Heart Failure Management The Evidence

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Heart Failure ManagementThe Evidence

• Dr. A. Al-Mohammad, MD, FRCP(E), FRCP(L),
• Consultant Cardiologist and Honorary Senior
  Clinical Lecturer,
• South Yorkshire Cardiothoracic Centre,
• Sheffield Teaching Hospitals NHS Foundation
  Trust,
• Sheffield,
• 13th of January 2009

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What is Heart Failure?

• The inability of the heart to deliver blood (and
  O2) at a rate commensurate with the requirements
  of the metabolising tissues, despite normal or
  increased cardiac filling pressures.
• There are several types of heart failure (well
  beyond an ejection fraction of lt40).

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The size of the problem

• The incidence of HF in the UK is 63,000 cases PA.
• The prevalence of HF in the UK is 878,000 cases.
• HF is associated with the worst quality of life.
• Mortality rates are
• 50-70 in 24/12 with acute HF,
• 80 of HF pts are dead in 5 years,
• The best after the initial 2 years is the
  attrition rate of 15-30 PA.

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What is the difference between the pts with acute
decompensated CHF and pts with AHF?

• ADCHF
• Generally lt70 yrs
• Male dominance
• LVEF lt 40

• AHF
• Mean age 71-76 yr
• 50 females
• 50 have LVEFgt40

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Therapeutic options in HF

• Pharmacological
• Electrical
• Surgical
• Prevention
• Treatment

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Diuretics

• BFZ
• Loop diuretics (furosemide, bumetanide)
• Metolazone
• Combinations
• Outcome
• Tailoring diuretic therapy
• Prevention of HF HYVET study 2008

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Treatment of Hypertension in Patients 80 Years of
Age or Older (HYVET study, NEJM
20083581887-1898)

• ? fears of increased risk of death in treating
  elderly hypertensive patient.
• 3845 patients (80 years of age or older) with
  sustained SBP of 160 mm Hg or more.
• Indapamide (SR 1.5 mg)/placebo /- perindopril (2
  or 4 mg)/Placebo.
• Target 150/80 mm Hg.
• 11.8 had a history of CV Disease.
• FU 1.8 years.
• 30 reduction in the rate of fatal or nonfatal
  stroke (95 CI, 1 to 51 P0.06),
• 39 reduction in the rate of death from stroke
  (95 CI, 1 to 62 P0.05),
• 21 reduction in the rate of death from any cause
  (95 CI, 4 to 35 P0.02),
• 23 reduction in the rate of death from cv causes
  (95 CI, 1 to 40 P0.06),
• 64 reduction in the rate of heart failure (95
  CI, 42 to 78 Plt0.001).

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Increase Dose Or Frequency Of diuretics
i.v. Bolus or infusion Of diuretics
Restrict Sodium And Fluids
Replace Fluids If Hypo-volaemic
Options to manage resistance to diuretics
Combine diuretics
Spironolactone
Diuretics and inotropes
Reduce the dose of ACEI / ARB
Consider haemo-filtration
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ACEI

• 31 reduction in mortality in severe CHF
  (CONSENSUS, Enalapril, 1987)
• 19 reduction in mortality 21 reduction in
  mortality and MACE in asymptomatic LVSD post-MI
  (SAVE, Captopril, 1992)
• 27 reduction in all cause mortality in clinical
  HF after AMI (AIRE, Ramipril, 1993)
• Chronic asymptomatic LVSD pts stand to benefit
  from ACEI (SOLVD-P, Enalapril, 1991 and XSOLVD,
  2002) 34 vs. 39 mortality at 12 years FU.

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ARB in LVSD

• VAL-HEFT 5010 pts RCT, Valsartan
• NYHA class II-IV, LVEF lt40
• Improved HF QOL
• Reduced mortality and morbidity,
• Reduced hospitalisations,
• CHARM-Added candesartan.
• 2548 pts NYHA II-IV, LVEF lt 40.
• Significant reduction of morbidity and mortality.

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ARB in HF with Preserved LV

• Irbesartan in Patients with Heart Failure and
  Preserved Ejection Fraction (I-PRESERVE)
• NEJM Dec 20083592456-2467
• 50 of the HF patients have LVEFgt45, and no
  treatment exists for them
• 4128 ptsgt60 yrs, NYHA II-IV, LVEFgt45.
• Irbesartan did not improve the outcome in these
  patients

• Effects of Candesartan in patients with chronic
  heart failure and preserved left-ventricular
  ejection fraction (The CHARM-Preserved trial)
• LANCET Sep 2003362777-781
• 3023 pts, NYHA II-IV, LVEFgt40.
• No effect on mortality as a single or combined
  end-point
• Reduced admissions with HF.

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ß receptor blockers

• MERIT-HF, RCT 3991 patients, (NYHA II-IV) LVEF
  lt 40. Metoprolol
• Reduced mortality 32, reduced SCD 50.
• CIBIS II Bisoprolol.
• 2647 pts NYHA III-IV, LVEF lt 35.
• Decreased all cause mortality 34
• Decreased SCD gt40.
• COMET.
• ?Carvedilol may have an edge over Metoprolol

• COPERNICUS carvedilol.
• 2289 pts severe CHF.
• LVEF lt 25, NYHA II-IV.
• 35 ? mortality.
• 20 ? hospitalisation.
• CAPRICORN 1959 post MI pts LVEF lt40.
• 23 reduction in mortality .
• 41 reduction non-fatal MI
• SENIORS gt70 years, including preserved LV.
• 14 reduction in the mortality and hospital
  admissions

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Hydralazine and Nitrates

• Arterial and Venous dilatation was the first
  successful attempt to alter the outcomes in HF
  through Hydralazine and a fixed dose nitrate.
• VHEFT I 1986
• NYHA IV. 35 reduction in mortality

• VHEFT II 1991
• Enalapril was better than the combination
• AHEFT 2004
• The addition of the combination to standard best
  treatment for HF improves the outcome in black
  patients.

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Aldosterone Antagonists

• RALES 1663 pts, LVEFlt35.
• Spironolactone.
• 30 reduced death from progressive HF or SCD.
• 35 reduction in hospitalisation.
• Hyperkalaemia 1-2.
• EPHESUS Eplerenone post MILVSD (EFlt40) cli
  HF (or DM).
• Improved survival by 15.
• Reduced SCD by 21
• Reduced HF hospitalisation by 23

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The Cardiac Resynchronization CRT

• Initially designed to reduce the patients
  morbidity, by re-synchronising the left
  ventricular contraction, using multisite pacing.
• The CARE-HF study published in 2005, demonstrated
  that using CRT resulted in reduction of
  mortality, even without adding a defibrillator.

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Mitral valve, LV surgery and CABG

• Options to be considered by the cardiologist in
  certain circumstances
• The evidence exists for MV surgery/LV surgery
• The evidence for CABG precedes the era of
  effective medical therapy for IHD and for HF

• Two trials of CABG surgery have been conducted in
  severe HF due to LVSD caused by IHD.
• STICH and HEART-UK have completed the recruitment
  but not reported yet.

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The issue of up-titration

• ACEI
• ß Blockers
• ARB
• Spironolactone
• Achieving the best results is related to
  attaining the MAXIMUM TOLERATED dose

• The vast majority of the problems facing us in
  uptitration are related to embedded fears of side
  effects.
• Start low and go slow is the catch phrase!
• Monitoring is another keyword!

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What do you need to uptitrate

• ß Blockers
• ECG
• Pulse
• BP
• Lack of adverse symptoms
• Patience
• Perseverence

• ACEI/ARB/AA
• UE
• Rules of FU
• Thresholds of creatinine levels and
• Lack of adverse symptoms
• Patience
• Perseverence

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Thank you for your kind attention