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N I C H O L A S ( N I C K ) A B B O T T , M D G E N E R A L C A R D I O L O G Y F E L L O W
N A B B O T T @ U C I . E D U
Intro to Heart Failure
Most references are from here
Helpful site for interns!!! • Go here!
• Look like a rock star!
• Well sir/mam you know the xxx guidelines say ***
• Individualization of care still possible and desirable!
General Overview
Methodology (quickly) Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Comorbidities… if I don’t go too slow
Methodology
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Epidemiology (quickly) Initial evaluation Treatment Fun things… if I get the time to show
Definition of HF
“Complex clinical syndrome that results from any structural or functional impairment of ventricular
filling or ejection of blood” Cardinal Manifestations Dyspnea Fatigue limiting exercise Fluid retention – pulmonary, splanchnic, peripheral
Ok but is there anything I can definitively order?
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun things… If I get the time to show
HFrEF: Systolic HF
HFpEF: Diastolic HF
HFpEF: Borderline
HFpEF: Improved
Heart Failure
Basic Ejection Fraction (EF) calculation
End Diastolic Vol – End Systolic Vol ------------------------------------------- x 100 End Diastolic Vol
But wait… what does that mean…
Types of systolic heart failure
Left sided heart failure Clinical syndrome in which the dominant feature is fluid congestion (primarily lung)
Right Sided heart failure Clinical syndrome of tissue congestion: JVP, peripheral edema, ascites, organ engorgement
Remember
Diastolic HF can happen w/o systolic HF
Systolic HF cannot happen w/o diastolic
ICM vs. NICM
Ischemic Cardiomyopathy (ICM)
Clinically apparent that the ischemic coronary disease is responsible for failure
Non-Ischemic cardiomyopathy (NICM) (systolic OR diastolic)
EVERYTHING ELSE: Valvular Heart Disease: Severe AS, MR Toxin mediated: Meth, EtOH, Cancer therapeutics Tachycardia-mediated: AF, AT, AFL… Inflammation: Myocarditis, HIV, Chagas Infiltrative: Iron, Amyloid, Sarcoid Other rare diseses
HFpEF
Clinical signs of heart failure Evidence of preserved/normal ejection fraction EF Evidence of ABNORMAL LV diastolic function 1. Echocardiography 2. Left heart catheterization Diagnosis largely of EXCLUSION 1. Not all that is edema is the heart 2. Look at kidneys… (Urine Pro/Cr) 3. Look at the liver… (US abdomen, LFT/Synthetic) 4. Lymphedema can masquerade
That’s fine and all but WHAT IS HFpEF!
US probe here
Diastole… since evaluating diastolic dysfunction…
Normal
E:A > 1
Abbey something… Abbeynormal..
E:A < 1
If you prefer to think in hemodynamics
LVEDP
SV
Functional Classifications
NYHA – New York Heart Association - Most widely studied evaluation of function - Somewhat limited as has a subjective component AHA/ACC - New classification for at risk of heart failure - Acknowledges you can have SHD w/o symptoms
NYHA – New York Heart Association
I No symptoms No limitation in ordinary physical activities
II Mild shortness of breath &/or angina Slight limitation during normal activity
III Marked Limitation in activity Happens in even less than ordinary activity (20-100m)
Comfortable only at rest
IV Severe Limitation Experiences symptoms even while at rest
Inotropes, VADs, Pre-transplant, Palliative?
ACA/AHA Functional Classification
A At risk for developing heart failure
HTN DM II
Inherited Cardiomyopathy Valvular heart disease
B Asymptomatic heart failure (has SHD w/o symptoms)
Previous MI Asymptomatic VHD
(EF can be < 40 w/o symptoms)
C Symptomatic Heart Failure (SHD with ≥ 1 symptom)
Any heart failure presentation
D Refractory End Stage HF Inotropes VAD
Transplant Palliative/Hospice
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show
Compensatory Mechanisms to Low CO
Activation of the RAAS
Don’t Panic…
Remember. You live HERE
It’ll be Ok… I promise
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun things… if I get the chance to show
Historical Findings
Weight Gain Rapid weight gain suggests volume overload
Guideline therapy? Intolerance, adverse event, lapse, or patient compliance
Exacerbating meds NSAIDS, steroid, TZD, CCBS (negative inotrope)
Diet Na restriction diet, Fast food, recent “cheats”
Early satiety GI symptoms common as splanchnic engorgement and can be the primary presentation
Classics Palpitations, syncope (?VT/SVT), chest pain
Common Precipitators of HF
Physical Findings
Hepato-jugular Reflex (HJR)
One of the most specific findings for congestion
Manual pulse palpation
Throw caution to the wind and… touch the patient
Extra heart sounds • S3 = fluid overload • S4 = stiff ventricle
PMI • Displaced or enlarged portends enlargement • Right ventricular heave portends RV/PA pathos
Peripheral edema • Young patients have less • Older patients can be peripheral causes and not cardiac
Limb temperature Cool lower extremities imply poor cardiac output
How good is the H&P Variable Sensitivity Specificity Accuracy Hx of HF 62 94 80
Dyspnea 56 53 54
Orthopnea 47 88 72
Rales 56 80 70
S3 20 99 66
JVD 39 94 72
Edema 67 68 68
Wang CS, et al, JAMA 2005; 294:1944-1956
Past Hx HF : most sens/spec PND : most specific DOE : most sensitive S3 gallop : most specific not very sensitive JVD : best combination sens/spec Rales : mod spec/sens
Presenter
Presentation Notes
So how reliable are signs and symptoms?
Biomarker Testing
Not all that is BNP is the heart you see
Non-invasive imaging testing
Invasive Evaluation / Monitoring
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show
Stage A
Treat the underlying disease
Diet and lifestyle
Monitor for progression
Stage B
Stage C
But Why ACE-I?
NYHA Class IV Double Blind Placebo controlled Prospective
Multinational Study
Mortality Benefit!
Great Symptom Improvement
What about ARBs?
Val-HeFT – Subgroup Analysis International Double Blind Prospective Trial
Primary Endpoints • All cause mortality
• Composite all cause mortality and morbidity
Survival Benefits
Endpoints
Beta Blockers?
Multi-center, prospective, double-blind NYHA III-IV LVEF ≤ 25%
Once again… mortality benefit…
Coreg… made of some of the best stuff on earth
Now you’re getting greedy…
Double blind, prospective, randomized LVEF < 35%, NYHA II-IV
What!!! More mortality benefit…
But statins you say?
Patients hospitalized for NSTEMI/STEMI Placed on either Atorvastatin 80 or Pravastatin 40 mg Primary Endpoint – Time until 1st HF hospitalization
N = 4,162
Not mortality but I’d take it
Almost everything improved
So what if I were to compare these…
But when can I add ACE/ARB or MRA?
ACE/ARB
Creatinine ≤ 3 Potassium ≤ 5.5 SBP ≥ 80 mmHg
Minearlocorticoid Antagonist
Creatinine ≤ 2.5 Potassium ≤ 5.0 SBP ≥ 80 mmHg
When are the patients able to go home?
Near optimal volume status achieved or euvolemia No heart failure complaints -declines PND -walk to RN station w/o DOE Near optimal medical therapy achieved /started Transition from IV to oral and appropriate diuresis
for 24 hours in hospital – not squeeze and go HF follow up in 7 days Received bedside education Has a 30, any yes at least 30, day supply of meds
Discharge Criteria-per MOA
1. Resolution of clinical signs of volume overload 2. Decrease of at least one NYHA Classification for heart failure (order changed) 3. Discharge BNP with a minimum reduction of 30% and an optimally reduction of 50%, less than admit BNP 4. Sodium >130 5. No creatinine rise (>0.5 from baseline or for elderly >0.3 from baseline) 6. Comorbid condition controlled & treated, and pain 7. Patient verbalizes understanding of discharge instructions and follow up care with physician/health care providers
In Summary
HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular
filling or ejection of blood
Guideline Directed Medical Therapy Saves Lives
Patients need to be near euvolemic at time of discharge
We have a lot of amazing tings in the pipeline
General Overview
Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show
ARNI Angiotensin Receptor and Neprolysin Inhibitor
Double Blind, Prospective, Randomized, 1:1 LVEF <40%, NYHA II-IV
Enalapril vs Valsartan + LCZ696
Superiority Achieved!
If your funny you’ll like this one…
Double blind, placebo-controlled, parallel-group LVEF ≤ 35%
IN SINUS RHYTHM Sinus Rate > 70 BPM
Mild decrease in the pulse…
Even this deceased the readmissions!
Trending to significance
VAD
HVAD
SC-ICD
CRT-D
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