Developments in heart failure management and clinical practice in the UK

1
Developments in heart failure management and
clinical practice in the UK

• Jamil Mayet
• Department of Cardiology
• St Marys Hospital

2
(No Transcript)
3
Problems in heart failure management

• Accurate diagnosis
• Optimising drug therapy
• Identification of patients who will benefit from
  revascularisation

4
(No Transcript)
5
Cardiac failure - diagnosis
6
Electrocardiogram
If ECG normal very unlikely to be systolic
dysfunction
7
Echocardiography

• Confirms / refutes diagnosis of systolic
  dysfunction
• Can exclude significant valvular disease
• Can suggest ischaemic aetiology if regional wall
  motion abnormality
• Can assess diastolic dysfunction

8
Easy access to investigations

• GP education
• Every patient with possible cardiac failure
  should be considered for echocardiography
• Open and rapid access to echocardiography
• Clear user-friendly reports
• Mild MR this is not clinically significant
• In the absence of clinical contra-indications

9
Optimising drug therapy

• ACE inhibitors
• High doses used in clinical trials
• If cough AII antagonists
• If contra-indications hydralazine/nitrates
• Beta blockers
• Spironolactone

10
(No Transcript)
11
ACE inhibitor doses used in large controlled
trials

• CONSENSUS Enalapril 20mg
• V-HeFT II Enalapril 10mg
• SOLVD Enalapril 10mg
• SAVE Captopril 50mg
• twice daily three times a day
• ATLAS study showed significant decrease in
  mortalityhospital admissions in high dose versus
  low dose lisinopril

12
Treatment AII antagonists

• ELITE STUDY
• 722 patients ?65 years with
• CCF (NYHA class II-IV)
• LVEF ? 40
• Captopril vs. losartan
• FU 1 year
• Mortality
• 4.8 losartan
• 8.7 captopril (p0.035)
• ELITE II

Evaluation of Losartan in the Elderly. Lancet
1997349747-52
13
(No Transcript)
14
Treatment beta blockers
15
Beta-blockers for CCF

• CIBIS-II cardiac insufficiency bisoprolol study
  (II)
• gt2500 patients
• EF ? 35 NYHA III-IV 50 IHD
• all on ACE I diuretics 50 on digoxin
• Bisoprolol vs. placebo
• Starting dose 1.25mg, gradually ? to 10mg od over
  4/52
• Study ended prematurely after 1.3 years
• Annual mortality
• 8.8 bisoprolol 13.2 placebo Hazards Ratio
  0.66
• Risk reduction greatest in patients with IHD

Lancet 1999 Jan 02 3539-13
16
Treatment beta blockers
Patients were largely in NYHA class II-III
Benefits are additive to those conferred by ACEI
17
Treatment beta blockers
18
Treatment spironolactone

• 1663 patients with
• Stable CCF NYHA III-IV
• LVEF ?35
• On ACE I and diuretics
• Some also on digoxin
• Spironolactone (25-50mg od) vs. placebo
• Primary endpoint death from any cause
• Study stopped prematurely
• 30 ? mortality in spironolactone group
• Significant improvement in functional class

Randomized Aldactone Evaluation Study. NEJM
1999341709-717
19
Diagnosing ischaemic heart disease

• 75 of white males in SOLVD were related to
  ischaemic heart disease
• 50 of patients in Framingham had an ischaemic
  aetiology to their heart failure
• Identification of patients who will benefit from
  revascularisation

20
Hibernating myocardium

• Chronic LV dysfunction does not necessarily imply
  dead myocardium
• Hibernating myocardium termed by Rahimtoola in
  1989
• LV systolic function improved following coronary
  revascularisation

Rahimtoola. Am Heart J 1989117211-21
21
Hibernating myocardium
22
Prediction of functional recovery following
revascularisation
Technique Sensitivity Specificity Number of Patients Number of Studies
Tc 99m MIBI Scanning 83 69 207 10
Dobutamine Stress Echo 84 81 448 16
Th 201 Stress Redistribution 86 47 209 7
18F PET 88 73 327 12
Th 201 Rest Redistribution 90 54 145 8
Wijns et al. N Engl J Med 1998339173-81
23
Implications of viable myocardium

• 87 patients with ischaemic CHF, LVEFlt0.35
• Low dose stress echo
• 40/-17 months follow up
• 37 patients received revascularisation
• 22 cardiac related deaths

Senior et al. J Am Coll Cardiol 1999331848-54
24
Implications of viable myocardium
MV - revascularised
MV med Px
No MV med Px
No MV - revascularised
Senior et al. J Am Coll Cardiol 1999331848-54
25
Cardiac failure services available at St Marys

• Open access ECG / CXR / echocardiography
• Routine outpatients for specialist opinion and
  invasive investigation
• Emergency assessment in AE
• Specialist cardiac failure follow up clinic
• Specialist heart failure nurse

26
Specialist referral

• Confirm diagnosis
• Invasive assessment to diagnose underlying
  ischaemic aetiology
• Addition of beta-blockers and/or spironolactone
• Management of difficult / deteriorating cases

27
Heart failure specialist nurse

• Monitoring weight and blood tests
• Educating patient and family
• Daily weighing
• Self management of diuretics
• Regular exercise
• Promoting long term compliance
• Implementing treatment protocols

28
Diastolic heart failure

• Up to a third of patients have clinical heart
  failure with normal LV systolic function
• Underlying pathophysiology relates to diastolic
  dysfunction
• Commonest underlying pathologies
• Normal ageing
• Hypertension
• Myocardial ischaemia

29
Mechanisms of diastolic dysfunction

• Impaired ventricular relaxation
• Energy dependent process
• Susceptible to myocardial ischaemia
• Decreased myocardial compliance
• Altered compliance mediated by collagen
• Fibrosis related to activation of RAAS

30
(No Transcript)
31
Doppler patterns of diastolic dysfunction

• Impaired relaxation
• Reduced E/A ratio
• Increased EDT
• Increased IVRT
• Restriction
• LA pressure increases due to myocardial stiffness
• High peak E wave velocity
• Short EDT
• Very short IVRT

32
(No Transcript)
33
Treatment of diastolic heart failure

• Treat underlying cause eg ischaemia
• Impaired relaxation
• Theoretically rate-limiting agents effective
• Beta-blockers, verapamil
• Reduce HR and prolong diastole
• Reduce myocardial oxygen demand
• Lower BP and reduce LVH

34
Treatment of diastolic heart failure

• Restriction
• Drugs which reduce fibrosis and lower LA pressure
  theoretically should be effective
• ACEI
• AII blockers
• Diuretics
• If LA pressure lowered too much cardiac output
  significantly worsened
• Can cause significant morbidity