2. Management of Heart Failure

3. Overview Interactive exercise What colour are your sunglasses? Update on pathophysiology of HF Interactive case study Heart failure with preserved systolic function Discussion Close

4. Which treatment do you want? A B C time % survival

5. What colour are your lenses?

6. Pathophysiology How we think about the failing heart affects our treatment strategies Changes in mechanistic understanding: 1.Cardio-centric view 2.Cardio-renal view 3.Neuro-hormonal view

7. Cardiocentric view Reduced cardiac output is the “cause” Cardiac compensatory mechanisms –Frank-Starling curve –LV dilatation –LV hypertrophy Problems –Positive inotropes kill! –Still some research on calcium sensitisers etc Benefits –Cardiac resynchronisation

8. Cardiorenal view Reduced perfusion to the renal arterioles causes salt and fluid retention (RAAS) Aim of treatment is to normalise volume status –Focus on diuretics and fluid balance –Stimulated development of ACEi / ARB’s / Aldosterone antagonists –New developments Direct renin inhibitors –Know the eGFR but …

9. Neurohormonal view Heart failure is due to chronically activated compensatory mechanisms –Autonomic nervous system –Renin-Angiotensin-Aldosterone system –Role of the peripheries (muscles, arterioles) Stimulated treatments –Beta blockers –ACEi/ARB/aldosterone antagonists –Natriuretic peptides –Exercise

10. Heart Failure Ventricular contractile dysfunction Sympathoadrena l activation Cardiac output peripheral resistance Renal perfusion Angiotensin II Angiotensin I Renin Salt and water retention Aldosterone vasodilators ACEi Diuretics Aldosterone antagonists ARB Renin inhibitors BB NPs

11. Case study Jean 76 year old lady Long history of type 2 diabetes (diet controlled) Previous episode of gout “mild” COPD Resistant hypertension for years Drugs –Atenolol 50 –Verapamil 120 bd (but only taking evening) –Aspirin 75 Tried –Felodipine –Bendroflumethiazide –Doxazosin

12. Presenting complaint Increasing abdominal swelling Increasing breathlessness on exertion Some ankle swelling

13. Examination Pulse 110 irreg irreg BP 176/94 JVP visible 3 cm Pitting oedema (mild) Distended abdomen but … Heart sounds normal Chest clear

14. Discuss What do you think is going on? What tests will you request and where? Are you going to start any treatment now? 7 mins

15. What the GP did ECG in the practice Open access CXR Open access U/S abdomen Bloods –FBC –U&E –LFT –TFT Started frusemide 40 mg od

16. Results FBC –Hb 9.7 MCV 85 U&E –Cr 120 eGFR 56K 4.5 CXR –Clear lung fields. Enlarged cardiothoracic ratio U/S Abdo –Dilated hepatic veins consistent with heart failure ECG –AF rate 110LBBBQRS duration 150ms

17. Discuss Is the diagnosis clear? More tests? Referral –Where? –Choose and book? Treatment? 7 minutes

18. What the GP did Referred to Cardiology at BRI by letter –24th August 2007 Triaged by Cardiology Consultants –One stop clinic –Seen 19th September 2007

19. One stop clinic Designed to see patients who are likely to need a test and review 7 new patients twice a week Suitable for: –Breathlessness, arrhythmias, murmurs, chest pain and pre-op assessment Patients warned may take all morning! ECG on arrival Letter reviewed and sent for echo prior to being seen

20. Echo

21. Discuss Heart Failure treatment AF treatment Follow up 5 minutes

22. What the Cardiologist did Make the diagnosis –Heart failure with impaired LV systolic function secondary to hypertension –AF Recommend changes in treatment (by GP) –Stop verapamil, atenolol and aspirin –Start bisoprolol, ramipril and warfarin Letter to GP and patient Discharged back to GP Review by Heart Failure nurses for education and monitor uptitration

23. Discuss Uptitration of drugs –By whom? –Monitoring of renal function What would trigger referral back to secondary care? Anaemia –Investigate? Causes? Treatment? 5 mins

24. Heart Failure with preserved systolic function 40 - 60% of HF Elevated LV filling pressures Normal ejection fraction on echo –Other supporting signs of heart failure Typical patient –Elderly –Female –Hypertension

25. Question? What would you have done differently if an open access echo had come back showing: –Good LV systolic function –Mild concentric LVH –Mild mitral regurgitation –Moderate tricuspid regurgitation –Moderate pulmonary hypertension –Probable diastolic dysfunction 2 mins

26. “Diastolic” Heart Failure Poor response to haemodynamic stress –AF –Tachycardia –  BP –Ischaemia Little direct trial evidence –CHARM preserved –SENIORS

27. Treatment options Control BP Control heart rate (esp in AF) Control congestion Revascularise if driven by ischaemia Be careful not to reduce preload too much

28. Discussion Questions Comments