CCS HEART FAILURE WORKSHOP THE PRACTICAL MANAGEMENT OF HEART FAILURE – 2012 UPDATE

1. CCS HEART FAILURE WORKSHOP THE PRACTICAL MANAGEMENT OF HEART FAILURE – 2012 UPDATE

2. WELCOME!

3. Learning Objectives At the conclusion of this workshop, participants willbe able to: • Reviewchanges and updates for optimal management of chronic and acute heartfailure; updating 2006 recommendations to 2012 context and environment; • Discussexercise for heartfailure patients - where to begin, what to do and where to end; and • Identifyopportunities and challenges of surgery for patients with an ischemicetiology for heartfailure.

4. Acute Heart Failure

5. What is heart failure? • Chronic Heart Failure (CHF): • Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. • Acute Heart Failure Syndrome (AHF): • “gradual or rapid change in heart failure signs and symptoms resulting in the need for urgent therapy”

6. Classification of AHF usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion. high BP, +/- preserved LV systolic fxn; increased sympathetic tone with ↑HR, vasoconstriction; may be euvolaemic or only mildly hypervolemic, and frequently with signs of pulmonary or systemic congestion Severe respiratory distress, ↑RR, orthopnea, rales. O2 sats <90% RA prior to O2 Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT). low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures Usually sys BP <90 mmHg or drop in MAP >30 mmHg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly ESC 2008

7. Has care evolved? Harrison’s Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501

8. CASE 1 • 74 year old female • 2 months worsening SOB/orthopnea • Presented to ED after Chinese food • Past Hx unclear, no meds • Physical exam • HR 98, BP 142/82, RR 28, temp 36.0C • JVP elevated, crackles, pulses 2+, legs warm and LEE+

9. CASE 1 • 74 year old female • CXR = pending • Labs = pending

10. Question …prepare to provide your answer!

11. How confident are you that it is AHF? • <20% • 21-40% • 41-60% • 61-80% • >80%

12. How confident are you that it is AHF? • <20% • 21-40% • 41-60% • 61-80% • >80% No right answer

13. AHF Dx Scoring systems e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48-54]. 

14. CASE 1 • 74 year old female • CXR = increased pulmonary markings c/w edema, no evidence of COPD • Labs = troponin I 0.20 • BNP 728 pg/ml • Creatinine 130

15. AHF Dx Scoring systems e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48-54]. 

16. CCS 2012 We recommend the use of a validated diagnostic scoring system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence). e.g. PRIDE score, Boston criteria This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation.

17. CCS 2012 • We recommend that in the clinical scenario when the clinical diagnosis of AHF is of intermediate pre-test probability, NP level be obtained to rule-out (BNP <100 pg/ml; NT-proBNP <300 pg/ml) or rule-in (BNP >500 pg/ml; NT-proBNP >900 pg/ml if age 50-75 years, NT-proBNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF (Strong Recommendation, Moderate Quality Evidence)

18. CCS 2012: Practical Tips • A precipitating cause for AHF should be sought. • An ECG and a chest x-ray should be performed within 2 hours of initial presentation. • Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin.

19. CCS 2012: Practical Tips • A transthoracic echocardiogram should be performed within 72 hours of presentation. • For patients with a prior echocardiogram, another is not required unless there has been a significant change in clinical status requiring investigation, a lack of clinical response to appropriate therapy and/or it is greater than 12 months since the prior echocardiogram.

20. CASE 2 • 52 year old male with history of HF • Presented to ED after the Edmonton Oilers won the Stanley Cup • SOBOE, orthopnea • HR 98, BP 99/52, RR 24, temp 36.0c • JVP difficult to assess (thick neck) • crackles • pulses weak, legs cool and LEE • Trop 0.15

21. Question …prepare to provide your answer!

22. Where on this table does this pt fit? 1 2 Dry and Warm Wet and Warm Increasing Perfusion/ Cardiac Output 3 4 Dry and Cold Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

23. Where on this table does this pt fit? • Dry and Warm • Wet and Warm • Dry and Cold • Wet and Cold

24. Where on this table does this pt fit? 1 2 Dry and Warm Wet and Warm Increasing Perfusion/ Cardiac Output 3 4 Dry and Cold Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

25. Admit or discharge?

27. Treatment options?

28. CCS 2012: Oxygen We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation >90% (Strong Recommendation, Moderate Quality Evidence). Values and Preferences: This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long-term clinical usage of supplemental oxygen without supportive data.

29. CCS 2012: CPAP/BIPAP We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate Quality Evidence). Values and Preferences: This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP may be appropriate for patients with persistent hypoxia and pulmonary edema.

30. CASE 2 • 52 year old male with history of HF • Presented to ED after the Edmonton Oilers won the Stanley Cup • SOBOE, orthopnea • HR 98, BP 99/52, RR 24, temp 36.0c • JVP difficult to assess (thick neck) • crackles • pulses weak, legs cool and LEE • Trop 0.15

31. Question …prepare to provide your answer!

32. How much diuretic will you give and how? • IV lasix 20 mg bid • IV lasix 40 mg bid • IV lasix 80 mg bid • IV lasix 10 mg/hour infusion • Other choice

33. Acute Heart Failure (1 symptom AND 1 sign) <24 hours after admission DOSE: Study Design 2x2 factorial randomization Low Dose (1 x oral) Q12 IV bolus Low Dose (1x oral) Continuous infusion High Dose (2.5 x oral) Q12 IV bolus High Dose (2.5 x oral) Continuous infusion 48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose e.g. Home dose = 40 mg BID Bolus = 80 (low) 200 (high) 72 hours Co-primary endpoints Felker, NEJM 2011 60 days Clinical endpoints

34. DOSE: Co-Primary Endpoints • Efficacy: • Patient Global Assessment by visual analog scale over 72 hours using area under the curve • Safety: • Change in creatinine from baseline to 72 hours

35. DOSE: patient global assessment

36. DOSE: Death, Rehosp, ER visit

37. DOSE-AHF Conclusions • There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either: • bolus vs. infusion or low vs. high • No clinical differences…but • High was associated with favorable trends: • Symptom relief (global assessment and dyspnea) • Weight loss and net volume loss • Proportion free from signs of congestion • Reduction in NT-proBNP

38. CCS 2012: Diuretics We recommend intravenous diuretics be given as first line therapy for patients with congestion (Strong Recommendation, Moderate Quality Evidence). We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).

39. Diuretic dosing for ADHF Creatinine clearance* Maintenance dose Initial IV dose† Patient ≥ 60 mL/min/1.73m2 New-onset HF or no maintenance diuretic therapyEstablished HF or chronic oraldiuretic therapyNew-onset HF or no maintenance diuretic therapyEstablished HF or chronic oraldiuretic therapy Furosemide 20-40 mg2-3 times dailyFurosemide bolus equivalentto oral doseFurosemide 20-80 mg2-3 times dailyFurosemide bolus equivalentto oral dose Lowest diuretic dosethat allows forclinical stability isthe ideal dose < 60 mL/min/1.73m2 *Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details. † Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option. Practical Tips When Response to Diuretic is Suboptimal • Reevaluate the need for additional diuresis by assessing volume status • Restrict NA+/H2O intake (and exercise caution reducing oral intake below 500 ml per 24 hours). • Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, furosemide 20-40 mg bolus then 5-20 mg/h) can be a useful strategy when other options are not available. • Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolazone 2.5-5 mg OB/BID or hydrochlorothiazide 25-50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have an adequate effect. • Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diuretic resistance. • Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency.

40. Question …prepare to provide your answer!

41. For a persistently symptomatic patient with HF, what is next option? • Higher dose lasix • Different diuretic • Add vasodilator • Add inotropic agent • Patience…. • Other choice

42. CCS 2012: Vasodilators • We recommend the following intravenous vasodilators, titrated to systolic blood pressure (SBP) > 100 mmHg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mmHg): • Nitroglycerin (Strong Recommendation, Moderate Quality Evidence); • Nesiritide (Weak Recommendation, High Quality Evidence); • Nitroprusside (Weak Recommendation, Low Quality Evidence). AHA 2012: RELAX-AHF, CARRESS

43. CCS 2012: Inotropes • We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine or milrinone (Strong Recommendation, High Quality Evidence). • Values and Preferences These recommendations for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.

44. Do I stop the beta-blockers on admission? • Cohorts suggest continuing beta-blockers advantageous • RCT: B-CONVINCED • Keep vs. Stop strategy in known HF pts on beta-blockers • Keep was non-inferior to Stop. • Does not delay clinical improvement • Predicts staying on BB in the longer term Eur Heart J 2009; 30:2186-92

45. RESYNCHRONIZATION THERAPY and DEVICES Anique Ducharme, MD MSc FRCPC

46. Conflict Disclosures The speaker has received fees/honoraria from the following sources: Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical None of the drugs, devices, or treatment modalities mentionedin this presentation are non approved indications. Anique Ducharme, Institut de Cardiologie de Montréal, Université de Montréal

47. A Case of Mild Heart Failure • 61 years old female, previous MI, • stable NYHA II, LVEF 25% • On optimal dose of lisinopril, eplerone and bisoprolol, occasional diuretics • Has not been assessed for device Rx • BP 99/67 mmHg, HR 76 bpm • K, 4.7 mEq/L; NT-proBNP 4500 pg/mL • EKG: old anterior MI, LBBB QRS 155 ms.

48. Question …prepare to provide your answer!

49. You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next? • Angiotensin receptor blocker • ICD • CRT • CRT + ICD (CRT-D)

50. CRT in Patients with Mild HF Symptoms:MADIT-CRT 1820 pts, mostly NYHA II, CRT+ICD vs ICD alone Low risk population, annual mortality ~3% 40% reduction in HF events in CRT-ICD group Moss et al, NEJM 2009