11/18/2018 CHF Update 2018 Peter M. Lewis, DO FACC 1 1

Which of the following is true? 11/18/2018 Which of the following is true? A. CHF incidence/prevalence is decreasing B. Incidence of CHF is the same in all populations C. Mortality has significantly decreased with newer treatment modalities D. HfpEF has similar mortality risk to HFrEF 2 2

Which of the following is true? 11/18/2018 Which of the following is true? A. ECHO is a simple, easily obtainable test in the workup of CHF B. Provides significant data on systolic/diastolic parameters, valvular disease, pericardial disease C. Worse outcome in patients when not utililized in diagnosis and follow up D. All of the above 3 3

CHF Update 2018 Definition Types Epidemiology Etiology Pathophysiology 11/18/2018 CHF Update 2018 Definition Types Epidemiology Etiology Pathophysiology Treatment strategies 4 4

CHF Update 2018 5.8 million prevalence Men > women 11/18/2018 CHF Update 2018 5.8 million prevalence Men > women 1970s-1990s epidemic decreasing Majority >65 years and older accounting for >80% of mortality 5 5

11/18/2018 CHF Update 2018 $ 31 billion in 2012 (80% direct costs from hospitalizations) Accounts for 1-2% of all health care cost in developed countries Costs expected to double by 2030 to over $70 billion 6 6

CHF Update 2018 Incidence higher and earlier in AA men/women 11/18/2018 CHF Update 2018 Incidence higher and earlier in AA men/women Higher incidence of CAD, DM, HTN Obesity and CKI More prevalent before age 50 7 7

CHF Update 2018 Incidence higher and earlier in AA men/women 11/18/2018 CHF Update 2018 Incidence higher and earlier in AA men/women Higher incidence of CAD, DM, HTN Obesity and CKI More prevalent before age 50 8 8

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CHF Update 2018 Systolic and Diastolic HFrEF and HFpEF 13 13 11/18/2018 CHF Update 2018 Systolic and Diastolic HFrEF and HFpEF 13 13

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HFpEF Now accounts for >50%of all CHF cases 11/18/2018 HFpEF Now accounts for >50%of all CHF cases More prevalent in females Diastolic abnormalities invariably noted on ECHO Similar mortality compared to HfrEF No proven therapies to date to alter course 15 15

Major Risk Factors Age Male HTN/LVH CAD/MI Valvular heart disease 11/18/2018 Major Risk Factors Age Male HTN/LVH CAD/MI Valvular heart disease Obeisity DM 16 16

Minor Risk Factors Smoking Hyperlipidemia CKI Albumimuria OSA Anemia 11/18/2018 Minor Risk Factors Smoking Hyperlipidemia CKI Albumimuria OSA Anemia Tachycardia 17 17

CHF 2018 Update Immune-mediated 11/18/2018 CHF 2018 Update Immune-mediated Peripartum cardiomyopathy, hypersensitivity Infectious Viral, parasitic (Chagas disease), bacterial Toxic risk precipitants Chemotherapy (anthracyclines, cyclophosphamide, 5-FU), targeted cancer therapy (trastuzumab, tyrosine kinase inhibitors), cocaine, NSAIDs, thiazolidinediones, doxazosin, alcohoSNP (e.g. α2CDel322-325, β1Arg389), family history, congenital heart 18 18

CHF Update 2018 Reduced Contractility------> decreased CO 11/18/2018 CHF Update 2018 Reduced Contractility------> decreased CO Increased preload/LAP BP maybe be decreased but SVR is increased Increased HR ( CO=HR x SV ) 19 19

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11/18/2018 CHF Update 2018 ECHO with depressed LVEF 23 23

11/18/2018 CHF Update 2018 ECHO with LVH 24 24

CHF Update 2018 Biomarkers BNP and proBNP 11/18/2018 CHF Update 2018 Biomarkers BNP and proBNP Utility in diagnosis and following response to treatment BNP levels responsive to ARNI Rx but not proBNP 25 25

CHF Update 2018 BNP 32 amino acid peptide (134 AA NT-pro BNP) 11/18/2018 CHF Update 2018 BNP 32 amino acid peptide (134 AA NT-pro BNP) Secreted by cardiac myocytes Predominant cardiac/renal effects Decrease in SVR and CVP 26 26

CHF Update 2018 Other causes for BNP elevations: ACS 11/18/2018 CHF Update 2018 Other causes for BNP elevations: ACS Atrial fibrillation Myocarditis Cardiac surgery 27 27

CHF Update 2018 Secondary causes of increased BNP: Age Anemia 11/18/2018 CHF Update 2018 Secondary causes of increased BNP: Age Anemia Renal failure Sepsis Pulmonary hypertension Toxic/metabolic 28 28

CHF Update 2018 ACC/AHA Classification Class A Class B Class C Class D 11/18/2018 CHF Update 2018 ACC/AHA Classification Class A Class B Class C Class D 29 29

CHF Update 2018 Stage A Asymptomatic but with significant risk 11/18/2018 CHF Update 2018 Stage A Asymptomatic but with significant risk Risk factor modification to include BP control Rx of lipids/DM Reduction/abstinence from alcohol 30 30

CHF Update 2018 Stage B Documented low EF but asymptomatic: ACEI/ARB 11/18/2018 CHF Update 2018 Stage B Documented low EF but asymptomatic: ACEI/ARB Beta blocker Surgery for any correctable disease 31 31

CHF Update 2018 Stage C Symptomatic with signs/symptoms of CHF 11/18/2018 CHF Update 2018 Stage C Symptomatic with signs/symptoms of CHF Standard Rx Aldosterone antagonists Nitrates/hydralazine 32 32

CHF Update 2018 Stage D Continued standard Rx Transplant 11/18/2018 CHF Update 2018 Stage D Continued standard Rx Transplant Resynchronization therapy LVAD Inotropic Rx 33 33

CHF Update 2018 NYHA Classification Class I asymptomatic 11/18/2018 CHF Update 2018 NYHA Classification Class I asymptomatic Class II symptoms with significant activity Class III symptoms with minimal activity Class IV symptoms at rest 34 34

CHF Update 2018 CBC UA CMP Fasting blood glucose levels Lipid profile 11/18/2018 CHF Update 2018 CBC UA CMP Fasting blood glucose levels Lipid profile Thyroid stimulating hormone (TSH) levels B-type natriuretic peptide levels/pro BNP N-terminal natriuretic peptide levels Electrocardiography 35 35

CHF Update 2018 Electrocardiography Chest radiography 11/18/2018 CHF Update 2018 Electrocardiography Chest radiography Two-dimensional (2-D) echocardiography Nuclear imaging Maximal exercise testing Pulse oximetry or arterial blood gas 36 36

CHF Update 2018 Diet/exercise Dietary consult Routine daily weights 37 11/18/2018 CHF Update 2018 Diet/exercise Dietary consult Routine daily weights 37 37

CHF Update 2018 Standard Medical Therapy Diuretics ACEI/ARB 11/18/2018 CHF Update 2018 Standard Medical Therapy Diuretics ACEI/ARB Aldosterone antagonists Hyralazine/nitrates ARNI 38 38

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11/18/2018 CHF Update 2018 Digoxin Spironolactone Neseritide 40 40

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CHF Update 2018 Cardiac Resynchronization Therapy (CRT) Based on LVEF 11/18/2018 CHF Update 2018 Cardiac Resynchronization Therapy (CRT) Based on LVEF NYHA functional class QRS duration Concomitant need for ventricular pacing 44 44

CHF Update 2018 CRT Simultaneous pacing of the RV/LV 11/18/2018 CHF Update 2018 CRT Simultaneous pacing of the RV/LV Acute hemodynamic benefits: Increased SBP Increased CO/CI Increased contractility 45 45

CHF Update 2018 CRT Anatomic benefits: Decreased adverse LV remodeling 11/18/2018 CHF Update 2018 CRT Anatomic benefits: Decreased adverse LV remodeling Decreased LV size/spherical shape Increased LVEF 46 46

CHF Update 2018 Device/ cardiac resynchronization therapy Class IA 11/18/2018 CHF Update 2018 Device/ cardiac resynchronization therapy Class IA NYHA II-IV class patients LVEF < 35% LBBB Other with QRS >140 msec 47 47

CHF Update 2018 CRT Class IIB Non LBBB with QRS > 150 msec and NYHA 11/18/2018 CHF Update 2018 CRT Class IIB Non LBBB with QRS > 150 msec and NYHA III/IV QRS 130-149msec and NYHA II-IV 48 48

CHF Update 2018 CRT CLASS III LVEF > 50% QRS <120 msecs 11/18/2018 CHF Update 2018 CRT CLASS III LVEF > 50% QRS <120 msecs Non-ambulatory NYHA Class IV Patients on inotropic Rx 49 49

CHF Update 2018 Device Therapy 11/18/2018 CHF Update 2018 Device Therapy 50 50

Summary Treatment Guidelines 11/18/2018 Summary Treatment Guidelines 51 51