Heart Failure

1
Heart Failure

• Susan Schayes, MD, MPH
• Program Director
• Emory Family Medicine Residency Program
• Adapted from Dr. Joel Felner and Dr. Eddie Needham

2
Objectives

• Define Heart Failure
• Know the 5 year mortality rate for heart failure
• Distinguish between New York Heart Association
  classes (I IV) and the new American College of
  Cardiology stages (A D)
• Review and become familiar with treatment options
• Know the three beta-blockers demonstrating
  benefit, and the two that are FDA approved

3
Objectives

• Know indications for an ICD
• Know percent of patients who have diastolic
  dysfunction

4
Pre-lecture Needs Assessment

• What are the four NYHA classes of HF?
• What are the four ACC stages of HF?
• Which medication classes are routinely prescribed
  in heart failure?
• Which three beta-blockers are approved to treat
  HF?

5
DEFINITION

• Clinical syndrome
• Inability of the heart to produce sufficient
  cardiac output to meet the metabolic demands of
  the peripheral tissues while operating at normal
  filling pressure.

6
Define Heart Failure

• Heart failure is a complex syndrome that can
  result from any structural or functional cardiac
  disorder that impairs the ability of the
  ventricle to fill with or eject blood. 1
• The cardinal symptoms are dyspnea and fatigue,
  while the predominant clinical sign is fluid
  retention (rales, elevated jugular venous
  pulsations, and pedal edema). Given that not all
  patients are volume overloaded at the time of
  diagnosis (diastolic dysfunction), the term
  heart failure is now preferred over congestive
  heart failure.

1Hunt S, et al, ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart
Failure in the Adult A Report of the American
College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee to
Revise the 1995 Guidelines for the Evaluation and
Management of Heart Failure). 2001, ACC web site,
accessed November 12, 2004.
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CLASSIFICATION

• 1. Acute (pulmonary edema)
• 2. Chronic stable a. Systolic /
  Diastolic dysfunction
• 3. Right / Left ventricular failure
• 4. High output states

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ACUTE PULMONARY EDEMA

• Definition
  Sudden change structure/function(?LVFP)
• Etiology
• Cardiac
  -myocardial (ischemia /
  infarction) -mechanical (acute
  regurg HTN urgency) -electrical (tachycardia
  AF/VT)
• Non-cardiac
  -high altitude pulmonary edema
  (HAPE) -heroin overdose chlorine,etc

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Pulmonary edema is caused by (1) imbalance of
the Starling forces in the lung (cardiogenic)
(2) disruption in the alveolar
capillary membrane (non-cardiogenic).
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CARDIOGENIC PULMONARY EDEMA
NON-CARDIOGENIC PULMONARY EDEMA
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1. hydrostatic APE

• Acute cardiogenic or volume-overload pulmonary
  edema -sudden ? in pulmonary venous
  pressure ? pulmonary interstitial and
  alveolar fluid -pulmonary and lymphatic
  drainage cant compensate acutely to remove
  the fluid

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continued

• Hallmark rapid increase in hydrostatic pressure
  in the pulmonary capillaries causing increased
  transvascular fluid filtration.
• It is usually due to ? pulmonary venous pressure
  from LVEDP/ LAP. As LAP rises above 25
  mmHg fluid breaks thru the lung epithelium
  flooding the alveoli with protein poor fluid.

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2. ?-permeability pulmonary edema (acute lung
injury)

• Non-cardiogenic pulmonary edema
  
  -Lymphatic
  drainage cannot compensate for the ? lung water
  caused by the disrupted alveolar capillary
  membrane. -Caused by ? vascular permeability
  of the lung ? ? flux of fluid into the
  interstitium and air spaces

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APE with NORMAL HEART SIZECARDIAC CAUSES

• Acute MR (torn chordae / ruptured PM)
• Acute AR (dissection / flail leaflet)
• Mitral stenosis
• Ischemic HD AMI / stunned myocardium
• Malignant HTN
• Acute rapid AF (WPW)

Enlarged heart Exacerbation of chronic HF
Myocarditis
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APE NON-CARDIAC CAUSESPATHOPHYSIOLOGY

• Lung injury damages alveolar-capillary membrane ?
  capillary leak syndrome ie, transudation of
  fluid from pulmonary capillaries to alveoli
• ? oncotic pressure (hypoalbuminemia)
• Impaired lymphatic drainage

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SYSTOLIC DYSFUNCTION

• Defect -myofibrils cannot
  shorten against a load
• Various clinical presentations -asymptomati
  c, w/ ?ejection fraction -evidence of ?CO
  fatigue/confused/?BUN -evidence of congestion
  DOE/leg edema -dilated LV chamber on chest
  x-ray
• Annual mortality -NYHA II-III
  15-20 / NYHA IV 50

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DIASTOLIC DYSFUNCTION

• Pathophysiology stiff ventricle LV
  poorly compliant ? filling/relaxation -systolic
  function normal or markedly ? -evidence of HF
  35
• Etiology --ischemia/LVH/fibrosis/normal
  aging
• Symptoms congestive (pul venous HTN)
• Signs apex-normal/ sustainedS4
• Hemodynamic abn ?LVEDP / ?LAP
• Prognosis not as bad as systolic dysfn

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COMPARISON of the TYPES of MYOCARDIAL DYSFUNCTION
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LEFT HEART FAILURE

• Etiology -CAD / HTN / Valvular HD
  / etc
• Symptoms -fatigue/congestion (SOB / DOE)
• Signs -narrow pulse pressure -hypokin
  etic carotid pulse -inferolaterally displaced
  apex -S3/S4 gallops murmurs of MR/TR

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RIGHT HEART FAILURE

• Etiology -lung disease parenchymal
  / vascular congenital ASD / Ebsteins
  anomaly
• Symptoms -fatigue / syncope /
  ?girth / edema
• Signs -hypotension / parasternal
  lift distended neck veins / HJ reflux
• -right-sided S3 / S4 murmur of
  TR hepatomegaly / ascites / peripheral edema

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HIGH OUTPUT FAILURE Non-cardiac circulatory
overload

• Etiology -fistula / anemia /
  pregnancy / hyperT4
• Pathophysiology -?SV ?preload (VR)
  ?PVR(vasodilate) -?CO at rest ? afterload /
  ?preload -?blood volume due to xs Na/H2O
• Symptoms congestion (?PCWP)
• Signs ?HR / ?SBP/?DBP / wide PP / S3

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CLINICAL EVALUATION- HF

• Risk factors for CAD
• Symptoms -only weakly related to LV
  dysfunction
• Fluid status serum Na / weight / edema
• Functional status NYHA classification

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PRECIPITATING FACTORS

• Diet xs Na / H2O alcohol
• Non-compliance with medications
• Arrhythmia
• Infection
• Anemia
• Stress
• Metabolic thyroid disease / renal failure

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LABORATORY EVALUATION 2-D ECHO / DOPPLER

• Most useful test
• Determines primary abnormality
• Derives Ejection Fraction (EF) -most
  important single measurement -but, poor
  correlation with symptoms
• Distinguishes systolic / diastolic dysfn
• Guide to prognosis (EF and ESV)
• Assesses disease progression (remodels)

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PATHOPHYSIOLOGY

• Ventricular injury / myocyte loss a. Chronic
  CAD / HTN / valvular disease b. Acute AMI /
  myocarditis / MR / AR
• Compensation a. Ventricular
  remodeling -initially adaptive and
  benficial -eventually maladaptive and
  harmful b. Peripheral remodeling
• Decompensation

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PATHOPHYSIOLOGY THEORIES

• OLD hemodynamic disorder -? ejection
  (EF) ?sx (fatigue / dyspnea) -Rx
  ?contractility inotropes unload
  periphery dilators / diuretics
• CURRENT uncontrolled LV remodeling -chamber
  dilates (spherical) hypertrophy -mechanism
  ?neurohormonal system -Rx counteract RAAS /
  SNS
• FUTURE genetic abn / xs cytokines

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PATHOPHYSIOLOGY EVENTS

• Primary response SNS activation
  (?/NE) -initiates vicious circle ?afterload
• Secondary response hormone constriction -?RAAS
  ?periph perfusion (Na retained) -?Vasopressin
  non-osmotic release
• Vascular endothelial dysfunction (?NO)
• Result of neurohormonal compensation -adaptive
  / beneficial maintains perfusion -long
  term maladaptive / deleterious

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COMPENSATORY MECHANISMSCOUNTERACTS ?SV and ?CO

• Starling effect ?preload -limited role
• ?muscle (LVH) vs myocyte loss -key
• ?neurohumoral action?contractility-bad -SNS
  ?EPI / NE (?HR / PVR) -RAAS Na/H2O
  retention?K/Mg?GFR -endothelin /
  vasopressin / prostacyclin
• Brain natriuretic peptide (BNP) -diagn
  ostic / prognostic
• Dilatation / remodeling

29
VENTRICULAR REMODELING

• Definition -altered chamber
  geometry -disproportionate
  ?cavity to wall thickness
• Pathophysiology -altered
  extracellular matrix? myoc fibrosis -up-regulates
  pro-inflam cytokines
  -myocyte hypertrophy/apoptosis
  -inotropy
  -imbalance between production of O- / NO
  -rearranges myocardial fibers
  alters length/width ratio

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NEUROHORMONAL RESPONSES TO CHF
31
SYSTOLIC DYSFUNCTION
DIASTOLIC DYSFUNCTION
NORMAL
LV Press.
Left Ventricular volume
LV PRESSURE-VOLUME LOOPS SYSTOLIC
DYSFUNCTION ?Contractility ejection
impaired DIASTOLIC DYSFUNCTION ?Chamber
stiffness filling impaired
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FRANK-STARLING LV FUNCTION CURVES
Normal LV
Review cardiac physiology to understand these
curves
Stroke Volume
Low CO
LV Failure
Congestion
10
15
20
LVEDP
THE RELATIONSHIP BETWEEN SV and LVEDP
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MYOCARDIAL DYSFUNCTION / FAILURE
ENDOTHELIAL DYSFUNCTION
SYSTOLIC DYSFUNCTION
DIASTOLIC DYSFUNCTION
?CO RESERVE
?ARTERIAL BLOOD VOL
?NO
?ENDO- THELIN
?LVEDP
?RAA
?VASO- PRESSIN
?SNS (NE)
?Periph cap press
?PCP
FATIGUE/ RENAL DYSFN
Periph constrict
Renal constrict
?ALDO- STERONE
?PVR
?ANF
CONGESTION
Na/H2O retention
?Vascular stiffness
Peripheral
Pulmonary
?PLASMA VOLUME
?LA cavity
EDEMA
DYSPNEA
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Epidemiology of Heart Failure

• Approximately 5 million patients in the USA have
  HF, with a yearly incidence of close to 500,000.
  
• It is primarily a disease of the elderly, with
  6-10 patients over 65 years old being diagnosed
  with HF.
• 80 of hospitalized patients with HF are gt 65yo.
  
• Heart failure is the most common Medicare DRG.

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Epidemiology of Heart Failure

• one-year mortality of approximately 45
  percent. 2
• Survival ranges from 80 at 2 years for patients
  rendered free of congestion to less than 50 at 6
  months for patients with refractory symptoms. 3

2 Jessup M, Brozena S, Medical Progress Heart
Failure, NEJM, 348(20) 2007-18, 2003. 3 Nohria
A, et al, Medical Management of Advanced Heart
Failure, JAMA, 287(5) 628-40, 2002.
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Epidemiology of Heart Failure

• Heart failure admission rates are rising, and
  the prognosis of heart failure has been compared
  with that of malignancy, with a 6-year mortality
  rate of 84 in men and 77 in women. 4
• Heart failure kills people much more surely than
  most cancers!
• Coronary artery disease is the cause of two
  thirds of left ventricular systolic dysfunction

4 Mair F, et al, Evaluation of suspected left
ventricular systolic dysfunction, JFP, 51(5)
466-71, 2002.
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Diagnosing Heart FailureSymptoms

• Decreased exercise tolerance
• Fluid retention
• Fatigue
• Incidentally noted left ventricular dysfunction
  in an asymptomatic patient

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Diagnosing Heart FailureClinical Signs

• Elevated jugular venous pressure
• Pulmonary rales
• S3
• S3 volume overload
• S4 pressure overload
• Peripheral edema

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Diagnosing Heart FailureClinical Signs
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Auscultatory Findings

• S3
• S4
• http//www.egeneralmedical.com/listohearmur.html
• Rales
• http//www.wilkes.med.ucla.edu/intro.html

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Common EKG Findings
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CXR findings in Heart Failure
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Diagnosing Heart Failure

• Many different terms
• Left vs right-sided failure
• Backward vs forward failure
• Volume vs pressure overload
• Systolic vs diastolic dysfunction there is a
  lot of overlap as many patients have aspects of
  both entities

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Echocardiography

• A generally accepted definition of depressed
  systolic function is an ejection fraction lt 40,
  from the ACC guideline on the use of
  echocardiography.
• Note that this is not a useful definition in
  diastolic dysfunction as the EF may actually be
  increased in diastolic dysfunction.

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Heart Failure Stages vsNYHA Classes
55
Stages of Heart Failure
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Heart Failure Treatment Options

• Angiotensin Converting Enzyme Inhibitors (ACEIs)
• Beta-blockers
• Diuretics
• Digoxin
• Angiotensin Receptor Blockers (ARBs)
• Other medications

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Site of Action of Medications
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ACEIs
59
ACEIs

• They are the most studied class with years of
  experience and large patient numbers in RCTs.
  Proven benefit to decrease mortality and
  hospitalization for HF.

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ACEIs

• A comparison of enalapril with hydralazine-isosirb
  ide dinitrate in the treatment of chronic
  congestive heart failure.
• 804 men on digoxin and diuretics were randomized
  to receive enalapril or hydralazine and
  isosorbide dinitrate. The enalapril arm
  demonstrated an 18 mortality rate at 2 years
  compared with 25 for the hydralazine and
  isosorbide dinitrate arm.
• Cohn JN, NEJM, 325(5) 303-10, 1991

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ACEIs what dose?

• ATLAS Patients with NYHA class II to IV with and
  EFlt or 30 were assigned to either low dose
  (2.5 5.0mg) or high dose (32.5 35mg) of
  lisinopril for up to five years. Patients on the
  higher dose had a nonsignificant decrease in
  mortality of 8 with a significant 12 decrease
  in death or hospitalization for any reason, as
  well as 24 fewer hospitalizations for heart
  failure.
• Packer M, Circulation, 100(23) 2312-8, 1999

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ACEIs what dose?

• Outcome of patients with congestive heart failure
  treated with standard versus high doses of
  enalapril a multicenter study.
• There were no differences in mortality or
  hospitalizations between patients treated with up
  to 20 mg or those treated with up to 60 mg of
  enalapril.
• Nanas J, JACC, 36 2090-5, 2000.

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ACEIs

• HOPE Trial The use of ramipril in patients with
  multiple cardiac risk factors without known CHF
  or left ventricular dysfunction reduces the risk
  of death from any cause, MI, stroke, and heart
  failure.
• HOPE investigators, NEJM, 342(3) 145-153, 2000
• Consider in patients with Stage A Heart Failure

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Beta-blockers
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Beta-blockers

• Beta-1 selective metoprolol and bisoprolol
• Alpha-1 and beta-nonselective carvedilol.
• Beta-blockers reduce the risk of death and the
  hospitalization. All three have shown benefit.

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Beta-blockers

• US Carvedilol Heart Failure Study Group
  Carvedilol was added to background therapy of
  ACEI, diuretics, and digoxin. Patients receiving
  carvedilol experienced a 65 decrease in
  mortality, a 27 decrease in hospitalizations,
  and a 38 decrease in the combination of the two.
• Packer M, NEJM, 334(21) 1349-55, 1996.

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Beta-blockers

• CIBIS-II Bisoprolol was added to standard
  therapy (diuretics and ACEIs) in patients with
  NYHA III or IV with EF lt 35. Study was stopped
  early because of the benefit. The hazard ratio
  of death was 0.56 vs placebo.
• Anon., Lancet, 353(9146) 9-13, 1999.

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Beta-blockers

• MERIT-HF Patients had NYHA class II to IV, an
  EFlt40, and were stabilized with optimum medical
  therapy. Patients were randomized to receive the
  beta-1 blocker metoprolol CR/XL. Patients in
  therapy experienced a 19 decrease in mortality
  or all-cause hospitalizations and a 31 decrease
  in HF hospitalizations.
• Hjalmarson A, JAMA, 283(10) 1295-1302, 2000.

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Beta-blockers

• CAPRICORN Effect of carvedilol on outcome after
  myocardial infarction in patients with
  left-ventricular dysfunction the CAPRICORN
  randomized trial.
• 1959 patients post MI with EFlt40 were randomized
  to carvedilol or placebo. All-cause (ARR 3) and
  cardiovascular mortality, as well as non-fatal MI
  were reduced in patients on carvedilol.
• Dargie H, Lancet, 357(9266) 1385-90, 2001.

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Beta-blockers

• COPERNICUS Effect of carvedilol on the morbidity
  of patients with severe chronic heart failure
  results of the carvedilol prospective randomized
  cumulative survival study.
• 2289 patients with severe heart failure (EFlt25)
  were randomized to receive carvedilol or placebo
  for an average of ten months. Mortality from
  cardiovascular causes and heart failure mortality
  or hospitalization were both decreased by 27 and
  31 respectively. In euvolemic patients with
  symptoms at rest or on minimal exertion, the
  addition of carvedilol to conventional therapy
  ameliorates the severity of heart failure and
  reduces the risk of clinical deterioration,
  hospitalization, and other serious adverse
  clinical events.
• Packer M, Circulation, 106(17)2194-9, 2002.

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Beta-blockers

• COMET Comparison of carvedilol and metoprolol on
  clinical outcomes in patients with chronic heart
  failure in the Carvedilol Or Metoprolol European
  Trial.
• 1511 patients on standard HF therapy with EFlt35
  were randomized to receive carvedilol or
  metoprolol. After 5 years, all cause mortality
  was 34 with carvedilol and 40 with metoprolol.
  The composite endpoint of all-cause mortality and
  hospitalization was the same in both groups.
• Poole-Wilson P, Lancet, 362(9377)7-13, 2003

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Diuretics
73
Diuretics

• No dedicated RCTs to evaluate the use of loop
  diuretics. (Perhaps unethical now that their use
  is standard of care)
• Diuretics are added when patients experience
  symptoms or signs of volume overload.

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Diuretics

• Furosemide (Lasix) usually the first line,
  although HCTZ could be used.
• Only loop diuretics are effective when the CrCl
  drops below 30cc/min.

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Diuretics and the neurohormonal basis of heart
failure

• RALES Trial Spironolactone was added to therapy
  in patients with severe heart failure and an
  EFlt35 being treated with ACEIs, diuretics, and
  (in most cases) digoxin. The study was stopped
  early after demonstrating an absolute decrease in
  mortality of 11 (RR 0.70) and an relative
  decrease in hospitalization of 35 (RR 0.65).
  10 of males had gynecomastia or mastalgia.
  Minimal hyperkalemia was reported.
• Pitt B, NEJM, 341(10) 709-17, 1999.

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Diuretics and the neurohormonal basis of heart
failure

• Ephesus trial - The use of eplerenone in patients
  post-MI who had an EFlt40 and clinical signs of
  heart failure showed benefit. Patients on the
  medication experienced and absolute risk
  reduction in mortality of 2.3 (RRR 14).
• Pitt B, et al. Eplerenone, a selective
  aldosterone blocker, in patients with left
  ventricular dysfunction after myocardial
  infarction. N Engl J Med, 3481309-21, 2003.

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Digoxin
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Digoxin

• RADIANCE Study Patients on a stable regimen of
  digoxin, ACEI, and diuretic were randomized to
  removal of digoxin or maintenance of therapy.
  Those patients off digoxin experienced a
  significant increase in worsening heart failure
  and decreased measures of functional capacity.
• Packer M, NEJM, 329(1) 1-7, 1993.

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Digoxin

• Digitalis Intervention Group Patients on ACEI
  and diuretics were randomized to receive digoxin
  or placebo. Overall mortality was similar in
  both groups. However, digoxin did decrease the
  risk of worsening heart failure and
  hospitalization.
• Rekha G, NEJM, 336(8) 525-33, 1997.

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ARBs
81
Angiotensin Receptor Blockers (ARBs)

• The ARBs studies have shown that they have
  efficacy close to that of ACEIs.
• ARBs are frequently used in patients who cannot
  tolerate ACEIs (cough, h/o angioedema).
• They are expensive.

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ARBs

• ELITE Evaluation of losartan in the elderly.
  722 patients older than 65 with EFlt40 and ACEI
  naïve were randomized to losartan or captopril,
  in addition to standard therapies (ACEIs,
  diuretics, digoxin, nitrates and hydralazine).
  Patients on losartan has less side effects, a
  nonsignificant decrease in death and/or hospital
  admission for heart failure, and a significant
  decrease in all-cause mortality (risk reduction
  46). Admissions for heart failure were the same
  in both groups.
• Pitt B, Lancet, 349(9054) 747-52, 1997

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ARBs

• ELITE-II Effect of losartan compared with
  captoril on mortality in patients with
  symptomatic heart failure a randomized trial
  the Losartan Heart Failure Survival Study. 3152
  patients 60 years or older with NYHA class II to
  IV heart failure and EFlt40 were randomized to
  losartan or captopril. The mortality and rates
  of sudden death or resuscitated arrests were the
  same in both groups.
• Pitt B, Lancet, 355(9215) 1582-7, 2000

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ARBs

• LIFE trial Hypertensive patients were treated
  with either losartan or atenolol. Patients were
  followed for at least four years. 508 patients
  on losartan experienced the composite endpoint of
  death, MI, or stroke, compared with 588 patients
  on atenolol (RR 0.87).
• Dahlof B, Lancet, 359(9311) 995-1003, 2002.

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ARBs

• Val-HeFT A randomized trial of the
  angiotensin-receptor blocker valsartan in chronic
  heart failure. 5010 patients with NYHA class II
  to IV HF were randomized to receive valsartan or
  placebo in addition to standard therapy. Overall
  mortality was the same. Hospitalizations were
  4.4 less. Treatment with valsartan improved
  NYHA class, EF, signs and symptoms of HF, and
  quality of life. Post hoc analysis showed the
  valsartan had a favorable outlook in patients
  receiving ACEI or beta-blockade but an adverse
  effect in patients receiving both.
• Cohn J, et al, NEJM, 345(23) 1667-75, 2001

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ARBs

• CHARM-Alternative Trial (Candesartan substituted
  for ACEI in ACEI intolerant patients).
• 2028 patients with symptomatic heart failure and
  EFlt40 were randomized to candesartan or placebo,
  in addition to standard therapy. After 3 years,
  cardiovascular mortality and hospital admissions
  for CHF were both less (3 and 8 absolute risk
  reduction).

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ARBs

• CHARM-Added Trial
• In this trial, 2548 patients taking ACEIs with a
  decreased EFlt40 were randomized to receive
  candesartan or placebo in addition to the ACEI.
• Cardiovascular and noncardiovascular mortality
  were reduced significantly in the candesartan
  group (ARR 4, RRR 10), as were
  hospitalizations.

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ARBs

• CHARM-Preserved Trial Candasartan in Heart
  failure Assessment of Reduction in Mortality and
  morbidity study. (A trio of trials.)
• In this trial, 3023 patients with a preserved
  EFgt40 were randomized to receive candesartan or
  placebo. Cardiovascular and noncardiovascular
  mortality were the same in both groups, while
  hospitalizations were modestly decreased.
• Yusuf S, Lancet, 362 777-81, 2003.

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ARBs

• VALIANT trial valsartan is as effective as
  captopril post-MI in patients with decreased EF.
• Pfeffer MA et al, NEJM, 349 1893-906, 2003
• RESOLVD trial candesartan with enalapril and ER
  metoprolol demonstrated the most improvement in
  EF from baseline. No clinical outcomes.
• McKelvie RS et al, Eur Heart J, 24 1727-34, 2003

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Now, lets have some shocking news
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Yes, were talking about ICDs

• Implantable cardioverter-defibrillator

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SCD-HeFT trialSudden Cardiac Death in Heart
Failure Trial Investigators

• 2521 pts with NYHA class II or III were
  randomized to placebo, amiodarone, or ICD.
• Pts were already receiving standard medical
  therapy
• Deaths
• Placebo group 244 (29)
• Amiodarone 240 (28)
• ICD 182 (22)

Bardy, G, et al, SCD-HeFT, NEJM, January 20,
2005 352 3, pp 225-237
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SCD-HeFT trialSudden Cardiac Death in Heart
Failure Trial Investigators

• The ICD group had a 23 relative risk reduction,
  or an absolute risk reduction of 7.2.
• NNT for benefit ?
• So, who should get an ICD?

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Current Indications for ICD

• Patients at high risk for ventricular arrhythmias
• Patients with EF lt 35 and NYHA class II or III
  heart failure
• Patients with a history of MI and EF lt 30

Goldberger, Z, Implantable Cardioverter-Defibrilla
tors, JAMA, February 15, 2006 2957, pp 809 -
818
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Summary Points

• Heart failure has a prognosis similar to that of
  cancer. As such, treat it aggressively.
• There is a new staging system to classify heart
  failure
• Stage A at risk but no structural heart disease
  (HD)
• Stage B no symptoms but structural HD present
• Stage C patient with symptomatic HF
• Stage D refractory heart failure

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Summary Points

• Standard medication classes for HF include
• ACEIs
• Beta blockers
• Diuretics if volume overloaded
• Consider digoxin, spironolactone
• Consider ARBs, especially in ACEI intolerant
  patient
• Beta-blockers continue to look good for HF

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Summary Points

• Preserved EF is about as common as depressed EF
  in heart failure.
• Many patients have diastolic dysfunction.
• Remember to also care for the patient as a
  person, not just a disease.
• A gentle touch and a kind smile might feel better
  than a lasix-induced diuresis ?

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Thank you for your time
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The End
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Additional material
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BNP

• The Breathing Not Properly study
• Maisel A, et al, Rapid Measurement of B-Type
  Natriuretic Peptide in the Emergency Diagnosis of
  Heart Failure, NEJM, 347(3) 161-7, 2002.
• A number gt 100 is suggestive of heart failure.
• Some thought to using this prospectively to
  screen for heart failure, stage B. No RCTs to
  date.

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ACEIs

• CONSENSUS Enalapril added to vasodilator
  therapy decreased mortality by 27 in patients
  with severe (NYHA IV) heart failure.
• Anon., NEJM, 316(23) 1429-35, 1987.

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ACEIs

• SAVE Trial Effect of captopril on mortality and
  morbidity in patients with left ventricular
  dysfunction after myocardial infaction. Results
  of the Survival And Ventricular Enlargement
  trial.
• 2231 patients with an EFlt40 who survived an MI
  were randomized to receive captopril and followed
  for 42 months. Risks for mortality (5 absolute
  risk reduction), fatal and nonfatal major
  cardiovascular events, development of severe
  heart failure, and recurrent MI were all reduced.
• Pfeffer MA, NEJM, 327(10) 669-77, 1992

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ACEIs

• SOLVD Trial Enalapril therapy in patients with
  an EFlt 35 not being treated for CHF demonstrated
  a statistically significant decrease in the
  combined endpoint of development of clinical CHF
  and death. Of note, when studying the end point
  of mortality, there was no statistical difference
  between enalapril and placebo.
• Anon., NEJM, 327(10) 685-91, 1992.

109
Beta-blockers

• Differential effects of beta-blockers in patients
  with heart failure A prospective, randomized
  double-blind comparison of the long-term effects
  of metoprolol versus carvedilol.
• 150 patients with EF lt35 were randomized to
  metoprolol or carvedilol. After 2 years,
  patients in the carvedilol showed a 3.7 increase
  in EF, greater stroke volume and decreased PCWP
  compared with metoprolol. Conversely, metoprolol
  showed a greater increase in exercise capacity.
  Mortality was similar (small study).
• Metra M, Circulation, 102(5) 546-51, 2000.

110
Trends in Prevalence and Outcome of Heart Failure
with Preserved Ejection Fraction

• 4596 patients admitted to Mayo Clinic Hospitals
  from 1987 to 2001.
• 53 had reduced ejection fraction
• 47 had preserved ejection fraction
• Survival was slightly better among those with
  preserved EF adjusted hazard ration for death
  0.96, p 0.01.

Owan, TE, et al, Trends in Prevalence and Outcome
of Heart Failure with Preserved Ejection
Fraction, NEJM, 3553, July 20, 2006, pp 251-259
111
Take home points

• Starting with an ACEI is still standard of care.
• However, future studies with FDA approved drugs
  for heart failure in the USA may confirm that
  beta-blockers are equally efficacious
  (noninferior) to ACEIs for the initial treatment
  of HF.

112
Outcome of Heart Failure with Preserved Ejection
Fraction in a Population-Based Study

• 2802 patients admitted to 103 Canadian hospitals
  from April 1999 to March 2001 with a discharge
  diagnosis of heart failure.
• 31 had ejection fraction (EF) gt 50
• More likely to be older, female, history of HTN,
  history of atrial fibrillation

Bhatia, RS, et al, Outcome of Heart Failure with
Preserved Ejection Fraction in a
Population-Based Study, NEJM, 3553, July 20,
2006, pg 260-269
113
Outcome of Heart Failure with Preserved Ejection
Fraction in a Population-Based Study

• Mortality rate of preserved EF (gt50) vs reduced
  EF (lt40) at 30 days
• 5 vs 7 respectively
• At one year, the rates were 22 vs 26, p0.07,
  not significantly different.
• Patients with preserved EF have similar rates for
  mortality and readmission for heart failure

Bhatia, RS, et al, Outcome of Heart Failure with
Preserved Ejection Fraction in a
Population-Based Study, NEJM, 3553, July 20,
2006, pg 260-269
114
Systolic blood pressure on admission and patient
outcomes

• 41,267 patients admitted for heart failure to 259
  hospitals between March 2003 December 2004.
• Good numbers!
• 21,149 (51) had preserved systolic function
• Meaning, half the patients had diastolic
  dysfunction

Gheorghiade, M, et al, Systolic Blood Pressure at
Admission, Clinical Characteristics, and
Outcomes in Patients Hospitalized With Acute
Heart Failure, JAMA, Nov. 8, 2006, Vol. 296, No.
18, pp 2217-26
115
Straw pollSys 120 outcome?vs Sys 150
outcome?Who does better?
116
Systolic blood pressure on admission and patient
outcomes
7.2
Percent mortality at discharge
3.6
2.5
1.7
Systolic blood pressure at admission in mmHg
117

• Interesting outcomes
• Lower systolic at admission directly correlated
  with increased mortality
• Concept of the J curve in treatment of
  hypertension
• So, what systolic blood pressure do we shoot for
  in patients with stable heart failure in the
  clinic?
• Still use national guidelines but stay tuned

118
Systolic and Diastolic Heart Failure in the
Community

• Inpatients and outpatients diagnosed with heart
  failure underwent echocardiographic testing
  between September 10, 2003 and October 27, 2005.
• 556 study participants
• Preserved EF gt 50 present in 308 (55) of
  patients
• Associated with older age, female sex, no h/o MI
• Isolated diastolic dysfunction present in 242 of
  patients of these patients 44 of total number
  (556) and 78 of patients with preserved EF
• EF lt 50 in 248 patients (45)
• Diastolic dysfunction present in 204 (83) of
  these patients

Bursi, F, Systolic and Diastolic Heart Failure in
the Community, JAMA, Nov. 8, 2006, 29618, pp
2209-2216
119
Systolic and Diastolic Heart Failure in the
Community

• Needhams take on this data
• A little more than half (55) of patients had
  preserved EF at the time of diagnosis of heart
  failure.
• Almost 80 of all patients with heart failure
  have diastolic dysfunction, whether they have
  depressed or preserved EF.
• Many patients will have a mix of systolic
  dysfunction (depressed EF) and diastolic
  dysfunction.

Bursi, F, Systolic and Diastolic Heart Failure in
the Community, JAMA, Nov. 8, 2006, 29618, pp
2209-2216
120
Patient Presentation

• Mr. Smith is a 67 yo male with a history of
  hypertension and diabetes who now presents to
  your clinic with mild dyspnea at the end of his 1
  mile walk. No chest pain. He has occasional
  pedal edema.
• VS stable
• Lungs CTA, normal work of breathing
• CV RRR, nl S1 S2, no MRG heard
• Extremities - 1-2 pitting edema.
• Where do you go from here?