1 / 97

Update in Heart Failure July 12, 2007

Update in Heart Failure July 12, 2007. Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program. Objectives. Define Heart Failure Know the 5 year mortality rate for heart failure

akio
Télécharger la présentation

Update in Heart Failure July 12, 2007

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Update in Heart FailureJuly 12, 2007 Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program

  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. 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?

  5. 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?

  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.

  7. 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 > 65yo. • Heart failure is the most common Medicare DRG.

  8. 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.

  9. 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.

  10. Diagnosing Heart FailureSymptoms • Decreased exercise tolerance • Fluid retention • Fatigue • Incidentally noted left ventricular dysfunction in an asymptomatic patient

  11. Diagnosing Heart FailureClinical Signs • Elevated jugular venous pressure • Pulmonary rales • S3 • S3 – volume overload • S4 – pressure overload • Peripheral edema

  12. Diagnosing Heart FailureClinical Signs

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

  14. Common EKG Findings

  15. CXR findings in Heart Failure

  16. 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

  17. Echocardiography • A generally accepted definition of depressed systolic function is an ejection fraction < 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.

  18. Heart Failure Stages vsNYHA Classes

  19. Stages of Heart Failure

  20. Heart Failure Treatment Options • Angiotensin Converting Enzyme Inhibitors (ACEIs) • Beta-blockers • Diuretics • Digoxin • Angiotensin Receptor Blockers (ARBs) • Other medications

  21. Site of Action of Medications

  22. ACEIs

  23. 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.

  24. ACEIs • A comparison of enalapril with hydralazine-isosirbide 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

  25. ACEIs – what dose? • ATLAS: Patients with NYHA class II to IV with and EF< 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

  26. 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.

  27. 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

  28. Beta-blockers

  29. 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.

  30. 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.

  31. Beta-blockers • CIBIS-II: Bisoprolol was added to standard therapy (diuretics and ACEIs) in patients with NYHA III or IV with EF < 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.

  32. Beta-blockers • MERIT-HF: Patients had NYHA class II to IV, an EF<40%, 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.

  33. 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 EF<40% 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.

  34. 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 (EF<25%) 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.

  35. 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 EF<35% 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

  36. Diuretics

  37. 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.

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

  39. Diuretics and the neurohormonal basis of heart failure • RALES Trial: Spironolactone was added to therapy in patients with severe heart failure and an EF<35% 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.

  40. Diuretics and the neurohormonal basis of heart failure • Ephesus trial - The use of eplerenone in patients post-MI who had an EF<40% 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, 348:1309-21, 2003.

  41. Digoxin

More Related