta-blockers*, Aldosterone antagonists*,
     Digoxin
• Electrophysiology (EP) Devices
   – Implantable cardioverter defibrillator (ICD)
   – Biventricular pacemaker (CRT)
• Surgery
   –   Revascularization
   –   Ventricular restoration (Dor procedure)
   –   Mitral valve surgery
   –   Cardiac transplantation
   –   Mechanical circulatory support (VAD)
HF Stages and Therapies



                                                   Stem cells?
                                                   Hemofiltration?




                                          ARB, H/I in some. ICD
                                    all



       Jessup M, Brozena S. NEJM 2003;348:2007
           Stepwise Therapy for HF




         , B-blockers




Kittleson MM, Kobashigawa JA, Circulation 2011;123:1569-1574
       HF Specific Management
• Identify and avoid exacerbating factors for HF
• Behavioral management
  –   Fluid restriction (2 L = ½ gallon)
  –   Salt restriction (2 g)
  –   Daily weights (?sliding scale diuretics for the savvy)
  –   Exercise
  –   Medical adherence             a.k.a. HF Core Measures
  –   No smoking
• Biomarkers: BNP/NT-proBNP
  – New ones but not commonly available (ST2, endoglin, galectin-
      3, cystatin C, neutrophil gelatinase-associated lipocalin, midregional pro-
      adrenomedullin, chromogranin A, adiponectin, resistin, leptin)

• “Baseline/dry” weights & NTproBNP helpful
       Timing: Medications
• Begin with ACC/AHA Stage A
• Optimize for Stages B-D
        Timing: Medications
• Lots of meds with good data, but challenges
  of polypharmacy
   – Compliance, cost, HF severity
• Priorities
   – B-blocker, ACE-I for all (aim for target doses)
   – ARB as ACE-I alternative or if congested/
     hypertensive
   – Hydralazine/nitrate if African-American or
     congested/hypertensive
   – Diuretic PRN and/or Aldosterone blocker
   – Digoxin if recurrent hospitalization
      Aim for Target Doses
          Enalapril (Vasotec)                       10 mg bid
ACE-I     Captopril (Capoten)                       50 mg tid*
          Ramipril (Altace)                         5 mg bid
          Lisinopril (Prinivil, Zestril)            20 mg qd
          Trandolapril (Mavik)                      4 mg qd
          Quinapril (Accupril)                      20-40 mg bid §

     Bisoprolol (Zebeta)                       10 mg qd
BB   Carvedilol (Coreg)                        25-50 mg bid **
     Metoprolol XL/CR (Toprol XL)              200 mg qd
     Metoprolol (Lopressor)                    100 mg bid § ‡
     Atenolol (Tenormin)                       100 mg qd § ‡
                    *affected by food, ** depends on weight
                    § no mortality data, ‡ not in guideline
           Hospitalized Pt: ADHF
• IV diuretics
    – Bolus or continuous
• IV vasodilators
    – Nitroglycerin, Nesiritide, Nitroprusside
• IV inotropes
                                    Advanced,
  – Milrinone, Dobutamine, Dopamine End-stage
• Optimize PO regimen               Systolic HF
Hunt SA, et al. ACC/AHA HF Guidelines Update. Circulation 2009;119(14):e391-479.
         Alternatives to Drugs
• Ultrafiltration (aquapheresis therapy):
   – Peripheral or central venous access, ≤4 L off in
     ≤8 hrs, max removal rate 500 mL/hour
   – UNLOAD trial: n=200, RCT, UF vs IV diuretics
      • At 48 hrs, UF group had 38%  weight loss, 28%  net
        fluid loss
      • At 90 days after hospital d/c, UF had  HF re-
        hospitalizations,  ED or clinic visits
                     Costanzo MR et al. JACC 2007;49(6):675-83

• EECP (enhanced external counterpulsation)
   – Already used for angina pts
   – PEECH trial: n=187, RCT, EECP vs usual care
      • EECP pts had  exercise time, QOL, NYHA Class, but
        no difference in peak VO2 changes
                     Feldman AM et al. JACC 2006;48(6):1198-205
 Implantable Cardioverter Defibrillator
               LVEF ≤35%
               • 2° Prevention
                 – AVID (1997)
               • 1° Prevention
                 –   MADIT (1996)
                 –   MUSTT (1999) (EF 35-40%, +EPS)
                 –   MADIT II (2002)
                 –   SCD-HeFT (2004)

ACC/AHA/ESC guidelines
• Class I: LVEF ≤ 35%, NYHA II-III,
            ICM LVEF ≤ 30%, NYHA I
• Class II: NICM LVEF ≤ 30% NYHA I
                 Timing: ICD
•   40+ days post-MI/revascularization
•   >3 months for NICM on optimal therapy
•   Life expectancy >1 year
•   Still, low referral rate
    – 42% (LVEF≤35%) & 49% (LVEF≤30%)
      eligible pts were referred (1 center, 2002-2006)
                        Bradfield J et al, PACE 2009; 32:S194–S197


    – Why? NNT = 6 (MADIT-II) to 14 (SCD-HeFT)
       • Patient vs Doctor?
          ICD implant rates overall low
    MADIT II eligible pts in GWTG hospitals –Implanted or Planned


                                                   Implant rate:
                                                   20% overall
                                                   <1% lowest tertile
                                                   35% highest tertile




Shah B et al, JACC 2009;53(5):416-22
                         ICD Implant Rates
  Highest in large
  centers with
  sophisticated
  cardiac facilities




Shah B et al JACC 2009;53(5):416-22
Reiterate the Message?


   • Life-saving

   • Prognostically Important
  ICD Shocks = Poor Prognosis
Any shock is bad




More shocks are worse




• 33% SCD-HeFT pts received ≥1 ICD shock (128 pts
  appropriate, 87 inappropriate, 54 both types)
• Most common cause of death = progressive HF

     Poole JE et al, NEJM 2008;359:1009-17
ICD Shocks = Poor Prognosis
 Cardiac Resynchronization Therapy
• 30% with chronic HF have
  Ventricular Dyssynchrony
• CRT with biventricular pacemakers can
  improve symptoms & survival*:
   NYHA Class III-IV, LVEF <35%, basal QRS
   duration of >120 msec
   – MUSTIC (QRS >150 ms) (2001)
   – MIRACLE (QRS >130 ms) (2002)
   – COMPANION (QRS >120 ms) (2004)
   – CARE-HF (QRS >120 ms) (2005)*
            Timing: CRT
• After medical therapy optimized
• CRT has been mostly studied in the
  NYHA III-IV population
  – If CRT, HF = “Advanced”
• Consider CRT earlier? (earlier than
  NYHA Class III)
  – REVERSE Trial (2008)
  – MADIT-CRT Trial (2009)
  – RAFT Trial (2010)
            REVERSE Trial




• 610 pts NYHA Class I-II, QRS ≥120, LVEF ≤40%:
  CRT-ON ▲ vs CRT-OFF ●
                      Linde C et al, JACC 2008;52:1834-43
              REVERSE Trial




• ~96% on ACEi/ARB and BB; ~35% at target BB dose
• ~80% NYHA II
                       Linde C et al., JACC 2008;52:1834-43
                 MADIT-CRT




• 1820 pts NYHA I-II, QRS≥130, LVEF≤30%: CRT-ICD vs ICD
• ~40% NYHA II; 10% NYHA III-IV prior to enrollment
                  Moss AJ et al, N Engl J Med 2009;361:1329-38.
             RAFT

• 1789 pts, NYHA II-III,
  LVEF ≤30, QRS ≥120
  or ≥200 paced:
  CRT-ICD or ICD



Tang AS et al, N Engl J Med 2010;363:2385-95.
          CRT “Subgroups”
• Pts who seem to benefit more:
  – QRS >150 msec (MADIT-CRT, RAFT)
  – Women (MADIT-CRT)
        Reverse Remodeling
                          MADIT-CRT




                                     Moss AJ et al, N Engl J Med 2009;361:1329-38.

• Responders: LA volume <40 ml/m2, women,
  nonischemic CM, LBBB, QRS ≥150, LVEDV
  ≥125 ml/m2, prior hospitalization for HF
        Goldenberg I et al, Circulation 2011;124(14):1527-36
                   CRT Limitations
• ~30% do not respond to CRT     (PROSPECT, Bax JJ et al,
 JACC 2009;53:1933-1943)


• HF does ultimately progress
Patient Preferences
              • Time trade (survival
                time vs perfect
                health)
              • Baseline: median
                trade for better quality
                = 3 months' survival
                time
              • Preferences in favor
                of survival for many
                pts despite advanced
                HF sxs, stable over
                time, but increase
                after hospitalization in
                68%
                   Stevenson LW et al,
                   JACC 2008;52:1702-8
         Heart Transplantation
• The only “cure”
• >89,000 Heart Tx worldwide, >50,000 in US (1988-)




              Hunt SA, Haddad F, JACC 2008:52:587-98. Hunt SA. NEJM 2006;355:3
         Transplant Eligibility



                        J Heart Lung Transplant 2006;25:1024–42.



• Objective assessment of functional
  capacity (limitation)
  – 6 minute walk
  – Cardiopulmonary exercise stress test (CPX)
    • Peak exercise O2 consumption (VO2)
The Problem: Organ Shortage
    • 4,000 pts are listed annually
    • Yearly wait list mortality 10%




          Gridelli and Remuzzi, NEJM 2000;303:404.
        Mechanical Circulatory Support:
  Ventricular Assist Devices: Bridge to Tx, Destination Therapy

                                                  • Volume Displacement
                                                    –   Thoratec
                                                    –   Novacor
                                                    –   Heartmate LVAS
                                                    –   Abiomed
                                                  • Axial Flow
                                                    – Heartmate II
                                                    – Jarvik
                                                  • Centrifugal
                                                    – CentriMag
                                                    – Heartware

Baughman KL, Jarcho JA. NEJM 2007;379(9):846-9.
     Timing: Transplant / VAD
•   On optimal therapy (meds, EP devices)
•   Progressive “advanced” HF (NYHA III-IV)
•   Before truly “end stage”
•   Failure of maximal medical therapy
    – Progressive HF symptoms
    – More arrhythmias
• Evaluation is multidisciplinary, similar to
  transplant
• Goal: ↑ quality and quantity of life
Real Patients
       Timing: Transplant / VAD
• Clinical Risk Factors for 1-yr Mortality
       Russell SD, Miller LW, Pagani FD, CHF 2008;14(6):316-21

   – Walk <1 block without dyspnea
   – Na <136 mEq ⁄ L
   – BUN >40 mg ⁄dL or creatinine >1.8 mg ⁄dL
   – Can’t tolerate ACEI ⁄ ARB ⁄ BB
   – Diuretic dose >1.5 mg ⁄ kg ⁄ d
   – HF admission in past 6 months
   – No clinical improvement with CRT therapy, or no
     CRT and QRS >140 ms
   – Hematocrit <35%
• Multiple risk models
Heart Failure Survival Score



                                                                                   This pt’s
                                                                                   abs value
                                                                                   sum score
                For 1-year event-free survival                                     = 7.28




           Aaronson KD et al, Circulation 1997;95(12):2660-7
     Reference for Table: Mehra MR et al, J Heart Lung Transplant. 2006:1024-42.
       Seattle Heart Failure Model




Levy WC et al. Circulation 2006;113:1424-1433   www.SeattleHeartFailureModel.org
    Systolic HF: Multidisplinary Care
 • Primary Care Provider

                             • Cardiac
• General                      Surgeon
  Cardiologist


                            • EP
 • Heart Failure              Cardiologist
   Cardiologist
              Summary
•   Systolic HF is common
•   Always R/O CAD
•   Do thorough FH
•   R/O and Rx sleep apnea and anemia
•   Aim for target doses for evidence-
    based HF pharmacologic therapies
          Stepwise Therapy for SHF
Start Rx for ACC/AHA Stage A
Optimize Rx for Stages B-D as follows:




                                       , behavioral modifications



           , B-blockers




     Stage B               Stage C                               Stage D


  Kittleson MM, Kobashigawa JA, Circulation 2011;123:1569-1574
                   Summary
• Aim for target doses for evidence-based HF
  pharmacologic therapies
• ICDs underutilized, yet prognostically important
• CRT can be considered earlier than “advanced
  stage”, but certain subgroups respond better
• If still symptomatic beyond optimal behavior,
  meds, and EP devices, consider HTx and VAD
  – Always better to consider these therapies early vs
    too late
                 UNC Heart Failure Team
                      www.uncheartandvascular.org
      Cardiology (ph 919-843-5214)   Cardiothoracic Surgery
    Pager 919-123-HEART (123-4327)                       (ph 919-966-3381)
                                                                          Brett Sheridan, MD
             Patricia Chang, MD MHS                                       brett_sheridan@med.unc.edu
             patricia_chang@med.unc.edu
                                                                          Andy Kiser, MD
               Brian Jensen, MD                                           andy_kiser@med.unc.edu
               brian_jensen@med.unc.edu
                                                                      Tracy Vernon-Platt, ANP
             Carla Sueta, MD PhD                                      tvernon@unch.unc.edu
             carla_sueta@med.unc.edu
                                                                      Michael Mill, MD
           Kirkwood Adams Jr, MD                                      michael_mill@med.unc.edu


            Jana Glotzer, ACNP
                                           Transplant Coordinators (ph 919-966-4728)
            jana_glotzer@med.unc.edu               Scott Kowalczyk, RN BSN CCTC
                                                   skowalc@unch.unc.edu
   Jason Katz, MD MHS                                                     Katie McMahon, RN BSN
                                                                          kmcmahon@unch.unc.edu
   jason_katz@med.unc.edu

                                              VAD Coordinators (pgr 919-216-2095)
                                              Mandy Bowen, RN BSN
                                              abowen@unch.unc.edu
                                                                          Danielle Miller, RN BSN
                                                                          drmiller@unch.unc.edu

 Heart Failure NP                          1-866-862-4327 = 866-UNC-HEART
 Sarah Waters, ANP                        UNC Center for Heart and Vascular Care
sarah_waters@med.unc.edu
                                                One Call Referral Service

				
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