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Heart Failure Review and Update Through CasesHeart Failure Review and Update Through Cases
Ankie Amos, MD, FACCAlaska Heart Institute
April 2017
Ankie Amos, MD, FACCAlaska Heart Institute
April 2017
Why Care about Heart Failure?Why Care about Heart Failure?
83% of CHF patient are taken care of solely by primary care physicians.
Common Problem: 5 million have HF in the USA 550,000 are diagnosed with HF each year.
Mortality and Morbidity: 4 million hospitalizations per year 60% 5-year Mortality
Costly! > $32 billion spent on HF in the USA in
2011.
83% of CHF patient are taken care of solely by primary care physicians.
Common Problem: 5 million have HF in the USA 550,000 are diagnosed with HF each year.
Mortality and Morbidity: 4 million hospitalizations per year 60% 5-year Mortality
Costly! > $32 billion spent on HF in the USA in
2011.
Heart Failure Hospitalizations Remain Common
Heart Failure Hospitalizations Remain Common
Mozaffarian D et al. Circulation. 2015;131:e29-e322.
Coronary Heart Disease Heart Failure
Page 2
Heart Failure DefinitionHeart Failure Definition
Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or ejectblood.
Dyspnea, edema, fatigue
Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or ejectblood.
Dyspnea, edema, fatigue
The Changing Epidemiology of HFThe Changing Epidemiology of HF
Steinberg et al. Circulation. 2012; 126(1):65–75Oktay et al. Curr Heart Fail Rep. 2013 Dec;10(4):401-10
Heart Failure: The Tip of the Iceberg?Heart Failure: The Tip of the Iceberg?
Page 3
Heart Failure StagingHeart Failure Staging
At risk for HF-------------------> Heart FailureAt risk for HF-------------------> Heart Failure
Stage AAt High risk for HF
But without structuralHeart disease orSymptoms of HF.
Stage BStructural heart
Disease but withoutSigns or symptoms.
Stage CStructural heart disease
With prior or currentSymptoms.
Stage DRefractory HF
Requiring specialized Interventions.
Patients with:-HTN-CAD-DM-Obesity-Metabolic Syndrome
Patients with:-Previous MI-LV remodeling-LVH-Low EF-Valvular disease
Patients with:-Structural Heart Ds-SOB/Fatigue-Reduced ExerciseTolerance
Patients with:-Rest Symptoms-On maximal medTherapy-Recurrent hosp.
Structural Hrt Ds Symptoms Refractory Rest Sx
Define your Heart Failure Patient!Define your Heart Failure Patient!
Heart Failure
L Heart Failure
R Heart Failure
HFpEFEF>50%
AdvancedChronic Stable
Acute Failure
New Onset
HFrEFEF <40%
Define Your Heart Failure PatientNYHA Class
Define Your Heart Failure PatientNYHA Class
I: NO symptoms
II: Symptoms with moderate activity
III: Symptoms with minimal activities of daily living
IV: Symptoms at rest
I: NO symptoms
II: Symptoms with moderate activity
III: Symptoms with minimal activities of daily living
IV: Symptoms at rest
Page 4
Case of Mr ACase of Mr A
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, minimal LE edema at feet
only, NO crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
What Quad is this patient in?
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, minimal LE edema at feet
only, NO crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
What Quad is this patient in?
The Quad of HF:A paradigm to Guide Treatment
The Quad of HF:A paradigm to Guide Treatment
Perfusion
VOLUME •BNP elevated
•Crackles in lung (dyspnea)•LE edema•Ascites•Increased weight•JVD
•Cr increased•AMS•Dyspnea•Elevated bilirubin/lfts-Abd pain•Hypotension•Feel cold in feet
HemodynamicsHemodynamics
Perfusion: CI: Digoxin, Inotropes SVR: Ace-I, ARBS, Nitrates/Hydralazine
Volume: PCW (Lung fluid): Diuretics only work if RA
pressure high! RA (peripheral fluid)=JVD:
Diuretics/ultrafiltration
Normal #’s: PCW 12, RA 5-10, CI >2, CO >4, SVR 900-1000.
Interrogate Device!! Many have Volume estimations or Echo.
Perfusion: CI: Digoxin, Inotropes SVR: Ace-I, ARBS, Nitrates/Hydralazine
Volume: PCW (Lung fluid): Diuretics only work if RA
pressure high! RA (peripheral fluid)=JVD:
Diuretics/ultrafiltration
Normal #’s: PCW 12, RA 5-10, CI >2, CO >4, SVR 900-1000.
Interrogate Device!! Many have Volume estimations or Echo.
Page 5
Hemodynamics in the QuadHemodynamics in the Quad
Perfusion
VOLUME
•RA/CVP: Normal•PCW: Normal•CI/CO: Low•SVR: High
•RA/CVP: 5-10•PCW: 10-15•CI/CO: >2, >4•SVR: 1000
•RA/CVP: High•PCW: High•CI/CO: ok•SVR: ok
The Quad of HF: TreatmentsThe Quad of HF: Treatments
Perfusion
VOLUME
•Diuretics•HF Cocktail
HF “Cocktail”•Ace-I/ARB•Beta – blocker•Spironolactone•Hydralazine/Nitrates•Digoxin
•Afterload Reduction•Nitrates/hydralazine•Ace-I/ARB
•Inotropes•Dobutamine•Milrinone
•Same as these quads
Case of Mr ACase of Mr A
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, No LE edema, NO crackles.
Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
Would you change anything?
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, No LE edema, NO crackles.
Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
Would you change anything?
Page 6
Target Doses: Important!Target Doses: Important!
Goal SBP: As low as they can tolerate!Goal HR 50’s
Goal SBP: As low as they can tolerate!Goal HR 50’s
What therapy changes would you recommend?What therapy changes would you recommend?
1. Add digoxin 0.25mg a day
2. Increase Coreg to 50mg BID
3. Add spironolactone 25mg a day
4. Switch Lisinopril to Entresto
5. No changes recommended
1. Add digoxin 0.25mg a day
2. Increase Coreg to 50mg BID
3. Add spironolactone 25mg a day
4. Switch Lisinopril to Entresto
5. No changes recommended
Page 7
Chronic Heart Failure : ENTRESTOChronic Heart Failure : ENTRESTO
Entresto now a class I recommendation for NYHA Class 2/3 on maximized ace/arb and BB
Entresto now a class I recommendation for NYHA Class 2/3 on maximized ace/arb and BB
Page 8
Who were the Patients?Who were the Patients?
<10% were in the USA
5% were African American
Mostly Class II-III HF with “sturdy BP”
<10% were in the USA
5% were African American
Mostly Class II-III HF with “sturdy BP”
Results of ParadigmResults of Paradigm
Stopped Early due to dramatic benefit
20% reduction of Mortality
Significant differences in 30 days.
More decreased death than all other HF trials combined and more patients than all other trials combined.
To prevent one death, need to treat 32 patients.
Stopped Early due to dramatic benefit
20% reduction of Mortality
Significant differences in 30 days.
More decreased death than all other HF trials combined and more patients than all other trials combined.
To prevent one death, need to treat 32 patients.
Page 9
10%
20%
30%
40%
ACEinhibitorARB
0%
Sacubitril/valsartan
% D
ecre
ase
in M
orta
lity 15%
16%
Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial.Effect of ARB vs placebo CHARM-Alternative and CHARM-Added,Effect of LCZ696 vs ACE inhibitor derived from PARADIGM-HF trial.
Sacubitril/valsartan doubles the survival benefit of current renin-angiotensin inhibitors
Sacubitril/valsartan doubles the survival benefit of current renin-angiotensin inhibitors
Neprilysin inhibition
Practical Entresto TidbitsPractical Entresto Tidbits
Not in Liver Failure
Contraindicated with Ace-I (36hr washout) Consider switching to ARB for 36 hrs
If following serial BNP’s, they will rise. Better to follow NT-BNP or pro-bnp
Not in Liver Failure
Contraindicated with Ace-I (36hr washout) Consider switching to ARB for 36 hrs
If following serial BNP’s, they will rise. Better to follow NT-BNP or pro-bnp
Switching to EntrestoSwitching to Entresto
Page 10
Mortality Reduction of Evidence Based ManagementMortality Reduction of Evidence Based Management
ACE Inhibitors/ARB 17-36%
ARB/Neprilysin (Entresto) 16-20%
β-blockers 20-35%
Hydralazine/nitrates 30%
Aldactone 25-30%
Inotropic Drugs 36-50% increase
ACE Inhibitors/ARB 17-36%
ARB/Neprilysin (Entresto) 16-20%
β-blockers 20-35%
Hydralazine/nitrates 30%
Aldactone 25-30%
Inotropic Drugs 36-50% increase
Mentz, Felker, Mann. Heart Failure, a Companion to Braunwald’s Heart Disease. 2014
New Developments in HF Therapy: 1999 EditionNew Developments in HF Therapy: 1999 Edition
The Body’s adaption to the disease becomes as important than the initial insult itself
The Body’s adaption to the disease becomes as important than the initial insult itself
Page 11
Adapted from Packer M. Prog Cardiovasc Dis. 1998;39(suppl I):39–52.
CNS sympathetic outflow
1-receptors
Cardiac sympathetic activity
2-receptors
1-receptors Activation
of RAS
VasoconstrictionSodium retention
Myocyte hypertrophy, dilation,ischemia, arrhythmias, death
Disease progression
Neurohormonal Hypothesis:SNS Activation Leads Directly to Impaired Cardiac Fnx
Sympathetic activity tokidneys + blood vessels
Lasix
RemodelingRemodeling
1 week 3 months
EDV 137 mL ESV 80 mLEF 41%
EDV 189 mL ESV 146 mLEF 23%
Apical 4 Chamber View
Chamber Enlargement
Page 12
Answer of Mr A CaseAnswer of Mr A Case
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, 1+ LE edema at feet only, NO
crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
Switch Lisinopril to Entresto!
Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8
years) Vitals: BP 128/65, P 72 PE: No JVD, 1+ LE edema at feet only, NO
crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg
BID, Lasix 10mg a day
Switch Lisinopril to Entresto!
Case Mr. ABCCase Mr. ABC
65yo with a PMH of an ICM with a stable EF of 30%, NYHA class II HF, CKD (Cr 1.8) presenting for routine follow up. Meds: Coreg 50mg BID, Entresto
97/103mg BID, Spironolactone 25mg QD, Lasix 20mg QD
Vitals: HR 95, BP 128/78 PE: Euvolemic
Do these vitals make sense?
65yo with a PMH of an ICM with a stable EF of 30%, NYHA class II HF, CKD (Cr 1.8) presenting for routine follow up. Meds: Coreg 50mg BID, Entresto
97/103mg BID, Spironolactone 25mg QD, Lasix 20mg QD
Vitals: HR 95, BP 128/78 PE: Euvolemic
Do these vitals make sense?
Case Mr. ABC: Compliance?Case Mr. ABC: Compliance?
CHF Medication non-adhearance is common After a hospital DC, 80% are still on their Ace-I
at 1 mo, only 60% at 1 year. 1 year after initiation of CHF meds, 10% are
still on the full regimen at the end of 1 year Moname M et al; Arch Int Med 1994; 154: 433-437. Vanderwal et al. Int J Cardiol 2008; 125: 203-208
Think about remembering 6-10 meds 3 times a day plus a regimen fluid/salt restriction (possibly also low sugar?). Takes high IQ, organization, Literacy Consider neurocognitive testing, mini-mental
status testing.
CHF Medication non-adhearance is common After a hospital DC, 80% are still on their Ace-I
at 1 mo, only 60% at 1 year. 1 year after initiation of CHF meds, 10% are
still on the full regimen at the end of 1 year Moname M et al; Arch Int Med 1994; 154: 433-437. Vanderwal et al. Int J Cardiol 2008; 125: 203-208
Think about remembering 6-10 meds 3 times a day plus a regimen fluid/salt restriction (possibly also low sugar?). Takes high IQ, organization, Literacy Consider neurocognitive testing, mini-mental
status testing.
Page 13
Super Bowl Sunday:Mean Heart Failure Admissions During Holidays
Super Bowl Sunday:Mean Heart Failure Admissions During HolidaysHoliday 4 Immediate
post-holiday Days
The month – 4 immediate post
holiday days
Holiday itself
Independence Day 5.6 5 3.8
Thanksgiving 5.7 5.6 4.2
Christmas 6.5 5.5 3.6
New Year’s 6.5 6.3 5.1
Superbowl Sunday 7 6.2 5.5
Shah, et al. HFSA poster 2014. Study of 12,727 CHF admits in Philadelphia.
Case Mr. ABCCase Mr. ABC
Assuming compliance, what med can be added to lower CV death and hospitalization? Meds: Coreg 50mg BID, Entresto
97/103mg BID, Spironolactone 25mg QD, Lasix 20mg QD
Vitals: HR 95, BP 128/78
Assuming compliance, what med can be added to lower CV death and hospitalization? Meds: Coreg 50mg BID, Entresto
97/103mg BID, Spironolactone 25mg QD, Lasix 20mg QD
Vitals: HR 95, BP 128/78
SHIFT Trial: Corlanor/IvabradineSHIFT Trial: Corlanor/Ivabradine >6500 patients with Class II-IV CHF and EF
<35%.
Corlanor/ivabradine adjusted to achieve a HR 50-60
Approved for Chronic, stable HF with HR >70 maximized on a BB.
18% decrease in CV death/hospitalization
(Criticism: not all patients on target BB therapy)
2016 HF Guidelines: Class IIarecommendation
>6500 patients with Class II-IV CHF and EF <35%.
Corlanor/ivabradine adjusted to achieve a HR 50-60
Approved for Chronic, stable HF with HR >70 maximized on a BB.
18% decrease in CV death/hospitalization
(Criticism: not all patients on target BB therapy)
2016 HF Guidelines: Class IIarecommendation
Page 14
Heart Rate as a Risk Factor in HFHeart Rate as a Risk Factor in HF
Bohm, M et al Lancet 2010
Ivabradine/Corlanor:Selectively blocks the Hyperpolarization-activated
cyclic nucleotide-gated Channel. (HCN)
Ivabradine/Corlanor:Selectively blocks the Hyperpolarization-activated
cyclic nucleotide-gated Channel. (HCN)
Corlanor Reduced the RR of hospitalization for worsening HF by 26%
Corlanor Reduced the RR of hospitalization for worsening HF by 26%
Page 15
Case Mr. ZCase Mr. Z
59yo with an ICM who has been in the hospital 9 times over a year for heart failure – he presents with SOB. Last cath 2 mo ago – Prior stents in LAD and RCA
patent. LCX non-dominant. Echo: 6 mo ago: EF 30% (down from 45% 1 yr
ago) Meds: Coreg CR 20, Lisinopril 10 BID, Lasix 80
qd, Kcl 40 qd Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA.
JVD 8cm, Lungs – decreased BS at bases, CV –tachy, RR, pmi displaced, SEM at LLSB 3/6, Ext –cool,trace edema
Labs: Na 128, K 5, Cr 1.9 (baseline 0.9), Hct 29,
59yo with an ICM who has been in the hospital 9 times over a year for heart failure – he presents with SOB. Last cath 2 mo ago – Prior stents in LAD and RCA
patent. LCX non-dominant. Echo: 6 mo ago: EF 30% (down from 45% 1 yr
ago) Meds: Coreg CR 20, Lisinopril 10 BID, Lasix 80
qd, Kcl 40 qd Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA.
JVD 8cm, Lungs – decreased BS at bases, CV –tachy, RR, pmi displaced, SEM at LLSB 3/6, Ext –cool,trace edema
Labs: Na 128, K 5, Cr 1.9 (baseline 0.9), Hct 29,
Case Mr Z:Case Mr Z:
What would you do first? 1) Increase lisinopril by 2.5mg a day 2) Re-echo 3) Cath or stress MRI 4) Give Lasix 80mg IV in clinic
What Quad is the patient in?
What would you do first? 1) Increase lisinopril by 2.5mg a day 2) Re-echo 3) Cath or stress MRI 4) Give Lasix 80mg IV in clinic
What Quad is the patient in?
The Quad of HF: Patient Physical ExamThe Quad of HF: Patient Physical Exam
Lasix would not help symptoms, may worsen.
Increasing lisinopril with a high K and Cr and low BP would probably worsen things.
Lasix would not help symptoms, may worsen.
Increasing lisinopril with a high K and Cr and low BP would probably worsen things.
Perfusion
VOLUME
•Cold hands/feet•Confusion, fatigue•Abdominal pain•Labs: Elevated Bili, LFt’s, Cr
Page 16
Definition of Heart Failure: StagingDefinition of Heart Failure: Staging
At risk for HF-------------------> Heart FailureAt risk for HF-------------------> Heart Failure
Stage AAt High risk for HF
But without structuralHeart disease orSymptoms of HF.
Stage BStructural heart
Disease but withoutSigns or symptoms.
Stage CStructural heart disease
With prior or currentSymptoms.
Stage DRefractory HF
Requiring specialized Interventions.
Patients with:-HTN-CAD-DM-Obesity-Metabolic Syndrome
Patients with:-Previous MI-LV remodeling-LVH-Low EF-Valvular disease
Patients with:-Structural Heart Ds-SOB/Fatigue-Reduced ExerciseTolerance
Patients with:-Rest Symptoms-On maximal medTherapy-Recurrent hosp.
Structural Hrt Ds Symptoms Refractory Rest Sx
Clinical Events and Findings Useful for Identifying Patients With Advanced HFClinical Events and Findings Useful for Identifying Patients With Advanced HF
Repeated (≥2) hospitalizations or ED visits for HF in the past yearProgressive deterioration in renal function (e.g., rise in BUN and creatinine)Weight loss without other cause (e.g., cardiac cachexia)Intolerance to ACE inhibitors due to hypotension and/or worsening renal functionIntolerance to beta blockers due to worsening HF or hypotensionFrequent systolic blood pressure <90 mm HgPersistent dyspnea with dressing or bathing requiring restInability to walk 1 block on the level ground due to dyspnea or fatigueRecent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapyProgressive decline in serum sodium, usually to <133 mEq/LFrequent ICD shocks
Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.
Highest Risk IndicatorsHighest Risk Indicators
Drug Intolerance
Lasix > 1.5mg/kg/day
BUN > 40
Drug Intolerance
Lasix > 1.5mg/kg/day
BUN > 40
Adapted from Russell SD, et al.
64% 1-year Mortality
Page 17
Recognize Stage D Heart Failure: Options
Recognize Stage D Heart Failure: Options
Options:1. Hospice2. Home Inotropes3. Mechanical support4. Transplant
Options:1. Hospice2. Home Inotropes3. Mechanical support4. Transplant
Mechanical Circulatory SupportMechanical Circulatory Support
DT Trial CAP: BackgroundDT Trial CAP: Background
1 Slaughter MS, Rogers JG, Milano CA et al: Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009 Dec 3;361(23):2241-51.
2 Fang JC: Rise of Machines – Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure N Engl J Med. 2009 Dec 3;361(23):2282-84.Source: Park SJ, AHA 2010
Page 18
HeartMate III TrialHeartMate III Trial
Worldwide HeartMate II Clinical ExperienceWorldwide HeartMate II Clinical ExperienceMore than 20,000+ patients worldwide have now been implanted with the HeartMate II®LVAS.
Over 6,000 patients on ongoing support
Patients supported ≥ 1 year: 1,634
Patients supported ≥ 2 years: 963
Patients supported ≥ 5 years: 143
8 Years is the longest
As of April 2016
*Based on clinical trial and device tracking data
More than 20,000+ patients worldwide have now been implanted with the HeartMate II®LVAS.
Over 6,000 patients on ongoing support
Patients supported ≥ 1 year: 1,634
Patients supported ≥ 2 years: 963
Patients supported ≥ 5 years: 143
8 Years is the longest
As of April 2016
*Based on clinical trial and device tracking data
HeartmatePatients
HeartmatePatients
Page 19
HeartMate II VADHeartMate II VAD
JarvickJarvick
Mastoid Bone Exit or Abdominal Mastoid Bone Exit or Abdominal
Heartware DeviceHeartware Device
Centrifugal pump Centrifugal pump
Page 20
HeartMate III TrialHeartMate III Trial
Smaller
Pulse Technology -Lower GI bleeding?
Magnetically levitated centrifugal pump
Smaller
Pulse Technology -Lower GI bleeding?
Magnetically levitated centrifugal pump
Case Mrs. DNCase Mrs. DN
33yo dx 3 mo ago with a PPCM EF 10% and recent h/o meth use who presents to the ER with abd pain. Cardiology consulted pre-op choly. Vitals: BP 90/66, P 110 Exam: +JVD, +crackles, no LE edema,
abd bloating per report, warm ext Labs: WBC nl, Hct 33, Cr 1.9, Bilirubin 2 Abd ultrasound unremarkable except for
ascites
Dx?
33yo dx 3 mo ago with a PPCM EF 10% and recent h/o meth use who presents to the ER with abd pain. Cardiology consulted pre-op choly. Vitals: BP 90/66, P 110 Exam: +JVD, +crackles, no LE edema,
abd bloating per report, warm ext Labs: WBC nl, Hct 33, Cr 1.9, Bilirubin 2 Abd ultrasound unremarkable except for
ascites
Dx?
Case Ms. DNCase Ms. DN
What is best first step? Clear for Choly Dobutamine Digoxin Hydralazine/nitrates
What is best first step? Clear for Choly Dobutamine Digoxin Hydralazine/nitrates
Page 21
The Quad of HF:A paradigm to Guide Treatment
The Quad of HF:A paradigm to Guide Treatment
Perfusion
VOLUME •BNP elevated
•Crackles in lung (dyspnea)•LE edema•Ascites•Increased weight•JVD
•Cr increased•AMS•Dyspnea•Elevated bilirubin/lfts-Abd pain•Hypotension•Feel cold in feet
Hemodynamics in the QuadHemodynamics in the Quad
Perfusion
VOLUME
•RA/CVP: Normal•PCW: Normal•CI/CO: Low•SVR: High
•RA/CVP: 5-10•PCW: 10-15•CI/CO: >2, >4•SVR: 1000
•RA/CVP: High•PCW: High•CI/CO: ok•SVR: ok
The Quad of HF: TreatmentsThe Quad of HF: Treatments
Perfusion
VOLUME
•Diuretics•HF Cocktail
HF “Cocktail”•Ace-I/ARB•Beta – blocker•Spironolactone•Hydralazine/Nitrates•Digoxin
•Afterload Reduction•Nitrates/hydralazine•Ace-I/ARB
•Inotropes•Dobutamine•Milrinone
•Same as these quads
Page 22
Case Ms DN: RHC on patientCase Ms DN: RHC on patient
RHC: CI 1.3, RA 5, PCW 30, SVR 2010 RHC: CI 1.3, RA 5, PCW 30, SVR 2010
Case Ms DN: Answer?Case Ms DN: Answer?
What is best first step? Dobutamine Digoxin Cholyctectomy Hydralazine/nitrates Nipride
What is best first step? Dobutamine Digoxin Cholyctectomy Hydralazine/nitrates Nipride
HFSA GuidelinesHFSA Guidelines
When adjunctive therapy is needed in patients with ADHF, administration of vasodilators should be considered instead of intravenous inotropes (milrinone or dobutamine). (Strength of Evidence 5 C)
When adjunctive therapy is needed in patients with ADHF, administration of vasodilators should be considered instead of intravenous inotropes (milrinone or dobutamine). (Strength of Evidence 5 C)
Page 23
HFSA Guidelines for our patientHFSA Guidelines for our patient
12.20 Intravenous inotropes (milrinone or dobutamine) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by LV dilation, reduced LVEF, and diminished peripheral perfusion or end-organ dysfunction (low output syndrome), particularly if these patients have marginal systolic blood pressure (! 90 mm Hg), have symptomatic hypotension despite adequate filling pressure, or are unresponsive to, or intolerant of, intravenous vasodilators. (Strength of Evidence 5 C)
12.20 Intravenous inotropes (milrinone or dobutamine) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by LV dilation, reduced LVEF, and diminished peripheral perfusion or end-organ dysfunction (low output syndrome), particularly if these patients have marginal systolic blood pressure (! 90 mm Hg), have symptomatic hypotension despite adequate filling pressure, or are unresponsive to, or intolerant of, intravenous vasodilators. (Strength of Evidence 5 C)
Journal of Cardiac Failure Vol. 16 No. 6 2010
The Failing Heart is more Afterload sensitive than the normal LV
The Failing Heart is more Afterload sensitive than the normal LV
Vasodilators Increase
Stroke Volume BP stays the
same
Vasodilators Increase
Stroke Volume BP stays the
same
Acute Heart Failure and Vasodilators:Do not hold meds if SBP >90!!
Acute Heart Failure and Vasodilators:Do not hold meds if SBP >90!!
By afterload reducing with vasodilators (hydralazine, nitrates, ace-I)
Stroke volume
Blood pressure
By afterload reducing with vasodilators (hydralazine, nitrates, ace-I)
Stroke volume
Blood pressure
Page 24
What we did: Patient Cold and wetWhat we did: Patient Cold and wet
Afterload reduction (Target SVR) with hydralazine/isosorbide/captopril
Lasix gtt at 5mg/hr
Bp stayed the same/then increased. HR decreased.
Bilirubin normalized, Cr normalized
Afterload reduction (Target SVR) with hydralazine/isosorbide/captopril
Lasix gtt at 5mg/hr
Bp stayed the same/then increased. HR decreased.
Bilirubin normalized, Cr normalized
Case Mr. SWCase Mr. SW
Mr. SW is a 63yo with a PMH of morbid obesity (BMI 50), Sleep apnea, and COPD who presents with SOB and edema. Over 3 mo he has gained 65lbs Vitals: BP 98/62, P 90, O2sat 89% on RA PE: JVD >20cm, CV: irr irr, mildly tachy,
Lungs – mild crackles, abd – ascites, Ext –anasarca – can pit up to mid chest. Feet are warm.
Labs: Cr 2, K 4, Hct 50
What kind of heart failure do you suspect?
Mr. SW is a 63yo with a PMH of morbid obesity (BMI 50), Sleep apnea, and COPD who presents with SOB and edema. Over 3 mo he has gained 65lbs Vitals: BP 98/62, P 90, O2sat 89% on RA PE: JVD >20cm, CV: irr irr, mildly tachy,
Lungs – mild crackles, abd – ascites, Ext –anasarca – can pit up to mid chest. Feet are warm.
Labs: Cr 2, K 4, Hct 50
What kind of heart failure do you suspect?
Case Mr SW: What kind of HF do you suspect?Case Mr SW: What kind of HF do you suspect?
1) Systolic left heart failure
2) Diastolic left heart failure
3) Right heart failure
4) This is not heart failure
1) Systolic left heart failure
2) Diastolic left heart failure
3) Right heart failure
4) This is not heart failure
Page 25
Pickwickian:Classic RV
Failure
Pickwickian:Classic RV
Failure
Afib
Hypotension
Renal failure
Anasarca
Afib
Hypotension
Renal failure
Anasarca
Case Mr. SW: What treatments would you suggest?Case Mr. SW: What treatments would you suggest?
1) Digoxin or inotropes?
2) Nesiritide
3) Lasix gtt or fluids?
5) Torsemide
6) Spironolactone
7) Isosorbide OR sildenafil
1) Digoxin or inotropes?
2) Nesiritide
3) Lasix gtt or fluids?
5) Torsemide
6) Spironolactone
7) Isosorbide OR sildenafil
What is the most common cause of Right Heart Failure?
What is the most common cause of Right Heart Failure?
Left heart failure Left heart failure
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Case Mr SW: Right Heart FailureThe cause is usually pulmonary.Case Mr SW: Right Heart FailureThe cause is usually pulmonary.
Pulmonary HTN work up: PFT V/Q scan for chronic PE’s LE U/s to rule out DVT Non-contrasted Chest CT Sleep study RHC with nitric oxide Echo with bubble
Pulmonary HTN work up: PFT V/Q scan for chronic PE’s LE U/s to rule out DVT Non-contrasted Chest CT Sleep study RHC with nitric oxide Echo with bubble
Case Mr. SWCase Mr. SW
Isolated RV failure TV issue? Carcinoid RV issue? Cardiac MRI
• ARVD
• Can consider RVAD
Isolated RV failure TV issue? Carcinoid RV issue? Cardiac MRI
• ARVD
• Can consider RVAD
RV Failure Treatment Strategies: No DataRV Failure Treatment Strategies: No Data
Reduce RV Afterload
Reduce RV Pressure
Increase RV contractility
Reduce RV Afterload
Reduce RV Pressure
Increase RV contractility
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RV failure Treatment Strategies: No DataRV failure Treatment Strategies: No Data
Reduce RV afterload O2 for hypoxia/CPAP Treat underlying causes for pulmonary
hypertension Sildenafil Isosorbide
Reduce RV Pressure Diuretics: Lasix gtt, high dose spiro Ultrafiltration *Careful as they are preload dependent
Reduce RV afterload O2 for hypoxia/CPAP Treat underlying causes for pulmonary
hypertension Sildenafil Isosorbide
Reduce RV Pressure Diuretics: Lasix gtt, high dose spiro Ultrafiltration *Careful as they are preload dependent
RV failure Treatment Strategies: No Data
RV failure Treatment Strategies: No Data
Increase RV contractility Digoxin Milrinone, dobutamine, NE, Dopamine
?Raise BP to help kidneys? Midodrine?
Increase RV contractility Digoxin Milrinone, dobutamine, NE, Dopamine
?Raise BP to help kidneys? Midodrine?
SummarySummary
New mortality reducing treatments in HF Entresto Corlanor
Recognize Stage D heart failure to refer for viable options to increase quality and quantity of life.
Afterload reduce the failing heart to improve perfusion.
RV failure: afterload reduce, reduce RV pressure, RV inotropy.
New mortality reducing treatments in HF Entresto Corlanor
Recognize Stage D heart failure to refer for viable options to increase quality and quantity of life.
Afterload reduce the failing heart to improve perfusion.
RV failure: afterload reduce, reduce RV pressure, RV inotropy.