Modern Management of heart Failure Dr Amanda Varnava Consultant Cardiologist Watford & St Mary’s Hospitals

Background What is HF? How to diagnose? 4 stages of HF and Rx of these stages Specific therapies Prognosis SCD and prevention HF with normal systolic function Who manages care?

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 ext tolerance Fatigue Fluid overload 3 rd Heart sound

Assessment ECG BNP Echo Non invasive testing for ischaemia Angiogram

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

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  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 epeleronone

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

Heart Failure Therapies

ACEIns Inhibit RAS at multiple sites Start low, go slow Probably class effect Side effects related to kinin production (cough ion 5-10%) and angioedema (1%) > common in Chinese and Blacks

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 is equivocal for ACEIn + ARB

 Blockers Inhibit advrse 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

Aldosterone antagonists Compensate for RAS escape with ACEIn RALES study provided 30%  mortality in NYHA III/IV EPESUS study showed 20%  mortality post MI 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

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

Cardiac resynchronisation therapy (CRT) Third of pts in NYHA III/IV have QRS>120ms (+electrical dysynchrony) Associated with suboptimal LV filling, prolonged MR and paradoxical septal motion Pacing both ventricles improves contractility and reduces MR

CRT cont’d When added to optimal drug Rx improves QOL, Ex Tol and  hopitalisation Recent trials have also shown 20-30%  mortality However, many pts do not benefit thus other discriminators echo TDI used to select pts Thus pts with persitent symptoms, wide QRS and echo dysynchrony

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

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

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