Transcript Congestive Heart Failure: Update 2002 Bruce D. Hettleman, MD DHMC
Congestive Heart Failure: Update 2002 Bruce D. Hettleman, MD DHMC December 2, 2002
CASE PRESENTATION
• 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990. • Echo demonstrated a severely dilated LV with an EF of 20% and 3+/4 mitral regurgitation.
• EKG showed sinus rhythm at 52 with first degree AV block and LBBB.
• Cardiac Cath revealed a patent IMA to the LAD, patent SVG to the RCA and a severely diseased SVG to the circumflex.
What should be done once the patient is initially stabilized?
• 1. Perform urgent repeat bypass surgery and mitral valve replacement.
• 2.Perform percutaneous intervention (stent) on the SVG to the circumflex.
• 3. Put in a dual chamber pacemaker • 4.Maximize medical therapy because he is too high a risk for revascularization.
Case Presentation--Continued
• After stenting the SVG to the circumflex his pulmonary edema subsequently responded to medical therapy and he was able to ambulate but remained Class III CHF.
• Discharge medications consisted of a diuretic,digoxin, beta blocker, ace inhibitor, aspirin, plavix and spironolactone.
• He was given dietary and weight-based diuretic adjustment guidelines.
• Follow-up in CHF Clinic was scheduled for 1 month.
What is the most likely adverse event after adding aldactone in the treatment of CHF?
• 1. Hypotension • 2. Breast enlargement • 3. Yellow vision • 4. Hyperkalemia • 5. Worsening CHF
After starting aldactone in Class IV CHF, when should electrolytes be rechecked?
• 1. No worries, mate • 2. One week ( big worries, mate) • 3. Four weeks • 4. Three months
Potassium Level 2 1 0 8 7 4 3 6 5 JNRY 15 JNRY 25 20-Feb 1-Apr Potassium
Drugs that have shown to prolong life in CHF are:
• 1. ACE inhibitors • 2. Beta Blockers • 3. Digoxin • 4. Aldactone • 5. 1,2 and 4
DIG Trial: Effect of Digoxin on Survival in CHF
•
NHLBI sponsored study of 7,788 patients with class II and III CHF and LVEFs < 45% or > 45%
•
Randomized, controlled, double-blinded
•
93% of patients on ACEIs
•
Superimposable survival curves
•
25% reduction with Dig on first CHF hospitalization
Weight of Evidence: ACE Inhibitors
Approximately 7000 patients evaluated in long-term placebo-controlled clinical trials Improvement in cardiac function, symptoms, and clinical status; equivocal effects on exercise tolerance Decrease in all-cause mortality by 20%-25% (
P
<.001) and decrease in combined risk of death and hospitalization by 30%-35% (
P
<.001) - Effect shown in SOLVD Treatment, CONSENSUS, and V-HeFT II trials Garg and Yusuf, 1995.
Weight of Evidence:
-Blockade
Traditionally contraindicated in heart failure, due to impaired inotropy, early lack of tolerability, and worsening heart failure Over 10,000 patients have now been evaluated in long-term placebo-controlled clinical trials; Improvement in cardiac function and NYHA class; and decrease in mortality and morbidity shown in multiple clinical trials Effects shown in patients
already receiving ACE inhibitors
Improved survival with aldactone in advanced CHF--Rales Trial
Will a permanent pacemaker help this man?
• 1. No, he has no indication for a pacemaker and if you put one in medicare will send you the bill.
• 2. Yes, he should have a VVI back up pacemaker prior to discharge because he has LBBB and may unpredictably develop complete heart block and die.
• 3. Yes, the placement of a routine DDD pacemaker will reliably improve his hemodynamics • 4.Yes, he ought to have a brand-spankin new biventricular resynchronization device because he has LBBB.
Cardiac Resynchronization Therapy for Heart Failure
Mechanisms, Clinical Outcomes, Patient Selection, and Implant
Ventricular Dysynchrony and Cardiac Resynchronization
• Ventricular Dysynchrony 1 –
Electrical:
Inter- or Intraventricular conduction delays typically manifested as left bundle branch block –
Structural:
disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency –
Mechanical:
Regional wall motion abnormalities with increased workload and stress —compromising ventricular mechanics • Cardiac Resynchronization – Therapeutic intent of atrial synchronized biventricular pacing • Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony • Complement to optimal medical therapy 1 Tavazzi L. Eur Heart J 2000;21:1211-1214
Animation – Ventricular Dysynchrony
Click to Start/Stop
Cardiac Resynchronization
Click to Start/Stop
Clinical Consequences of Ventricular Dysynchrony
• • • • • • Abnormal interventricular septal wall motion 1 Reduced dP/dt Reduced pulse pressure 4 3,4 Reduced EF and CO 4 Reduced diastolic filling time 1,2,4 Prolonged MR duration 1,2,4 1 Grines CL, Bashore TM, Boudoulas H, et al.
Circulation
1989;79:845-853.
2 Xiao, HB, Lee CH, Gibson DG.
Br Heart J
1991;66:443-447.
3 Xiao HB, Brecker SJD, Gibson DG.
Br Heart J
1992;68:403-407.
4 Yu C-M, Chau E, Sanderson JE, et al.
Circulation
. 2002;105:438-445.
Proposed Mechanisms: Improved Intraventricular Synchrony Improved Intraventricular Synchrony 1,2
dP/dt 1,3,4
EF 1,5 Pulse Pressure 3,4
SV&CO 1, 2
MR 1
LVESV 1
LA Pressure 1
1 Yu C-M, Chau E, Sanderson J, et al.
Circulation
2002;105:438-445 2 S øgaard P, Kim W, Jensen H, et al.
Cardiology
2001;95:173-182 3 Kass D Chen-Huan C, Curry C, et al.
Circulation
4 Auricchio A, Ding J, Spinelli J, et al. 1999;99:1567-73
J Am Coll Cardiol
2002;39:1163-1169 5 Stellbrink C, Breithardt O, Franke A, et al.
J Am Coll Cardiol
2001;38:1957- 65
Prevalence of Inter- or Intraventricular Conduction Delay
General HF Population 1,2 Moderate to Severe HF Population 3,4,5
IVCD >30% IVCD 15%
1 2 3 4 5 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293 Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250
Increased Mortality Rate with LBBB
• Increased 1-year mortality with presence of complete LBBB (QRS > 140 ms) • Risk remains significant even after adjusting for age, underlying cardiac disease, indicators of HF severity, and HF medications * HR = Hazard Ratio
20 15 HR * 1.70
(1.41-2.05) 16.1
All patients N=5517 LBBB N=1391 10 5 0 11.9
HR * 1.58
(1.21-2.06) 7.3
5.5
All Cause Sudden Cardiac Cause of Death
Baldasseroni S, Opasich C, Gorini M, et al. Am Heart J 2002;143:398-405
Proposed Mechanisms of Cardiac Resynchronization Improved Intraventricular Synchrony Cardiac Resynchronization Improved Atrioventricular Synchrony Improved Interventricular Synchrony
Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445
Summary of Proposed Mechanisms Cardiac Resynchronization Intraventricular Synchrony Atrioventricular Synchrony Interventricular Synchrony
(
dP/dt,
EF,
CO Pulse Pressure)
MR
LA Pressure
LV Diastolic Filling
RV Stroke Volume
LVESV
LVEDV Reverse Remodeling
Yu C-M, Chau E, Sanderson J, et al.
Circulation
2002;105:438-445
Achieving Cardiac Resynchronization Mechanical Goal: Atrial-synchronized bi-ventricular pacing
• Transvenous Approach – – – Standard pacing lead in RA Standard pacing or defibrillation lead in RV Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus
Right Atrial Lead Left Ventricular Lead Right Ventricular Lead
CRT Improves Quality of Life Score and NYHA Functional Class QoL NYHA
PATH-CHF 1 (n=41) InSync (Europe) 2 (n=103) InSync ICD (Europe) 3 (n=84) MUSTIC 4 (n=67)
+ + + + + + +
MIRACLE 5 (n=453)
+ +
MIRACLE ICD 6 (n=364)
+
Blank
+ +
Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.
J Am Coll Cardiol
2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.
Eur J Heart Failure
Kuhlkamp V.
JACC
2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.
J Am Coll Cardiol
2002;4:311-320 2002;40:111-118 5 Abraham W, Fisher W, Smith A, et al.
N Engl J Med.
2002;346:1845-1853 6 Leon A.
NASPE Scientific Sessions – Late Breaking Clinical Trials.
May 2002; Medtronic Inc. data on file
CRT Improves Exercise Capacity 6 Min Walk Peak VO 2 Exercise Time
PATH-CHF 1 (n=41) InSync (Europe) 2 (n=103) InSync ICD (Europe) 3 (n=84) MUSTIC 4 (n=67) MIRACLE 5 (n=453) MIRACLE ICD 6
+
Blank (n=364)
+ + + + +
+
+ + + +
Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.
J Am Coll Cardiol
2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.
Eur J Heart Failure
Kuhlkamp V.
JACC
2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.
J Am Coll Cardiol
2002;4:311-320 2002;40:111-118 5 Abraham W, Fisher W, Smith A, et al.
N Engl J Med.
2002;346:1845-1853 6 Leon A.
NASPE Scientific Sessions – Late Breaking Clinical Trials.
May 2002; Medtronic Inc., data on file
CRT Improves Cardiac Function/Structure LVEF MR Other
PATH-CHF 1 (n=41) + LVEDP + LV dP/dt max InSync (Europe) 2 (n=103)
+
+ Filling Time InSync ICD (Europe) MUSTIC 4 (n=67) 3 (n=84)
+
+ Filling Time LVEDD,LVESD Filling Time MIRACLE 5 (n=453) MIRACLE ICD 6
+
Blank (n=362)
+
+ +
+ LVEDD, + LVEDV, LVESV + LVESV, + LVEDV Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.
J Am Coll Cardiol
2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.
Eur J Heart Failure
Kuhlkamp V.
JACC
2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.
J Am Coll Cardiol
2002;4:311-320 2002;40:111-118 5 Abraham W, Fisher W, Smith A, et al.
N Engl J Med.
2002;346:1845-1853 6 Young J.
ACC Scientific Sessions – Late Breaking Clinical Trials III.
March 2002; Medtronic Inc., data on file
Cardiac Resynchronization Outcomes Sustained for at least 12 months NYHA QoL 6 Minute Walk Peak VO 2 InSync European and Canadian Study 1 (n=67, followed to 12 months) PATH-CHF Study 2 (n=29, followed to 12 months) MUSTIC Study 3 (n=42 in sinus rhythm group, n=33 in atrial fibrillation group followed to 12 months) + + + + + + + + + +
+
Statistically significant improvement with CRT (p 0.05) No statistically significant improvement with CRT Blank Indicates test neither performed nor reported 1 Gras D, Leclercq C, Tang A, et al.
Eur J Heart Fail
2002;4:311-320 2 Auricchio A. Stellbrink C, Sack S., et al.
J Am Coll Cardiol
2002;39:2026-2033 3 Linde C, Leclercq C, Rex S, et al.
J Am Coll Cardiol
2002;40:111-118
Step 1: Cannulate CS Attain LDS Model 6216A
•
Use extreme care when passing the guide catheter through vessels
•
Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations
Step 2: Perform Venograms Varying Patient Anatomy
1,2,3
Photos Courtesy of Dr. Daniel Gras
1. Potkin et al.
Am J Cardiol
1987;60:1418-1421 2. Neri et al.
Europace
2000;I :D95 Abstract 88/2 3. Hill et al.
Europace 2000;I:D238 Abstract 167/2
Step 2: Perform Venograms CS Os Middle Posterior Great Postero-lateral Antero lateral Lateral Anterior Cardiac Venous Anatomy
Step 2: Perform Venograms Lead in Lateral Cardiac Vein
Step 4: Place Lead Attain OTW Model 4193
Click to Start/Stop
Step 4: Place Lead Attain OTW Model 4193
Click to Start/Stop
Courtesy of Dr. Daniel Gras
LAO View: Tracking Over the Wire
Click to Start/Stop
Courtesy of Dr. Daniel Gras
Step 4: Place Leads Attain LV Model 2187
Click to Start/Stop
Video compliments of Dr. Vince Paul
Biventricular Pacing is indicated for the reduction of CHF symptoms in patients with:
• 1. Stable Class III-IV CHF • 2. QRS> 130 ms • 3.EF <35% • 4. Optimal medical therapy