Page 1
Pathophysiologic targets for acute heart failure
therapy: The Cardiorenal Syndrome
Professor and Co-Head, Dept of Cardiology
President-elect ESC-HFA
University Heart Center
Zürich, Switzerland
Frank Ruschitzka, MD, FRCP, FESC
Conflict of interest: Abbott, Aventis, Bayer, Biotronik, Cardiorentis, Merck, Novartis, Pfizer,
SJM, Servier
Interest in Conflict: none
Page 2
Acute
Acute
Acute
Acute
Allen L A et al. Circulation 2012;125:1928-1952
A depiction of the clinical course of heart failure
Chronic
Chronic
Chronic
What Are We Talking About?
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Current Estimate of the Number of
Advanced HF Patients
Miller and Guglin JACC 2013
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Ekman Circ CV Outcomes 2010
Heart Failure is Moving Center Stage in Cardiology
-Twice as many hospitilizations than all Cancers
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Heart Failure is Taking Center Stage
Deutscher Herzbericht 2014, Statistisches Bundesamt
Fatal MI Heart Failure
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Acute Heart Failure: Clinical challenges
AHF ACS
Incidence ~ 1.000.000/y ~ 1.000.000/y
Mortality:
pre-hospital
in-hospital
60-90 days
?
3 – 6%
10%
high
3 – 4%
2 %
Targets of therapy Unclear Clearly defined
Clinical trials results
Guidelines (level of
evidence)
Minimal /no benefit
/harmful
A/B – minimal
mostly C
Beneficial
A/B – mostly
Weintraub Circ 2010
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CardioRenal Syndrome
With patients‘ permission for publication
• 53y., banker
• Ischemic cardiomyopathy
• 3 HF hosp. in the last year
• Lisinopril 10mg 0-0-1
• Carvedilol 12.5mg 1-0-1
• Eplerenone 25mg 0-0-1
• Lasix 40mg 2-2-0
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CardioRenal Syndrome
With patients‘ permission for publication
•NYHA IV, Dyspnea at rest
•170 cm, 76 kg (weight gain 4 kg in last 7 days)
•RR right arm, supine: 92/66mmHg
•Heart rate: 84/min/SR
•Cardiac auscultation:
• gallop
• 3/6 murmur, pm apex (MR)
• HJR pos.
• Pulmo: respiratory rate 18/min, right pleural effusion
• liver 11 cm in MCL
• peripheral edema
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Cardiorenal Syndrome
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Cardiorenal Syndrome
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The New Definition of Cardiorenal Syndrome
Ronco C. et al, EHJ 2010
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Filippatos G et al. Eur Heart J 2013
Classification and Stages of Acute Kidney
Injury
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The Cardiorenal Syndrome
Decreased
cardiac
performance
Increased
water and Na+
retention
Impaired renal
function
Decreased
cardiac output
Neurohormonal
activation
Diminished
blood flow
Decreased renal
perfusion
Page 14
//Ronco et al., JACC 2008
AKI = 1.5-2 x Cr (baseline)
Cardiorenal Syndrome Type 1
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Ronco et al., JACC 2008
Cardiorenal Syndrome Type 1
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What`s next?
1. Lasix iv
2. Levosimendan
3. Dobutamine
4. Milrinone
5. Norepinephrine
6. Nesiritide
7. LVAD
8. ECMO
9. Hemofiltration
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Carubelli Heart Fail Rev 2012
Causes of renal dysfunction in HF
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Approach to Acute Therapy in Volume
Overloaded Heart Failure Patients
IV Diuretics
Adequate Perfusion
IV Diuretics
plus
IV Vasodilators
Reduced Perfusion
IV Diuretics
IV Inotropes
Cardiogenic Shock
Clinical Congestion
MCS
RR<85mmHgRR 85-110 mmHgRR >110mmHg
mod. JJ McMurray EHJ 2012
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The Dilemma of Drug Therapy in Acute Heart Failure:
Patients with Pulmonary Edema/without shock
JJ McMurray EHJ 2012
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Algorithm for the management of AHF
Mebazaa EHJ 2015
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Felker NEJM 2011
JACC 2012
Diuretic Strategies in Patients with Acute
Heart Failure. The Dose Trial
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Blunted Response to Loop Diuretics in Acute Heart Failure
Braunwald EHJ 2014
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Adaptative and maladaptative mechanisms to renal hypoperfusion in heart failure
Ruggenenti and Remuzzi Eur Heart J 2011
Compensated HF Decompensated HF
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Carubelli Heart Fail Rev 2012
Causes of resistance to furosemide
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Ultrafiltration in Decompensated Heart
Failure with Cardiorenal Syndrome: CARRESS-HF
Bart NEJM 2012
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CARRESS Trial: Changes from Baseline
in Serum Creatinine and Body Weight
Bart NEJM 2012
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CARRESS-HF: Serious Adverse Events
Bart NEJM 2012
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The Dilemma of Drug Therapy in Acute Heart Failure
JJ McMurray EHJ 2012
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Cardiorenal Syndrome
•Lasix iv boli
•Levosimendan•0.1 to 0.2 μg/kg/min
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Hasenfuss and Teerlink, EHJ
2011
Inotropic Therapies
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Packer JACC HF 2013
Baseline Characteristics in REVIVE I/II
Hospitalized ADHF but remained dyspneic at rest despite
treatment with intravenous diuretics
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Packer JACC HF 2013
Outcomes in REVIVE I/II
Time to Death for Any Reason
During First 90 DaysHazard Ratio for All-Cause
Mortality
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Packer JACC HF 2013
Worsening Clinical Status Requiring Rescue
Therapy in REVIVE I and REVIVE II
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Mebazaa JAMA 2007
SURVIVE: Survival of Patients With Acute Heart
Failure in Need of Intravenous Inotropic Support
(SURVIVE)
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Mebazaa JAMA 2007
SURVIVE: Primary and Secondary Outcomes
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So etiology may influence response to milrinone (all inotropes?)
JAMA 2002; JACC 2003
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Teerlink, Lancet 2011
Dose-dependent changes in echocardiogram
measures by omecamtiv mecarbil dose
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Metra Eur Heart J 2012
Effects of pharmacological agents on renal
function parameters
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deGoma JACC 2006
Diuretics and Aquaretics
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Rolofylline: Change in Serum Creatinine
Gottlieb Circ 2002
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PROTECT: Rolofylline fails to meet PrimaryEndpoint which included renal function!
Massie NEJM 2010
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PROTECT: Rolofylline fails to meet PrimaryEndpoint which included renal function
Massie NEJM 2010
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deGoma JACC 2006
Diuretics and Aquaretics
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EVEREST: Primary Endpoints
Konstam JAMA 2007
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deGoma JACC 2006
Diuretics and Aquaretics
??
Page 46
mod. Forssmann Cardiovasc Res 2006
Urodilatin
• Synthesized in distal tubular cells
• Binds downstream in IMC duct to NPR-A
• Increases Renal Plasma Flow (via cGMP)
• Increases GFR:
• Dilates Vas afferens
• Constricts Vas efferens
• Relaxes mesangials cells
• Decreases sodium reabsorption in PCT and CD
via cGMP dependent phosphorylation of ENaC
• Inhibits renin, aldosterone, and vasopressin secretion
• NOT degraded by NEP inhibition
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ANP, BNPUrodilatin/ularitide
Neprilysin
degrades NPs
Natriuretic Peptides and Receptors
Second messenger mediated effects of ularitide
↑cGMP
NPRA NPRBNPRC
GCGC
ANP, BNPUrodilatin/ularitide CNP
PDEProtein-
kinase G
cGMP-
gated ion
channels
NPRA-triggered effects
renin and
aldosterone
inhibiting
vasodilating
Anti-fibrotic
Anti-
hypertrophic
lusitropic
Anti-
apoptotic
Vascular
regeneration
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Ularitide in the Kidney
Physiological and pharmacological effects
Physiology
Pharmacology
1
2
1
Synthesis of Urodilatin
as response to ↑Na+
2 Inhibition of sodium and
water reabsorption,
↑ diuresis and ↑ natriuresis
Meyer M, et al., Am J Physiol, 1996; 271(40);F489-497
Lenz W, et al., Kidney Int, 1999; 55:91-99.
1 2
3
4
1
2
3
Pre-glomerular vasodilation
Post-glomerular vasoconstriction
Endlich K, et al., Kidney Int, 1995 Jun;47(6):1558-68
↑ GFRCarstens J, et al., Clin Sci, 1997, 92(4):397-407
4
5
Less susceptible to NEP degradation
Kenny AJ et al. Biochem J, 1993;291:83-8
↑ diuresis and ↑ natriuresis
Abassi ZA, et al., Am J Physiol. 1992;262:F615-21
Villarreal D, et al, Am J Hypertens 1991;4(6):508-15
5
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SIRIUS II: Patient-assessed Dyspnea
Moderately or Markedly Better
Mitrovic Eur Heart J 2006
% p
ati
en
ts
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SIRIUS II: Renal Safety of Urodilatin
Mitrovic Eur Heart J 2006
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TRUE–AHF: TRial of Ularitide`s Efficacy in Patients with Acute Heart Failure
•Co-primary Efficacy Endpoints:• Improvement in a hierarchical clinical composite• All-cause mortality
clinicaltrials.gov
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Relaxin
• Peptide hormone
• Similar in size and shape to insulin (MW 5963)
• Found in men and women
• Normal hormone of pregnancy
• Women “exposed” for 9 months to increased plasma concentrations:0.8-1.6 ng/ml pregnancy*
Szlachter et al, Obstet & Gynecol 1982;59:167-70
Stewart et al, J Clin Endocrinol Metab 1990;70:1771-3.
Relaxin
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RELAX-AHF: Patient reported Dyspnea
Teerlink Lancet 2012
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RELAX-AHF: CV death or readmission to hospital
for heart or renal failure during 60-day follow-up
Teerlink Lancet 2012
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RELAX-AHF:
Cardiovascular and All-Cause Death
Teerlink Lancet 2012
Page 56
clinicaltrials.gov
Primary Outcome Measures:
•Time to confirmed cardiovascular (CV) death during the follow-up
period of 180 days
•Time to worsening of heart failure (WHF) through Day 5
RELAX-AHF-2
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Therapy of Acute Heart Failure
DiuresisVasodilators
Inotrope
MCS
Vasoconstricted
(no real criteria)
Admission Low output
(No real criteria) or
refractory symptoms
10-15% of Patients
Nitro/Vasodilators
Relaxin?
Urodilatin?
Congestion
Loop
Diuretics
> 80% of
Patients
< 5% of patients
Levosimendan
Dobutamine
Milrinone
MCS
mod. Gheorghiade&Ruschitzka EHJ 2012
Page 58
Another 3 days later...
Cardiorenal Syndrome
•Lasix iv boli
•Levosimendan•0.1 to 0.2 μg/kg/min
Page 60
Renal Function pre and post LVAD-
Implantation
pre-LVAD post-LVAD
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CardioRenal Syndrome
With patients‘ permission for publication
Page 62
Kidney Functions Remains Stable 7 years
post Heart Transplantation
Page 63
Merci
Frank Ruschitzka, MD, FRCP, FESC
President-elect ESC-HFA
University Heart Centre Zürich
[email protected]
Page 64
Approach to Renal Dysfunction in Acute
Heart Failure
Damman EHJ 2014
Page 65
Henry Kissinger (1923 - )
The absence of
alternatives clears the
mind marvelously
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Prevalence and Impact of Worsening Renal
Function in Patients with Acute Heart Failure:
POSH trial
Cowie EHJ 2006
Page 67
Prevalence and Impact of Worsening Renal
Function in Patients with Acute Heart Failure:
POSH trial
Cowie EHJ 2006
Page 68
BUN and Death or HF Rehospitalization
Log-Rank Test
P-Value = 0.0005
PR
OP
OR
TIO
N O
F R
EM
AIN
ING
IN
ST
UD
Y
0.5
0.6
0.7
0.8
0.9
1.0
DAYS IN STUDY
0 10 20 30 40 50 60 70
BUN > 40 mg/dL
BUN < 18 mg/dL
BUN 19-26 mg/dL
BUN 27-39 mg/dL
Filippatos G et al .J Cardiac Failure 2007
Page 69
Baseline BUN and 60-day probability of death
Klein Circ Heart Failure 2008
Death /CTX Death /CTX/HF Rehosp.
Page 70
Worsening Renal Function and Residual
Congestion Increase the Hazard for Death or
HF Rehospitalization
Metra Circ Heart Failure 2012
Death /CTX Death /CTX/HF Rehosp.
Page 71
Determinants and forms of worsening
renal function in heart failure
Filippatos G et al. Eur Heart J 2013
Page 72
Peacock, W. F. et al. J Am Coll Cardiol 2010;56:343-351
Risk Stratification Data Points in ED Patients With
Suspected Acute Heart Failure
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Treatment of Cardiorenal Syndrome Type 1
Roubille et al., Blood Purif 2014
Page 74
Treatment : acute effects of IV diuretics in heartfailure
• Increase heart rate
• Decline cardiac filling pressure
• Rise in plasma renin activity
• Increase NA, renin, vasopressin
Page 75
//
CRS and Diuretics HF, Diuretics and NGAL
Treatment : Diuretics
Ronco et al.
Page 76
Algorithm for the management of AHF
Mebazaa EHJ 2015
Page 77
Relaxin
• Peptide hormone
• Similar in size and shape to insulin
(MW 5963)
• Found in men and women
• Normal hormone of pregnancy
• Women “exposed” for 9 months to
increased plasma concentrations:
0.8-1.6 ng/ml pregnancy*
Szlachter et al, Obstet & Gynecol 1982;59:167-70
Stewart et al, J Clin Endocrinol Metab 1990;70:1771-3.
Relaxin
Page 78
RELAX-AHF: Patient reported Dyspnea
Teerlink Lancet 2012
Page 79
RELAX-AHF: CV death or readmission to hospital
for heart or renal failure during 60-day follow-up
Teerlink Lancet 2012
Page 80
RELAX-AHF:
Cardiovascular and All-Cause Death
Teerlink Lancet 2012
Page 81
Natriuretic Peptides
Cardiovasc Res 2006
Page 82
NT pro BNP and BNP
Cardiomyocyte
Blood
Page 83
Corti Circ 2001
Natriuretic Peptides- The Natural Born
Enemies of Angiotensin II
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VMAC: Nesiritide vs Nitroglycerin
JAMA 2002
Page 85
Meta-Analysis can be misleading...
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Effect of Nesiritide in Patients with Acute
Decompensated Heart Failure
O’Connor NEJM 2011
Page 88
Effect of Nesiritide in Patients with Acute
Decompensated Heart Failure
O’Connor NEJM 2011
Page 90
deGoma JACC 2006
Diuretics and Aquaretics
??
Page 91
Rank Order of Hydrolysis by NEP is
CNP>ANP>BNP>Urodilatin
Cardiovasc Res 2006
Page 92
mod. Forssmann Cardiovasc Res 2006
Urodilatin
• Synthesized in distal tubular cells
• Binds downstream in IMC duct to NPR-A
• Increases Renal Plasma Flow (via cGMP)
• Increases GFR:
• Dilates Vas afferens
• Constricts Vas efferens
• Relaxes mesangials cells
• Decreases sodium reabsorption in PCT and CD
via cGMP dependent phosphorylation of ENaC
• Inhibits renin, aldosterone, and vasopressin secretion
• NOT degraded by NEP inhibition
Page 93
Differential Processing of ANP and Urodilatin – Cleavage of the signal peptide is different in heart and kidney
mod. Forssmann CVR 2006 and Histochem Cell Biol 1998
Page 94
SIRIUS II: Patient-assessed Dyspnea
Moderately or Markedly Better
Mitrovic Eur Heart J 2006
% p
ati
en
ts
Page 95
SIRIUS II: Renal Safety of Urodilatin
Mitrovic Eur Heart J 2006
Page 96
Outcome in SIRIUS-II
Mortality in SIRIUS II
13.2
3.3 3.8
1.8
0
5
10
15%
of
pat
ien
ts
Placebo 7.15 15 30Ularitide, ng/kg/min
European Heart Journal (2006) 27, 2823–2832
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TRUE–AHF: TRial of Ularitide`s
EFFICACY IN PATIENTS with ACUTE HEART
FAILURE
STUDY DESIGN
Primary Efficacy: Global composite score (superiority)
Primary Safety: All-cause mortality and cardiovascular rehospitalisation and other significant cardiovascular events at 30 days / 3 months (non-inferiority)
Status: recruiting
clinicaltrials.gov
Page 98
• BP 86/60 mmHg
• HR 90/min/SR
• PC 22 mmHg
• „lukewarm“
• iv Furosemide
•Dobutamine
•Levosimendan
Bromocriptine
Page 99
Hasenfuss and Teerlink, EHJ
2011
Inotropic Therapies
Page 100
OPTIME: Long-Term Effects of Inotropes
JAMA 2002
Page 101
So etiology may influence response to
milrinone (all inotropes?)
JAMA 2002; JACC 2003
Page 102
Mebazaa JAMA 2007
SURVIVE: Effect of Dobutamine and
Levosimendan on All-Cause Mortality
Page 103
Hasenfuss and Teerlink, EHJ
2011
Mode of action of cardiac myosin
activators
Page 104
Teerlink, Lancet 2011
Dose-dependent changes in echocardiogram
measures by omecamtiv mecarbil dose
Page 105
• BP 82/60 mmHg
• HR 90/min/SR
• PC 22 mmHg
• „lukewarm“
• iv Furosemide
•Norepinephrine
•Levosimendan
•CVVHDF
•Bromocriptine
Page 106
So now what?
1. ECMO
2. IABP
3. LVAD
4. BiVAD
5. CRT
6. high urgency listing
7. 2+5+6
8. 3+6
Page 107
Circuit Configuration of VA ECMO
Page 108
Gaffney BMJ 2010
Circuit Configuration for VA vs VV ECMO
Page 109
Moraca J Card Surg 2012
Strategy for Acute Refractory Cardiac
Failure: Bridge to Decision
ventilation, Systolic BP < 80
mmHg
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Wer nur die Chemie versteht,
versteht die auch nicht recht.
Georg Christoph Lichtenberg
1742-1799
Page 111
Wer nur das Herz versteht,
versteht die Kardiologie nicht recht.
Zürich 2012
Page 112
Wer das Herz nicht versteht,
ist kein guter Internist.
Zürich 2012