Outpatient Heart Failure Management

Outpatient Heart Failure Management UCVA 4 th Annual Cardiovascular Conference 09/29/2012 Eugene Storozynsky, M.D., Ph.D., F.A.C.C Assistant Professor of Medicine Program in Heart Failure and Transplantation Director, Cardio-Oncology Program Cardiology Division University of Rochester

No Disclosures

EVOLUTION OF CLINICAL STAGES No symptoms Normal exercise Normal LV fxn NORMAL Asymptomatic LV Dysfunction No symptoms Normal exercise Abnormal LV fxn Compensated CHF No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Decompensated CHF Refractory CHF Symptoms not controlled with treatment

ACC/AHA Classification of Heart Failure (HF) Stage A High risk for developing HF Patient Description Hypertension (HTN), diabetes, CAD, FHx of cardiomyopathy B C D Asymptomatic HF Symptomatic HF Refractory end-stage HF Previous MI LV systolic dysfunction Asymptomatic valvular disease Known structural heart disease Shortness of breath and fatigue Reduced exercise tolerance Symptoms at rest despite maximal medical therapy; candidates for device Rx or transplantation Hunt SA et al. J Am Coll Cardiol. 2001;38:2101 2113.

Epidemiology of Heart Failure in the United States Patients in US (millions) 10 8 6 4 2 0 3.5 4.8 10.0 1991 2001 2037 Year 4.79 million patients 1 ; estimated 10 million in 2037 2 Incidence: about 550,000 new cases each year 1 Prevalence is 2% in persons aged 40 to 59 years, progressively increasing to 10% for those aged 70 years and older 3 Sudden cardiac death is 6 to 9 times higher in the heart failure population 1 1. American Heart Association. 2002 Heart and Stroke Statistical Update. 2001. 2. Croft JB et al. J Am Geriatr Soc. 1997;45:270 275. 3. National Heart, Lung, and Blood Institute. Congestive Heart Failure Data Fact Sheet. Available at: http://www.nhlbi.nih.gov/health/public/heart/other/chf.htm.

Neurohormonal Activation in Heart Failure: A Vicious Cycle Myocardial injury Ventricular remodeling Vasoconstriction Increased afterload Na + and H 2 O retention CO LVEDP Neurohormonal activation RAAS SNS

Lechat, P. Eur Heart J Suppl 2006 8:C5-12C; doi:10.1093/eurheartj/sul008 Total Mortality by Subgroups in ACE-inhibitor Trials N > 7000

ACE-I Approved for Treatment of Various Stages of Heart Failure

Survival Studies with Beta Blockers in Heart Failure 20 MERIT-HF Percent of patients 15 10 5 0 0 3 6 9 12 15 18 21 Months of follow-up Placebo (n=2001) ER metoprolol succinate (n=1990) Mortality: 34% P=.0062 (adjusted) P=.00009 (nominal) n=3991 MERIT-HF Study Group. Lancet. 1999;353(9169):2001-2007.

Survival Studies with Beta Blockers in Heart Failure Survival 1.0.8.6 0 P<.0001 n=2647 0 200 6.6 Mortality: CIBIS-II 400 13.3 Time after inclusion Bisoprolol 600 20 CIBIS-II, Cardiac Insufficiency Bisoprolol Study II; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival Study. Placebo 800 26.6 Days Months Survival (% of patients) 100 90 80 70 60 0 COPERNICUS P=.00013 (unadjusted) P=.0014 (adjusted) n=2289 0 3 6 9 12 15 18 21 Months 34% 35% Carvedilol Placebo CIBIS-II Investigators and Committees Lancet. 1999;353:9-13. Packer M, et al. N Engl J Med. 2001;344:1651-1658.

Beta Blockers Approved for Treatment of Various Stages of Heart Failure ACC Heart Failure Slide Deck, 2006

Effect of BB vs. Placebo in CHF Patients who were not (left panel) or were(right panel) receiving ACE-I or ARB at baseline Krum, H. et al. Eur Heart J 2005 26:2154-2158; doi:10.1093/eurheartj/ehi409

Mortality Benefit of Dual Neurohormonal Inhibition with an ACE-I and Beta Blocker in Patients with NYHA Class II-III HF McMurray, J. et al. Circulation 2002;105:2099-2106

Aldosterone Blockade in Heart Failure RALES: Randomized Aldactone Evaluation Study Probability of Survival (%) 100 80 60 40 20 0 0 10 20 30 36 Follow-up (months) Spironolactone Placebo RR 0.70 (0.60 0.82) P<.001 1663 pts NYHA II, III, and IV, average age 65 and LVEF.35, on ACEI, loop diuretic, ± digoxin randomized to spironolactone 25 mg PO qd vs placebo. Pitt B et al. N Engl J Med. 1999;341:709 717.

Eplerenone Reduces Mortality in Patients with LV Dysfunction Post MI -Patients assigned to epleronone 25-50 mg qd (n=3313) or placebo (n=3319) ->75% receiving ACE-I (or angio blocker), βeta Blockers, aspirin -90% have symptoms of CHF Epl reduced deaths (RR.85), CV deaths (RR.87), sudden CV deaths (RR.79) -$10,400-$21,900 per life-year gained NEJM 2003;348:1309-21 Circulation 2005;Feb 21 Epub 600 500 400 300 200 100 Number of Deaths 0 All All Sudden CV CV Epl Pla

ARB and Aldosterone Antagonists Approved for Treatment of Various Stages of Heart Failure ACC Heart Failure Slide Deck, 2006

Oral Diuretics Approved for Treatment of Fluid Retention in Chronic Heart Failure ACC Heart Failure Slide Deck, 2006

Overzelous Diuretic Use May Decrease Cardiac Output and Impair Renal Function Schrier, R. W. Circ Heart Fail 2008;1:2-5 Copyright 2008 American Heart Association

Measurement of BNP in Diagnosing Heart Failure

Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-HF Trial) Primary and Secondary Outcomes in the 2 Treatment Groups 500 patients followed for 18 months Pfisterer, M. et al. JAMA 2009;301:383-392.

Fixed Dose Combination of Isosorbide Dinitrate/Hydralazine Treatment of Heart Failure

A-HEFT Trial 1050 black patients with CHF (NYHA Class III or IV) Lechat, P. Eur Heart J Suppl 2006 8:C5-12C; doi:10.1093/eurheartj/sul008

Therapies Provided by Today s Dual-Chamber ICDs Ventricle Antitachycardia pacing Cardioversion Defibrillation Atrium & Ventricle Bradycardia sensing Bradycardia pacing

Primary Prevention: ICD

Indications for ICD for Primary Prevention in Patients with Cardiomyopathy Nonischemic CMP (9 months) EF < 35% Ischemic CMP EF < 30% * Ischemic CMP EF 31-35% * Ischemic CMP & NSVT EF < 40% Class I Yes If + EPS Class II Yes Yes Yes If + EPS Class III Yes Yes Yes If + EPS Class IV Only if CRT Only if CRT Only if CRT SCD-HeFT + COMPANION MADIT II + COMPANION SCD-HeFT + COMPANION * No MI in 40 days or revascularization in 3 months for ischemic CMP. MUSTT: NSVT at least 4 days after Cardiac event

ICD or CRT for Treatment of Various Stages of Heart Failure

Recommendations for Treatment of Atrial Fibrillation in Setting of Heart Failure

Hemodynamic Subsets in Congestive Heart Failure Cardiac Index Normal Hypoperfusion Congestion Hypoperfusion & Congestion PC WP Nohria, A. et al. J Am Coll Cardiol 2003;41:1797-1804

Risk Factors for Mortality with HF >3 Should Prompt Referral for Advanced Treatment Evaluation Hospitalization for HF on oral HF therapy Na+ < 136 BUN> 45, Creat>2.1, CrCl< 45 cc/min BNP >4 x s upper limit of normal Hct < 34 mg/dl Inability to take ACEI/ARB/BB LVEDD >7.0 VO2 <55% predicted

JCAHO Heart Failure Performance Improvement Measures HF-1: Discharge Instructions (Activity, Diet, Follow-up, Medications, Symptoms Worsening, Weight Monitoring) HF-2: Assessment of Left Ventricular Systolic Function (Before, during, or planned for after discharge) HF-3: LVEF < 40% Prescribed ACEI (or ARB) at Discharge HF-4: Smoking Cessation Advice/Counseling

Summary: Heart Failure Management -Prevent CHF--risk factor modification, early treatment of coronary artery disease, reduce exposure to agents -Treat any reversible conditions -Treat arrhythmias -Medical therapy of heart failure

Questions?