Transcript Issues in Heart Failure
The Treatment of Advanced Heart Failure
Shiva Roy FRACP POWH Nov 2000
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 Failure
Definition
“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return” E. Braunwald
Chronic CCF: Evolution of stages
Normal
1
Asymptomatic LV dysfunction
2
Symptoms on exercise
3
Symptoms with minor exertion •
LV dysfunction = CCF
•
Symptoms may not be proportional to extent of LV dysfunction
4
Symptoms at rest
Assessment of Heart Failure
Diagnosis » » » symptoms often more useful than signs CXR, ECG helpful echocardiography is essential Exclusion of treatable causes » » » » » » ischaemia valvular lesions uncontrolled HT thyrotoxicosis arrhythmias anaemia
Determinants of Cardiac Output
CONTRACTILITY PRELOAD AFTERLOAD STROKE VOLUME •Synergy of LV contraction •Valvular competence HEART RATE
CARDIAC OUTPUT
Pharmacological Therapy
Drug Class ACE-I NYHA 1 - 4 Diuretics Digoxin ß-blockers 2 - 4 2 - 4 2 - 3 Spironolactone Amlodipine 3 - 4 2 - 4 A2 receptor blockers 2 - 4
(if ACE-Inhibitor cough)
Mortality Symptoms ?
( ) ?
ACE Inhibitors
Alters balance between vasoconstrictive, salt retaining, hypertrophic properties of angiotensin II and, the vasodilatory and natriuretic properties of bradykinin.
Morbidity and mortality data from large trials in spectrum of LVF make ACE inhibitors mandatory (SAVE, SOLVD, CONCENSUS, AIRE…) ? High dose – ATLAS study HOPE – reduced Cardiac death, CVA, & non fatal MI in ramipril treated pts with documented vascular disease but no heart failure
Aldosterone antagonists
Aldosterone causes Na retention, K/Mg loss, myocardial fibrosis, baroreceptor dysfunction, catechol augmentation and ventricular arrhythmogenicity.
RALES demonstrated 30% reduction in all cause mortality, and in hospitalisation in spironolactone (md 26mg) treated pts with NYHA III & IV heart failure Well tolerated with conventional therapy.
Angiotensin receptor antagonists
High levels of Angiotensin II predict poor outcome, and ACE inhibition of bradykinin metabolism may induce cough. Unexpected benefit of Losartan in ELITE, not confirmed in ELITE II Adverse outcome with Candesartan v Enalapril in RESOLVD Val- HeFT (class II and III)standard triple Rx v combination Rx, and VALIANT – valsartan v Captopril V combination post MI Current role of AII R blockers is in ACE I intolerant pts and as adjunct to conventional therapy.
Sympathetic activation in CCF
B Blockers ? Contraindicated Down regulation of B1 AR’s due to high catechol levels with failing myocardium.
US Carvedilol heart failure study 65% decrease mortality, ANZHF 24% NS reduction in mortality.
COPERNICUS – favourable carvedilol effect in severe HF.
B1 selective blockers Metoprolol (CR) – MERIT-HF 3991 pts, FC II-IV, 34% decrease in CV mortality, 41% decrease in SCD with similar results for Bisoprolol – CIBIS II.
COMET – Carvedilol or Metoprolol European Trial…
Therapy of Heart Failure
Comprehensive
care is essential
» » » 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
Diastolic Heart Failure
Stiffening of the ventricle » » » Poor filling, need for higher than normal filling pressures Small fluid shifts often poorly tolerated Difficult balance between pulmonary congestion and systemic hypotension Often accompanies systolic heart failure Isolated diastolic failure: Common causes Uncommon causes Hypertension Ischaemia Hypertrophic cardiomyopathy Infiltration
Isolated Diastolic Heart Failure
Management is difficult!
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 Pacing
DCM with IVCD is associated with significant interventricular dyssynchrony BV pacing may promote a coordinated ventricular pattern of contraction.
Symptomatic benefit demonstrated to date.
Surgery for Heart Failure
Conventional revascularisation valve replacement or repair transplantation mechanical ‘bridge’ to transplant cardiomyoplasty LV reduction surgery permanent mechanical heart xenotransplantation Investigational
Heart 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 - 1999
Actuarial Survival
Years post Heart Transplant
ISHLTx Reg 2000
Heart Transplantation
Australian Transplants
120 100 80 60 40 20 0 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99
Year Disadvantages: Donor shortage Long waiting times 10-20% mortality on waiting list Risks of immuno suppression Risk of rejection: acute & chronic
Evolution in VAD Support
Thoratec in Intensive Care Thoratec on the ward Novacor out of hospital
Case 1
40 yr old female lawyer, N Coast 30 cigarettes daily, Hypertension Severe chest pain, nausea, diaphoresis Refused thrombolysis Medical therapy
Case 2
77 yr old female Independent with medical therapy for ischemic cardiomyopathy and hypertension Known moderate LV impairment (EF ~40%) Sudden onset of increasing breathlessness No chest pain
Case 3
19 yr old indigenous Australian 22 wks pregnant Intermittent palpitations Increasing dyspnoea and peripheral oedema
Case 4
70 yr old surgeon Sudden dyspnoea after driving off 1 st tee Previously well with no CV history Loud apical PSM on auscultation with pulmonary oedema
Case 5
24 yr old Chinese basketballer ?Deteriorating physical fitness
Case 6
43 yr old radio presenter ESRF secondary to wegeners granulomatosus, x3/wk HD Hypertensive Inceasingly dyspnoeic
Heart Failure 2000: Therapeutic Options
CPAP
Medical Therapy
ß-blockers ACE-Inhibitors Spironolactone Angio-II blockers diuretics Exercise digoxin Bi-ventricular pacing?
Myoplasty?
Surgical Therapy
High risk conventional surgery
LVADs
Transplantation Left Ventricular reduction surgery?
Tolerance?
Xenografts?
Total artificial heart?