The Treatment of Advanced Heart Failure
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Transcript of The Treatment of Advanced Heart Failure
The Treatment of Advanced The Treatment of Advanced Heart FailureHeart Failure
Shiva Roy FRACP Shiva Roy FRACP
POWH Nov 2000POWH Nov 2000
Heart Failure: where are we now?Heart Failure: where are we now?
CCF is a major health problem» 400,000 new cases / yr in USA » 300,000 Australians affected
Care is expensive» 70% of costs relate to hospitalisation» $1.1 billion/year inpatient costs in Australia » commonest hospital DRG in USA in pts > 65 yrs
High mortality & readmission rates» > 40% readmissions / year after index admission
Heart FailureHeart Failure
DefinitionDefinition
““The situation when the heart is The situation when the heart is incapable of maintaining a cardiac output incapable of maintaining a cardiac output adequate to accommodate metabolic adequate to accommodate metabolic requirements and the venous return”requirements and the venous return”
E. BraunwaldE. Braunwald
Normal
Chronic CCF: Evolution of stagesChronic CCF: Evolution of stages
NYHA Class
AsymptomaticLV dysfunction
1
Symptoms on exercise
2
Symptoms with minor exertion
3
•LV dysfunction = CCF•Symptoms may not be proportional to extent of LV dysfunction
4
Symptoms at rest
Assessment of Heart FailureAssessment of Heart Failure
DiagnosisDiagnosis» symptoms often more useful than signssymptoms often more useful than signs» CXR, ECG helpfulCXR, ECG helpful» echocardiography is essentialechocardiography is essential
Exclusion of treatable causesExclusion of treatable causes» ischaemiaischaemia» valvular lesionsvalvular lesions» uncontrolled HTuncontrolled HT» thyrotoxicosisthyrotoxicosis» arrhythmias arrhythmias » anaemiaanaemia
Determinants of Cardiac OutputDeterminants of Cardiac Output
STROKE VOLUMESTROKE VOLUME
CONTRACTILITYCONTRACTILITY
PRELOADPRELOAD
HEART RATEHEART RATE
CARDIAC OUTPUTCARDIAC OUTPUT
AFTERLOADAFTERLOAD
•Synergy of LV contractionSynergy of LV contraction•Valvular competenceValvular competence
Pharmacological TherapyPharmacological Therapy
Drug ClassDrug Class NYHA NYHA MortalityMortality SymptomsSymptomsACE-IACE-I 1 - 4 1 - 4
DiureticsDiuretics 2 - 4 2 - 4
DigoxinDigoxin 2 - 4 2 - 4
ß-blockersß-blockers 2 - 3 2 - 3 ( ) ( )
SpironolactoneSpironolactone 3 - 4 3 - 4
AmlodipineAmlodipine 2 - 4 2 - 4
A2 receptor blockers 2 - 4A2 receptor blockers 2 - 4 ? ? ? ? (if ACE-Inhibitor cough)(if ACE-Inhibitor cough)
ACE InhibitorsACE Inhibitors
Alters balance between vasoconstrictive, salt Alters balance between vasoconstrictive, salt retaining, hypertrophic properties of angiotensin II retaining, hypertrophic properties of angiotensin II and, the vasodilatory and natriuretic properties of and, the vasodilatory and natriuretic properties of bradykinin.bradykinin.
Morbidity and mortality data from large trials in Morbidity and mortality data from large trials in spectrum of LVF make ACE inhibitors mandatory spectrum of LVF make ACE inhibitors mandatory (SAVE, SOLVD, CONCENSUS, AIRE…)(SAVE, SOLVD, CONCENSUS, AIRE…)
? High dose – ATLAS study? High dose – ATLAS study HOPE – reduced Cardiac death, CVA, & non fatal MI HOPE – reduced Cardiac death, CVA, & non fatal MI
in ramipril treated pts with documented vascular in ramipril treated pts with documented vascular disease but no heart failuredisease but no heart failure
Aldosterone antagonistsAldosterone antagonists
Aldosterone causes Na retention, K/Mg loss, Aldosterone causes Na retention, K/Mg loss, myocardial fibrosis, baroreceptor dysfunction, myocardial fibrosis, baroreceptor dysfunction, catechol augmentation and ventricular catechol augmentation and ventricular arrhythmogenicity.arrhythmogenicity.
RALES demonstrated 30% reduction in all RALES demonstrated 30% reduction in all cause mortality, and in hospitalisation in cause mortality, and in hospitalisation in spironolactone (md 26mg) treated pts with spironolactone (md 26mg) treated pts with NYHA III & IV heart failureNYHA III & IV heart failure
Well tolerated with conventional therapy.Well tolerated with conventional therapy.
Angiotensin receptor antagonistsAngiotensin receptor antagonists
High levels of Angiotensin II predict poor outcome, and High levels of Angiotensin II predict poor outcome, and ACE inhibition of bradykinin metabolism may induce ACE inhibition of bradykinin metabolism may induce cough. cough.
Unexpected benefit of Losartan in ELITE, not confirmed Unexpected benefit of Losartan in ELITE, not confirmed in ELITE IIin ELITE II
Adverse outcome with Candesartan v Enalapril in Adverse outcome with Candesartan v Enalapril in RESOLVDRESOLVD
Val- HeFT (class II and III)standard triple Rx v Val- HeFT (class II and III)standard triple Rx v combination Rx, and VALIANT – valsartan v Captopril combination Rx, and VALIANT – valsartan v Captopril V combination post MIV combination post MI
Current role of AII R blockers is in ACE I intolerant pts Current role of AII R blockers is in ACE I intolerant pts and as adjunct to conventional therapy.and as adjunct to conventional therapy.
Sympathetic activation in CCFSympathetic activation in CCF
B Blockers ? Contraindicated B Blockers ? Contraindicated Down regulation of B1 AR’s due to high catechol levels Down regulation of B1 AR’s due to high catechol levels
with failing myocardium.with failing myocardium. US Carvedilol heart failure study 65% decrease US Carvedilol heart failure study 65% decrease
mortality, ANZHF 24% NS reduction in mortality.mortality, ANZHF 24% NS reduction in mortality. COPERNICUS – favourable carvedilol effect in severe COPERNICUS – favourable carvedilol effect in severe
HF.HF. B1 selective blockers Metoprolol (CR) – MERIT-HF B1 selective blockers Metoprolol (CR) – MERIT-HF
3991 pts, FC II-IV, 34% decrease in CV mortality, 41% 3991 pts, FC II-IV, 34% decrease in CV mortality, 41% decrease in SCD with similar results for Bisoprolol – decrease in SCD with similar results for Bisoprolol – CIBIS II.CIBIS II.
COMET – Carvedilol or Metoprolol European Trial…COMET – Carvedilol or Metoprolol European Trial…
Therapy of Heart FailureTherapy of Heart Failure
» pharmacological management» treatment of arrhythmias: esp AF» lifestyle: Na+ & fluid restriction, weight
loss, cessation of smoking, alcohol» exercise » management of co-morbidities:
depression, sleep apnoea» vaccination against respiratory pathogens
Comprehensive care is essential
Diastolic Heart FailureDiastolic Heart Failure
Stiffening of the ventricle Stiffening of the ventricle » Poor filling, need for higher than normal filling pressures Poor filling, need for higher than normal filling pressures » Small fluid shifts often poorly tolerated Small fluid shifts often poorly tolerated » Difficult balance between pulmonary congestion and Difficult balance between pulmonary congestion and
systemic hypotensionsystemic hypotension
Often accompanies systolic heart failureOften accompanies systolic heart failure Isolated diastolic failure:Isolated diastolic failure:
Common causes Uncommon causes
Hypertension Hypertension Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Ischaemia Ischaemia InfiltrationInfiltration
Management is difficult!
Isolated Diastolic Heart FailureIsolated Diastolic Heart Failure
treat the underlying cause lower the HR, improve relaxation:
ß-blocker or verapamil atrial fibrillation: attempt restoration of
sinus rhythm ACE-inhibitors, spironolactone: may
cause regression of hypertrophy cautious use of diuretics digoxin unhelpful
Biventricular PacingBiventricular Pacing
DCM with IVCD is associated with significant DCM with IVCD is associated with significant interventricular dyssynchronyinterventricular dyssynchrony
BV pacing may promote a coordinated BV pacing may promote a coordinated ventricular pattern of contraction.ventricular pattern of contraction.
Symptomatic benefit demonstrated to date.Symptomatic benefit demonstrated to date.
Surgery for Heart FailureSurgery for Heart Failure
ConventionalConventionalrevascularisationrevascularisationvalve replacement or repairvalve replacement or repairtransplantationtransplantationmechanical ‘bridge’ to transplantmechanical ‘bridge’ to transplantcardiomyoplastycardiomyoplastyLV reduction surgeryLV reduction surgerypermanent mechanical heartpermanent mechanical heartxenotransplantationxenotransplantation
InvestigationalInvestigational
Heart TransplantationHeart Transplantation
Indications•End stage heart failure, NYHA class 3-4, no further therapeutic options•Poor LV function alone is not an indication in the absence of significant symptoms
Contraindications•Severe systemic disease limiting survival•Active infection•Irreversible pulmonary hypertension•Adverse psycho-social factors
Heart Transplantation 1982 - 1999Heart Transplantation 1982 - 1999
Years post Heart Transplant
Actuarial SurvivalActuarial Survival
ISHLTx Reg 2000
Heart TransplantationHeart Transplantation
Disadvantages:Disadvantages: Donor shortageDonor shortage Long waiting timesLong waiting times 10-20% mortality 10-20% mortality
on waiting list on waiting list Risks of immuno-Risks of immuno-
suppressionsuppression Risk of rejection: Risk of rejection:
acute & chronicacute & chronic0
20
40
60
80
100
120
'84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99
Nu
mb
er
Australian Transplants
Year
Thoratec in Intensive Care
Evolution in VAD SupportEvolution in VAD Support
Novacor out ofhospital
Thoratec on the ward
Case 1Case 1
40 yr old female lawyer, N Coast40 yr old female lawyer, N Coast 30 cigarettes daily, Hypertension30 cigarettes daily, Hypertension Severe chest pain, nausea, diaphoresisSevere chest pain, nausea, diaphoresis Refused thrombolysisRefused thrombolysis Medical therapyMedical therapy
Case 2Case 2
77 yr old female77 yr old female Independent with medical therapy for Independent with medical therapy for
ischemic cardiomyopathy and hypertensionischemic cardiomyopathy and hypertension Known moderate LV impairment (EF ~40%)Known moderate LV impairment (EF ~40%) Sudden onset of increasing breathlessnessSudden onset of increasing breathlessness No chest pain No chest pain
Case 3Case 3
19 yr old indigenous Australian19 yr old indigenous Australian 22 wks pregnant22 wks pregnant Intermittent palpitationsIntermittent palpitations Increasing dyspnoea and peripheral oedemaIncreasing dyspnoea and peripheral oedema
Case 4Case 4
70 yr old surgeon70 yr old surgeon Sudden dyspnoea after driving off 1Sudden dyspnoea after driving off 1stst tee tee Previously well with no CV historyPreviously well with no CV history Loud apical PSM on auscultation with Loud apical PSM on auscultation with
pulmonary oedemapulmonary oedema
Case 5Case 5
24 yr old Chinese basketballer24 yr old Chinese basketballer ?Deteriorating physical fitness?Deteriorating physical fitness
Case 6Case 6
43 yr old radio presenter43 yr old radio presenter ESRF secondary to wegeners ESRF secondary to wegeners
granulomatosus, x3/wk HDgranulomatosus, x3/wk HD HypertensiveHypertensive Inceasingly dyspnoeicInceasingly dyspnoeic
Heart Failure 2000: Therapeutic OptionsHeart Failure 2000: Therapeutic Options
High risk conventional
surgery
TransplantationLVADs
Total artificial heart?
Xenografts?
Tolerance?
Bi-ventricular pacing?
Myoplasty?
Left Ventricular reduction surgery?
Exercise
ß-blockersACE-Inhibitors
Angio-II blockers digoxindiureticsSpironolactone
CPAP
Medical Therapy
Surgical Therapy