Management in patients with Acute Decompensated Heart Failure

Dr Elaine Chau HK Sanatorium & Hospital, Hong Kong 3 August 2014 1

Acute decompensated heart failure • Acute heart failure defined as onset of symptoms or signs of heart failure in a patient with/without prior history of heart failure •Heterogeneous group of disorders leading to worsening of left ventricular function •About 50% of patients with HF have preserved systolic function (LVEF > 50%)  diastolic dysfunction (HF-PEF) 2

Causes of acute HF due to LV dysfunction • Primary cardiac – cardiomyopathy, myocarditis, ischaemia, arrhythmia, valvular dysfunction, pericardial syndrome • Pressure overload – hypertensive urgency or emergency • Volume overload hepatic dysfunction – sodium or volume load, renal or • High output – shunt, anaemia, septicaemia, thyroid disease • Other – inflammation or infection, major surgery, lack of compliance with heart failure medications, substance abuse 3

Signs and symptoms • Prior history of HF or myocardial injury • Dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea • Fatigue • Increasing oedema, weight or abdominal girth • Signs: •Elevated JVP •Peripheral oedema or ascites •Rales, hypoxia or tachypnoea •Tachycardia, arrhythmia 4

Evaluation of heart failure • ECG, CXR • echocardiogram • blood tests - BNP, NT-proBNP or MR-proANP (to differentiate dyspnoea due to HF from dyspnoea of other causes) • Evaluate possibility of coronary artery disease – coronary angiography • Evaluate possibility of myocardial disease – endomyocardial biopsy (e.g. myocarditis, infiltrative heart disease, anthracycline toxicity in cancer patients) • Functional capacity (6-min walk, exercise testing with measurement of peak oxygen uptake) 5

Assessment of patient with suspected acute HF 6

Precipitating factors

• • • • • • • • Atrial fibrillation Other arrhythmias (eg, atrial flutter, other supraventricular tachycardia or ventricular tachycardia) Exacerbation of hypertension Myocardial ischemia/infarction Exacerbation of pulmonary congestion Anaemia Thyroid disease Significant drug interactions 7

Causes of acute heart failure 8

Causes of acute heart failure 9

Hospitalization recommended

Evidence of severely decompensated HF, including:

• Hypotension • Worsening renal function • Altered mentation

Dyspnea at rest

• Typically reflected by resting tachypnea • Less commonly reflected by oxygen saturation <90%

Hemodynamically significant arrhythmia

• Including new onset of rapid atrial fibrillation

Acute coronary syndromes

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Hospitalization should be considered

Worsened congestion

• Even without dyspnea • Typically reflected by a weight gain ≥5 kilograms

Signs and symptoms of pulmonary or systemic congestion even in the absence of weight gain Major electrolyte disturbance Associated comorbid conditions

• Pneumonia • Pulmonary embolus • Diabetic ketoacidosis • Symptoms suggestive of transient ischemic accident or stroke

Repeated ICD firings Previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion

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Treatment goals for patients admitted for ADHF

• • • • • • • • • Improve symptoms, especially congestion and low output symptoms Optimize volume status Identify etiology Identify precipitating factors Optimize chronic oral therapy Minimize side effects Identify patients who might benefit from revascularization Educate patients concerning medications and self-assessment of HF Consider and, where possible, initiate a disease management program 12

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Current IV Treatments for Acute Heart Failure

Diuretics Preload • Other agents (inotropes) • ß-receptor agonists (dobutamine, dopamine) • PDE inhibitors (milrinone) Contractility • Nitrates and/or any other IV vasodilators Afterload 13

Management of acute pulmonary oedema 14

Fluid overload

• • • • • • • i.v. loop diuretics Daily body weight, intake / output balance Daily RFT/electrolytes (K, Mg) Low sodium diet(2g daily) Fluid restriction (<2L/day)for patients with moderate hyponatraemia (congestion fails to improve) Increased doses of loop diuretics or continuous infusion of loop diuretic Add second type of oral diuretic (metolazone or spironolactone) or i.v.

(chlorothiazide) 15

Diuretics For relief of congestion in patients with elevated filling pressures (PCWP > 25mmHg) due to volume overload •Loop diuretics (e.g. frusemide) – when high doses are required, continuous infusion may have benefits over bolus dosing • add metolazone to potentiate natriuresis • spironolactone to stem potassium losses • acetazolamide to correct hypochloremic metabolic acidosis 16

Ultrafiltration UNLOAD (Ultrafiltration versus Intravenous Diuretics for patients Hospitalized for Acute Decompensated Heart Failure) • 200 patients with acute decompensated HF •Peripheral venovenous ultrafiltration compared with diuretics alone •Improved weight loss at 48 hours •Decreased need for vasoactive drugs •Reduced rate of readmission to hospital at 90 days Costanzo MR et al. J Am Coll Cardiol 2007; 49: 675-683 17

Respiratory therapies •Supplementary oxygen •Short-term positive pressure ventilation, e.g. CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure) •(in acute MI with respiratory distress) invasive mechanical ventilation 18

Management of acute pulmonary oedema 19

IV Vasodilators / Inotropes

• • • • • (absence of hypotension) i.v. nitroglycerin, nitroprusside or nesiritide iv vasodilators and diuretics recommended for rapid relief of acute pulmonary oedema and hypertension i.v. inotropes (milrinone or dobutamine) to improve symptoms and improve end-organ function in patients with advanced heart failure (LV dilatation ,reduced LVEF, diminished peripheral perfusion or end organ dysfunction, low-output syndrome, symptomatic hypotension despite adequate filling pressure or unresponsive to iv vasodilators) Continuous monitoring of cardiac rhythm Frequent blood pressure monitoring 20

Vasodilators For afterload reduction (by decreasing myocardial oxygen demand and improving forward flow) •i.v. nitroglycerin (10-20mcg/min initially; increasing by 5 20 mcg/min every 3-5 min as BP allows) •i.v. morphine (bolus 2-4mg) •i.v. nitroprusside (continuous infusion of 0.3mcg/kg/min; titrate rapidly to desired BP; max dose 10mcg/kg/) 21

i.v. vasodilators to treat acute heart failure 22

Positive inotropes or vasopressors for acute HF 23

Inotropes Vasodilating inotropes: for short-term use in patients with significantly impaired cardiac output •Dobutamine 2-20mcg/kg/min •Milrinone 0.125-0.75mcg/kg/min (renal adjustment necessary) Vasopressor inotropes: for patients with hypotension (avoid in pure HF with high systemic vascular resistance) •Dopamine 1-50mcg/kg/min •Norepinephrine 0.01-0.4mcg/kg/min 24

ATP Inotropic drugs Dobutamine β-receptor Digoxin [K + ] [Ca 2+ ] Gs Gi Na + /K + exchanger [Na + ] Na + /Ca 2+ exchanger cAMP (active) PDE Milrinone AMP (inactive) rise in intracellular calcium 25

Haemodynamic monitoring

• • Routine invasive haemodynmaic monitoring not recommended Invasive haemodynamic monitoring to be considered in • Patient refractory to initial therapy • Patient whose volume status and cardiac filling pressures are • • unclear Patient with clinically significant hypotension (SBP <80mmHg) or worsening renal failure during therapy Patient in whom documentation of an adequate haemodynamic response to the inotropic agent is necessary when chronic outpatient infusion is being considered 26

Management of acute pulmonary oedema 27

Treatment of patients with acute heart failure 28

Treatment of patients with acute heart failure 29

Treatment of patients with acute heart failure 30

Treatment of patients with acute heart failure 31

Levosimendan Clinical Effect Cardiac Output Heart Rate Blood Pressure Oxygen Demand Arrhythmogenic Potential Cardiac Filling Pressure Tachyphylaxis Ideal Agent Dobutamine PDE Inhibitors Levosimendan or 32

Levosimendan for treatment of acute decompensated heart failure  Dual mechanism of action: 1) Calcium sensitization (improves cardiac contractility without concomitantly increasing myocyte oxygen consumption) 2) potassium-ATP channel opening (results in vasodilation, improving blood flow to vital organs) 33

Levosimendan

• Calcium sensitizer with inodilatory properties (PDE III inhibitory activity) • Pharmacokinetics: – Onset of action 10-20 min – Duration of action – haemodynamic effects maintained for at least 24 hours after discontinuation of a 24-hour infusion – Excretion : liver • Adverse reaction: Dose-related hypotension • No significant conduction disturbance or proarrhythmia 34

Levosimendan

• LIDO (Lancet 2002; 360:196-202) - Benefit & safety better than standard inotrope in ADHF • RUSSLAN study (Eur Heart J 2002;23:1422-32) – Safe & effective for patients with LV failure complicating acute MI • CASINO – (Eur J Heart Fail 2004;6:673-6) Clear mortality benefit in favour of levosimendan compared with dobutamine in class IV CHF patients • REVIVE I trial (Crit Care 2004;8(suppl 1):P88) – Levosimendan reduces length of intensive and hospital day in patient with acute decompensated HF 35

Levosimendan for treatment of acute decompensated heart failure

REVIVE II

(Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy Study) (AHA Scientific Sessions 2005 Late Breaking Clinical Trials II)  600 patients, 103 sites  ADHF, dyspnoea at rest despite iv diuretics, LVEF <35%  Levo bolus (6-12 mcg/kg) + 24-hour infusion (0.1 0.2mcg/kg/min) vs placebo  After 5 days, more Levo patients improved (19.4% vs 14.6%), fewer Levo patients worsened (19.4% vs 27.2%)  Significant BNP reduction in Levo arm at 24 hours & 5 days  No difference in mortality at 90 days 36

Levosimendan for treatment of acute decompensated heart failure

SURVIVE

(Survival of Patients with Acute Heart Failure in Need of Intravenous Inotropic Support Study) (JAMA 2007; 297:1883-1991)  1327 patients, 75 sites  ADHF, LVEF <35%, clinical requirement for iv inotropic therapy   Levosimendan bolus + infusion vs dobutamine Reduction of mortality by 28% at 5 days and of 14% at 31 days in in Levo arm  Effect greatest (42% reduction at 5 days) in patients with previous heart failure  Statistically non-significant but consistently lower mortality at 6 months with Levo 37

Conclusions from REVIVE II and SURVIVE  Levosimendan represents an effective alternative to current therapies for ADHF  Short-term improvement in symptoms and clinical course, associated with marked reduction in BNP  Mortality was numerically greater vs placebo but lower vs dobutamine  AF was increased during 3- to 6-month FU period  VT was increased vs placebo but not increased vs dobutamine 38

Nesiritide

• B-type natriuretic peptide  counter-regulation of renin angiotensin-aldosterone system  stimulating cGMP  muscle cell relaxation smooth • Vasodilatory properties, natriuretic effects, neurohormonal antagonism

VMAC

• (JAMA 2002; 287(12):1531-1540)  PAP, PCWP; no tachyphylaxis/tolerance (unlike nitroglycerin) PRECEDENT (Am Heart J 2002; 144(6):1102-1108) • Nesiritide had no significant effect on HR or ventricular arrhythmias • Dobutamine but not nesiritide was proarrhythmic 39

Nesiritide

• 2001 FDA approved for treatment of acute decompensated heart failure • Pooled analysis of randomized controlled trials   risk of death at 1 month (Sackner-Bernstein et al, JAMA 2005;293:1900-1905) & worsening renal function (Sackner-Bernstein et al, Circulation 2005;111:1487-1491) 40

Nesiritide

Expert panel (Braunwald et al 2005) • Use of nesiritide should be limited to patients presenting to hospital with acutely decompensated CHF • Should not be used to replace diuretics • Not for • Intermittent outpatient use • Scheduled repetitive use • Improvement of renal function • Enhancement of diuresis 41

Serelaxin

• • • • • • Recombinant human relaxin-2 (vasoactive peptide hormone)

RELAX-AHF

(randomised placebo-controlled trial – Serelaxin for treatment of acute heart failure) Patients with dypsnoea, congestion on CXR, increased BNP or NT proBNP, mild-mod renal insuffuciency, SBP >125mmHg Standard care plus 48-hour infusion of placebo or serelaxin (30mcg/kg per day) within 16 hours from presentation Tx of acute HF with serelaxin was associated with – Dyspnoea relief (as measured by visual analogue scale area under the curve / VAS AUC to day 5) – Reduced 180-day mortality No effect on re-admission to hospital Teerlink JR et al - Lancet 2013; 381(9860):29-39 42

Goals of treatment in acute heart failure 43

Discharge criteria for HF patients

• Exacerbating factors addressed • At least near optimal volume status achieved • Transition from intravenous to oral diuretic successfully completed • Patient and family education completed • At least near optimal pharmacologic therapy achieved • Follow-up clinic visit scheduled, usually for 7-10 days 44