ACUTE HEART FAILURE AFTER MYOCARDIAL INFARCTION Nurkić Midhat MD PhD FESC

ACUTE HEART FAILURE AFTER ACUTE HEART FAILURE AFTER MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION

Nurkić Midhat MD PhD FESCNurkić Midhat MD PhD FESC

• In most patients with heart failure due to left In most patients with heart failure due to left ventricular systolic dysfunction, the underlying ventricular systolic dysfunction, the underlying

cause is coronary heart diseasecause is coronary heart disease

• To reduce progression to heart failure in a To reduce progression to heart failure in a

patient with acute myocardial infarction, it is patient with acute myocardial infarction, it is important to achieve the earliest possible important to achieve the earliest possible

reperfusion, whether by thrombolysis or primary reperfusion, whether by thrombolysis or primary percutaneous coronary interventionpercutaneous coronary intervention

ACUTE HEART FAILUREACUTE HEART FAILURE

Sudden development of a large Sudden development of a large myocardial infarction or rupture of a myocardial infarction or rupture of a

cardiac valve in a patient who cardiac valve in a patient who previously was entirely wellpreviously was entirely well

LV Remodelling Post MILV Remodelling Post MIAcute infarctionAcute infarction

(hours)(hours)

Infarct expansionInfarct expansion(hours to days)(hours to days)

Global remodellingGlobal remodelling(days to months)(days to months)

• Acute heart failure (AHF) is the one of the Acute heart failure (AHF) is the one of the most common disorders encountered in most common disorders encountered in

medical practice, and is associated with a medical practice, and is associated with a high mortality and morbidity rate despite high mortality and morbidity rate despite

contemporary therapy contemporary therapy

Kannel et al, 1979Kannel et al, 1979

00 11 22 33 44 55 66 77 88 99DaysDays

Cumulative HF (%)Cumulative HF (%)

3030

2525

2020

1515

1010

55

00

YearsYears

TimeTime

10103030

Heart Failure after Acute MIHeart Failure after Acute MI

1 week1 week

EDV: 137 ml ESV: 80 mlEDV: 137 ml ESV: 80 mlEF: 41%EF: 41%

3 months3 months

EDV: 189 ml ESV: 146 mlEDV: 189 ml ESV: 146 mlEF: 23%EF: 23%

LV Remodelling Post Anteroseptal MILV Remodelling Post Anteroseptal MI

Apical 4 chamber view: End diastoleApical 4 chamber view: End diastole

Sharpe N. 2000Sharpe N. 2000

Heart failureHeart failure

• Clinical syndrome that may result from any Clinical syndrome that may result from any structural or functional cardiac disorder that structural or functional cardiac disorder that

impairs the pumping ability of the heartimpairs the pumping ability of the heart

• It not only reduces life expectancy but is It not only reduces life expectancy but is associated with symptoms of breathlessness, associated with symptoms of breathlessness, fluid retention and fatigue that markedly impair fluid retention and fatigue that markedly impair

quality of lifequality of life

Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.

Pathologicremodeling

Low ejectionfraction Death

Symptoms:DyspneaFatigueEdema

Chronicheartfailure

•Neurohormonalstimulation

•Endothelial dysfunction

•Myocardial toxicity

SuddenDeath

Pump failure

Coronary artery disease

Hypertension

Cardiomyopathy

Valvular disease

Myocardialinjury

Pathologic Progression of CV DiseasePathologic Progression of CV Disease

Diabetes

Explosive Increase in HFExplosive Increase in HFAHA.Heart Disease and Stroke Statistics – 2005 UpdateAHA.Heart Disease and Stroke Statistics – 2005 Update

• 1979 – 2002: Hospital discharges from HF rose from 1979 – 2002: Hospital discharges from HF rose from 377,000 to 970,000 per year377,000 to 970,000 per year

• 1992 – 2002: Deaths increased 35.3%1992 – 2002: Deaths increased 35.3%

• Number of patients with HF is expected to double in 30 Number of patients with HF is expected to double in 30 yearsyears

Similarities Between Acute MI and Acute Similarities Between Acute MI and Acute Decompensated HF in the USDecompensated HF in the US

(Gheorghiade M, et al. Circulation 2005;112:3958-68)(Gheorghiade M, et al. Circulation 2005;112:3958-68)

Acute MIAcute MI ADHFADHF

IncidenceIncidence 1 million per year1 million per year 1 million per year1 million per year

MortalityMortality

In-hospitalIn-hospital 3–4%3–4% 3–4%3–4%

After discharge (60–90 After discharge (60–90 d)d) 2%2% 10%10%

Pathophysiological Pathophysiological target(s)target(s)

Clearly defined Clearly defined (coronary (coronary

thrombosis)thrombosis)UncertainUncertain

Clinical benefits of Clinical benefits of interventions in published interventions in published clinical trialsclinical trials

BeneficialBeneficialMinimal/no benefit or Minimal/no benefit or

deleterious compared with deleterious compared with placeboplacebo

ACC/AHA ACC/AHA recommendationsrecommendations

ManyManyLevel ALevel A NoneNone

Natural History of Chronic and Acute Natural History of Chronic and Acute Heart FailureHeart Failure

Initial phaseInitial phase Last yearLast year

Normal heartNormal heart Chronic heart failureChronic heart failure5 million in the US5 million in the US

10 million in Europe10 million in Europe

DeathDeath

Initial Initial myocardial myocardial

injuryinjury

First ADHF episode:First ADHF episode:Pulmonary edemaPulmonary edema

ER admissionER admission

Later ADHF episodes:Later ADHF episodes:Rescue therapyRescue therapyICU admissionICU admission

What if fluid overload What if fluid overload causes progressive HF?causes progressive HF?

Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.

Hea

rt V

iab

ility

Hea

rt V

iab

ility

Mechanism of Worsening HF with Renal Mechanism of Worsening HF with Renal DysfunctionDysfunction

Renal dysfunction

(Schrier RW. JACC 2006;47:1-8)

Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))

♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?

Current Treatment of Heart FailureCurrent Treatment of Heart Failure

Copyright restrictions may apply.

Fonarow, G. C. et al. JAMAFonarow, G. C. et al. JAMA 2005;293:572-580.2005;293:572-580.

Predictors of In-

Hospital Mortality

Heart Failure Risk Scoring SystemHeart Failure Risk Scoring System

Lee, D. S. et al. JAMA 2003;290:2581-2587.

Lee, D. S. et al. JAMA 2003;290:2581-2587.

Mortality Rates in Acutely Decompensated Heart Failure by Risk Score

They’re Sicker Than We ThinkThey’re Sicker Than We Think

•In-hospital: 3%In-hospital: 3%•30-day: 7.9%30-day: 7.9%

•One year: 30%One year: 30%•Five years: Five years: 60%60%

Baker, DW et al. Am Heart J 2003; 146(2): 258-64Baker, DW et al. Am Heart J 2003; 146(2): 258-64

Ho KK, et al. Circulation 1993; 88(1): 107-15Ho KK, et al. Circulation 1993; 88(1): 107-15

Jong P, et al. Arch Int Med 2002; 162(15) 1689-94Jong P, et al. Arch Int Med 2002; 162(15) 1689-94

Narang R ,et al. Eur Heart J 1996; 17(9) 1390-1403Narang R ,et al. Eur Heart J 1996; 17(9) 1390-1403

Mortality risk after 1Mortality risk after 1stst hospitalization for ADHF: hospitalization for ADHF:(Age, male gender, ischemia and decreased LVEF worsen (Age, male gender, ischemia and decreased LVEF worsen prognosis)prognosis)

Comparative Five Year MortalityComparative Five Year Mortality

• Adenocarcinoma of the colon (IIIB): 36%Adenocarcinoma of the colon (IIIB): 36%

• COPD (FEVCOPD (FEV11 30-39% predicted): 53% 30-39% predicted): 53%

• ESRD (dialysis-dependent): 60-80%ESRD (dialysis-dependent): 60-80%




Congestion in HF: Congestion in HF: Most Admitted Patients are “Wet”Most Admitted Patients are “Wet”

(ADHERE Registry. 3rd Qtr 2003 National Benchmark Report.)(ADHERE Registry. 3rd Qtr 2003 National Benchmark Report.)

89%

74%67% 65%

34%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Dyspnea PulmonaryCongestion

(CXR)

Rales PeripheralEdema

Dyspnea at Rest

Ad

mit

ted

Pat

ien

ts (

%)

<<

I I I I I I I I II I I I I I I I I

Time Course of Events Preceding Time Course of Events Preceding ADHF HospitalizationADHF Hospitalization

-90 -25 -20 -15 -10 -5 -90 -25 -20 -15 -10 -5 00 5 10 5 10 I I I I I I I I IIII I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Days Days

Admission Admission

Dyspnea Dyspnea (8-9)(8-9)

Cough Cough (10)(10)

Weight gain Weight gain (11)(11)

Edema Edema (12)(12)

Edema, Edema, Cough,Cough,Fatigue Fatigue (7)(7)

Dyspnea Dyspnea (3)(3)

(-89 to -1)(-89 to -1)

(-25 to -5)(-25 to -5)

(-21 to ?)(-21 to ?)

ePAD ePAD (19)(19)

Thoracic Thoracic Impedance Impedance (15)(15)

SDAAM SDAAM (16)(16)

Rapid Assessment of Hemodynamic StatusRapid Assessment of Hemodynamic Status

Congestion at RestCongestion at Rest

LowLowPerfusionPerfusion

at Restat Rest

NO

NO YES

YES

Signs/Symptoms of Congestion:

Orthopnea / PNDJV DistensionHepatomegalyEdemaRales (rare in chronic

heart failure)Elevated est. PA

systolic( loud P2 and RV lift)

Valsalva square waveAbdominojugular

refluxS3Possible Evidence of Low Perfusion:

Narrow pulse pressure Cool extremitiesSleepy / obtunded Hypotension with ACE inhibitorLow serum sodium Renal Dysfunction (one cause)Elevated LFTs Pulsus alternans

Rapid Assessment of Hemodynamic StatusRapid Assessment of Hemodynamic Status

Congestion at RestCongestion at Rest

LowLowPerfusionPerfusion

at Restat Rest

NO

NO YES

YES

Warm & Dry

Warm & Wet

Cold & Wet

Cold & Dry

Nohria,J Cardiac Failure 2000;6:64

67%

28%5%

Potential Endpoints of Therapy in ADHFPotential Endpoints of Therapy in ADHF

• Resting symptomsResting symptoms• JVDJVD• RalesRales• EdemaEdema• PCW or Cardiac OutputPCW or Cardiac Output• BNPBNP• Echo (mitral regurgitation or PA Echo (mitral regurgitation or PA

pressure)pressure)

(Drazner M, et al. J Heart Lung Tx 1999;1126. Rosario, et al. JACC 1998;1819-24. Johnson, et (Drazner M, et al. J Heart Lung Tx 1999;1126. Rosario, et al. JACC 1998;1819-24. Johnson, et al. Ciruclation 1998 [abstract])al. Ciruclation 1998 [abstract])

Is the Swan-Ganz Catheter Useful in the Is the Swan-Ganz Catheter Useful in the Patient with Acute Decompensated HF?Patient with Acute Decompensated HF?

(Stevenson, et al. JAMA 2005;294:1625-1633)(Stevenson, et al. JAMA 2005;294:1625-1633)

NO

00 66 1212 1818 2424MonthsMonths

00

1010

2020

3030

4040

5050

6060

Total Mortality Risk%Total Mortality Risk%

199199

257257

PCW > 16 mmHgPCW > 16 mmHg

PCW PCW << 16 mmHg 16 mmHg

P=0.001P=0.001

00 66 1212 1818 2424MonthsMonths

00

1010

2020

3030

4040

5050

6060

Total Mortality Risk%Total Mortality Risk%

236236

220220

Cardiac Index > 2.6 L/min-MCardiac Index > 2.6 L/min-M22

Cardiac Index Cardiac Index << 2.6 L/min/M 2.6 L/min/M22

Early Response of PCW but not CI Predicts Early Response of PCW but not CI Predicts Subsequent Mortality in Advanced Heart FailureSubsequent Mortality in Advanced Heart Failure

Final hemodynamic measurement in 456 advanced HF patients after tailored vasodilator therapy Final hemodynamic measurement in 456 advanced HF patients after tailored vasodilator therapy

P=NSP=NS

(Fonarow G Circulation 1994;90:I-488)




BNP is Increased with HF and BNP is Increased with HF and Systolic or Diastolic DysfunctionSystolic or Diastolic Dysfunction

Maisel AS, et al. JACC 2003;41:2010Maisel AS, et al. JACC 2003;41:2010

BNP Levels Pre-discharge Predict Mortality BNP Levels Pre-discharge Predict Mortality and Readmisssionand Readmisssion

(Logeart D, et al. JACC 20042;40:976-82)(Logeart D, et al. JACC 20042;40:976-82)




Sodium Reabsorption Sites in the NephronSodium Reabsorption Sites in the Nephron

Proximal TubuleProximal Tubule70%70%

Distal TubuleDistal Tubule

20%20%

5%5%

1-4%1-4%Loop of HenleLoop of Henle

Collecting T

ubuleC

ollecting TubuleGlomerulusGlomerulus

Thiazide Thiazide DiureticsDiuretics

Loop Loop DiureticsDiuretics

Ceiling Doses of Loop Diuretics (mg)Ceiling Doses of Loop Diuretics (mg)

FurosemideFurosemide bumetanidebumetanide torsemicletorsemicle

IVIV popo IVIV popo IVIV popo

Renal InsufficiencyRenal Insufficiency

moderatemoderate 8080 8080 2-32-3 2-32-3 20-5020-50 20-5020-50

severesevere 200200 240240 8-108-10 8-108-10 50-10050-100 50-10050-100

Cirrhosis with Cirrhosis with

normal GFRnormal GFR4040 80-16080-160 11 11 10-2010-20 10-2010-20

CHF with normal GFRCHF with normal GFR 40-8040-80 160-160-240240 2-32-3 2-32-3 20-5020-50 20-5020-50

(Adapted from Brater C. New Engl J Med 1999)

Bioavailability of Loop DiureticsBioavailability of Loop Diuretics

100%100%

80%80%

50%50%

10%10%

--

--

--

--

furosemidefurosemide torsemidetorsemide bumetanidebumetanide




(de Silva, R. et al. Eur Heart J 2006 27:569-581)(de Silva, R. et al. Eur Heart J 2006 27:569-581)

Baseline Renal Dysfunction and Worsening Renal Function (WRF) are Additive in Predicting Mortality in HF Patients

sCreatinine ≤1.2 1.2-2.0 ≥2.0 ≤1.2 1.2-2.0 ≥2.0WRF (>0.3mg/dL) no no no yes yes yes

And a fall in sCr of >0.3 mg/dL was associated with improved mortality

Predictors of WRF were thiazidediuretics, increased BUN, and vascular disease

What to do when the creatinine begins to What to do when the creatinine begins to increase?increase?

• Check volume statusCheck volume status• Check blood pressure (especially at peak Check blood pressure (especially at peak

onset of vasodilators)onset of vasodilators)• Restrict sodium intake (and water if Restrict sodium intake (and water if

hyponatremic)hyponatremic)• Check for renal problems (obstructions, Check for renal problems (obstructions,

prooteinuria, interstitial nephritis)prooteinuria, interstitial nephritis)• Consider vasodilators or inotropesConsider vasodilators or inotropes• Consider ultrafiltrationConsider ultrafiltration

Ultrafiltration Improved Weight Loss But Ultrafiltration Improved Weight Loss But Not SymptomsNot Symptoms

Costanzo MR. American College of Cardiology 2006 Scientific Sessions; March 12, 2006; Atlanta, GA.

End pointsEnd points UltrafiltrationUltrafiltration DiuresisDiuresis pp

nn 8383 8484

48 hours48 hours

•Weight loss, primary end point Weight loss, primary end point (mean kg)(mean kg)

5.0 5.0 3.1 3.1 0.0010.001

•Dyspnea score, primary end Dyspnea score, primary end point (mean)point (mean)

6.46.4 6.16.1 0.350.35

•Net fluid loss (mean L)Net fluid loss (mean L) 4.64.6 3.33.3 0.0010.001

•K<3.5 mEq/L (%)K<3.5 mEq/L (%) 11 1212 0.0180.018

•Need for vasoactive drugs (%)Need for vasoactive drugs (%) 33 1313 0.0150.015

Ultrafiltration Decreased RehospitalizationUltrafiltration Decreased Rehospitalization

CostanzoCostanzo MR. MR. American College of Cardiology 2006 Scientific American College of Cardiology 2006 Scientific SessionsSessions; March 12, 2006; Atlanta, GA. ; March 12, 2006; Atlanta, GA.

End pointsEnd points UltrafiltrationUltrafiltration DiuresisDiuresis pp

90 days90 days

•Rehospitalization (%)Rehospitalization (%) 1818 3232 0.0220.022

•Rehospitalization days (mean)Rehospitalization days (mean) 1.41.4 3.83.8 0.0220.022

•Unscheduled office/ED visits (%)Unscheduled office/ED visits (%) 2121 4444 0.0090.009




ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-III CIBIS-III

(Willenheimer R, et al. Circulation 2005;112:2426-2435)

ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-IIICIBIS-III


Bisoprolol first

Enalapril first

(HR 0.94, CI = 077-1.16, = = 0.0.019 for noninferiority)



(HR 0.88, CI = 0.63-1.22, p = 0.44)

Bisoprolol first

Enalapril first

Survival


(Willenheimer R, et al. Circulation 2005;112:2426-2435)(Willenheimer R, et al. Circulation 2005;112:2426-2435)

Freedom from hospitalization for worsening HF

Bisoprolol first

Enalapril first

(HR = 1.25, CI = 0.87-1.81, p = 0.23)




Goals in the Treatment of the Patient with Goals in the Treatment of the Patient with Acutely Decompensated HFAcutely Decompensated HF

DiureticsDiuretics NesiritideNesiritide MilrinoneMilrinone

Improve symptomsImprove symptoms yes (+++)yes (+++) yes (+)yes (+) ??

Decrease mortalityDecrease mortality ?? ?(?(↑)↑) ?(?(↑)↑)

Decrease hospitalizationDecrease hospitalization

DurationDuration yesyes nono nono

Repeat hospitalizationRepeat hospitalization ?? nono nono

Decreased costsDecreased costs yesyes no(no(↑)↑) no(no(↑)↑)

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ACUTE HEART FAILURE AFTER MYOCARDIAL INFARCTION Nurkić Midhat MD PhD FESC