Modern Management of Heart Failure Dr Amanda Varnava Consultant Cardiologist Watford General Hospital & Imperial College Healthcare Trust

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

What is heart failure? Impaired ventricular filling and / or contraction SignsSymptoms Dyspnoea Impaired ex tolerance Fatigue Fluid overload 3 rd Heart sound

Assessment of SOB ECG /CXR or BNP abnormal > Echo Additionally –Non invasive testing for ischaemia –Angiogram –MRI

Measurement BNP in CHF  Accurately identifies CHF 81-97% of patients  Levels > 100 (sens 90% & spec 76%)  Levels vary according to age and gender BNP < 100BNP BNP > 400 CHF unlikely Uncertain diagnosis CHF very likely

BNP assessment

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

Heart Failure Therapies

ACEIns Inhibit RAS at multiple sites Start low, go slow Probably class effect Side effects related to kinin production (cough in 5-10%) and angioedema (1%) > common in Chinese and Blacks Continue unless > 50% rise in Cr above baseline/ Cr >350 / K> 5.9

ACEIn titration DrugStarting doseTarget dose Lisinopril2.5 or 5mg od30 or 35mg od Ramipril2.5mg od5mg bd or 10mg od Perindopril2mg od4mg od

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 1 st line Data does not support combination of ACEIn + ARB

 Blockers Inhibit adverse 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

β blocker titration DrugStarting doseTarget dose Carvedilol3.125mg bd25mg or 50mg bd Bisoprolol1.25mg od10mg od

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

Nitrate and Hydralazine Less well tolerated Trials show inferior to ACEIn Subgroup analysis showed benefit in black pts when added to standard Rx Use when ACEIn contraindicated (RF)

Diuretics Often first line agent Treat volume overload Symptomatic relief, but no clear prognostic benefit

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

Polyunsatureated fatty acids GISSI study –n-3 polyunsaturated fatty acids (PUFA) vs placebo in > 7000 heart failure pts –Small, but signif reduction in mortality (27% vs 29%, HR 0.9, p= 0.04)

Current GP prescribing practices in UK 163 practices from with 9311 pts Loop diuretics 79% ACE In or ARB 71% (35% to target) β blocker 36% (11% to target)

Non pharmacological intervention

MV - revascularised MV – med Px No MV – med Px No MV - revascularised Implications of myocardial viability (MV) Senior et al. J Am Coll Cardiol 1999;33:

Cardiac resynchronisation therapy CRT (biventricular pacing) As add on Rx it improves QOL, Ex Tol and  hospitalisation Recent trials have also shown 20-30%  mortality

CRT indications Third of pts in NYHA III/IV have QRS>120ms (= electrical dysynchrony) However, 40% pts do not benefit thus need echo evidence of mechanical dysynchrony to further select pts Thus for pts with: Persistent symptoms, in SR with wide QRS and echo dysynchrony

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

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 epleronone

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

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

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

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 

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 1 st 30 days post MI, no benefit within 1 st year and most trials did not inc large no’s of elderly

Lifestyle & rehab Exercise Aerobic and resistive ideally within rehab programme Diet Wt reduction, salt and fluid restriction (daily wts) Stopping smoking Alcohol –Cessation if causative/ moderate if unrelated Vaccination Pneumococcal and annual influenza Air travel Safe in most pts

Clinical Review Interval dependent on status but not > 6 monthly Clinical review –Fluid status –Functional capacity –Cardiac rhythm Medication review Bloods

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

NICE guidelines for specialist referral CCF not related systolic dysfunction Co-morbidities (COPD, CRF, An, Gout) Angina Arrhythmias (inc AF) Women planning pregnancy Severe or very symptomatic heart failure

Specialist referral Confirm diagnosisConfirm diagnosis Invasive assessment to diagnose underlying aetiology and RxInvasive assessment to diagnose underlying aetiology and Rx Addition of beta-blockers and/or spironolactoneAddition of beta-blockers and/or spironolactone Management of difficult / deteriorating casesManagement of difficult / deteriorating cases Consideration of device therapyConsideration of device therapy

Heart failure with normal systolic function Differential causes of signs of HF with normal EF Incorrect diagnosis Incorrect assessment of LV function Restrictive Cardiomyopathy Pericardial constriction Episodic systolic dysfunction (ischaemia, arrhythmias) High output failure Diastolic dysfunction

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

Cardiac failure services available at West Herts Routine outpatients for specialist opinion and invasive investigationRoutine outpatients for specialist opinion and invasive investigation Emergency assessment in A+E with BNPEmergency assessment in A+E with BNP Specialist heart failure nurse service with consultant supervision (WGH & HH)Specialist heart failure nurse service with consultant supervision (WGH & HH) Specialist cardiac failure device clinicSpecialist cardiac failure device clinic

Thank You