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Heart Failure

A ‘real world’ update for General

Practice

Dr Christine Burdeniuk Southern Adelaide Local Health Network

Learning Objectives

Ø Heart failure signs and symptoms Ø Causes of heart failure Ø Diagnosis and investigation of heart failure Ø NYHA classification of heart failure Ø Treatment

l  Pharmacological and non-pharmacological Ø Monitoring clinical signs of heart failure

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What is heart failure?

Ø Chronic Heart Failure (CHF) is l  a complex clinical syndrome l  characterised by an underlying structural

abnormality or cardiac dysfunction that impairs the ability of the heart to fill with or eject blood

l  Manifests with typical symptoms (dyspnoea and fatigue) that occur at rest and on exertion

Left heart failure Ø  Involves impairment of the left ventricle

Ø  Systolic heart failure (cardiomyopathy) l  Inability of the heart to contract and pump blood into

the circulation Ø  Diastolic heart failure (HF-preserved EF)

l  Inability of the heart to relax and fill properly between each beat

Ø  Fluid ‘backs up’ in the lungs (pulmonary oedema)

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Right heart failure

Ø Most commonly occurs as a consequence of left ventricular failure.

Ø  Isolated RHF can occur l  due to lung disease (cor pulmonale) or

pulmonary embolism Ø Fluid backs up in the peripheral tissues

l  Peripheral oedema, ascites

Incidence of Heart Failure Ø  1.5-2% of Australians are living with chronic heart failure. Ø  Heart failure is the leading cause of hospitalization of

patients over 65 years in age. Ø  Prevalence increases sharply with age.

Ø  Rapidly increasing number because of the aging population.

Ø  > 15 million new cases of Heart failure estimated each year worldwide.

12/06/12 6

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Prognosis of Heart Failure Ø  Despite many new advances in drug therapy and cardiac

assist devices, the prognosis for chronic heart failure remains very poor.

Ø  One year mortality figures:

l  50-60% for patients diagnosed with severe failure l  15-30% in mild to moderate failure l  10% in mild or asymptomatic failure

Ø  30–40% of patients die within a year of diagnosis

Causes of heart failure

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Causes of heart failure …1

Ø Loss of myocardium l  Infarction (50%) l  Myocarditis

•  inflammatory, viral l  Myopathy

•  Genetic/familial •  Peri-partum •  Alcohol •  Chemotherapy-related

l  Idiopathic (5-10%)

Causes of heart failure …2

Ø Abnormal myocardium l  Haemochromatosis l  Sarcoidosis l  Amyloidosis l  Hypertrophic cardiomyopathy

Ø Tachycardia l  Rapid Atrial Fibrillation / Flutter

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Causes of heart failure …3

Ø Pressure load l  Hypertension l  Aortic stenosis l  Obstructive sleep apnoea

Ø Volume load l  Mitral / Aortic regurgitation

Causes of HF-preserved EF

Ø  Hypertrophy l  Hypertension l  Infiltration l  Fibrosis

Ø  Mitral stenosis

Ø  Tamponade l  Restrictive / constrictive pericarditis

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Heart Failure Signs and Symptoms

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Signs and Symptoms …1

Ø Think FACES….

Ø Fatigue Ø Activities limited Ø Chest congestion Ø Edema or ankle swelling Ø Shortness of breath

Signs and Symptoms …2

Left heart failure Ø  Dyspnoea Ø  Decreased exercise

tolerance Ø  Orthopnoea Ø  Paroxysmal nocturnal

dyspnoea Ø  Cough

l  Pink, frothy sputum

Right heart failure Ø  Decreased exercise

tolerance Ø  Pitting oedema Ø  Hepatomegaly Ø  Ascites

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Shortness of breath Ø  Blood ‘backs up’ in the

pulmonary veins l  Fluid leaks into the lungs

Ø  Dyspnoea at rest Ø  Dyspnoea on exertion Ø  Difficulty lying flat

(orthopnoea) Ø  Waking short of breath

(paroxysmal nocturnal dyspnoea)

Progression of signs and symptoms

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Diagnosis of heart failure

Diagnosis …1

Ø  In patients with signs and symptoms of heart failure

l  Measure serum NT-proBNP

l  Refer for echocardiogram

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⇐ normal

cardiomyopathy ⇒

⇐ normal

cardiomyopathy ⇒

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Diagnosis …2

Role of BNP / NT-proBNP Ø Differential diagnosis of dyspnoea to RULE OUT heart failure

l  BNP < 100pg/mL BNP Trial NEJM 2002

l  NT-proBNP < 300 pg/mL PRIDE Trial JACC 2005

Ø Both are superior to clinical judgement alone in diagnosing / confirming acute heart failure

Natriuretic peptides

Ø Family of peptides with natriuretic, diuretic and vasorelaxant effects

Ø Role in body’s defence against hypertension and plasma volume expansion

Ø Atrial Natriuretic Peptide (ANP) l  Released from atria in response to increased

atrial wall tension Ø Brain / B-type Natriuretic Peptide (BNP)

l  Released predominantly from ventricle in response to increased ventricular wall tension

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BNP and NT-proBNP

—COOH

H P L G S P G S A S Y T L R A P R S P K M V Q G

S G C

F C R

K M D R I S

S S S G

L C C

K V

L R

R H

H2N—

1

10 70

76

80

90

100

108

Cleavage

H2N—

—COOH S P K M V Q G

S G C

F C R

K M D R I S

S S S G

L C C

K V

L R

R H

—COOH H2N—

H P L G S P G S A S Y T L R A P R

1 10 70 76

proBNP

BNP NT-proBNP

BLOOD

CARDIOMYOCYTE

-increased collection stability -t½≈2 hours -similar clinical utility, ∝ wall stress Richards et al Br Heart J 93

-biologically active -∝ wall stress -t½≈22 minutes

NT-proBNP

NT-proBNP in CHF

†

controls .1

10

100

1000

10000

II III IV NYHA CHF

NT-p

roBN

P(p

g/m

l)

*

*p<0.001 ‡p=0.02 †p<0.001

‡

De Pasquale et al Circulation04

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Using BNP to guide follow up

Ø  Urgent follow up within 2 weeks l  BNP > 400 pg/mL l  NT-proBNP > 2000 pg/mL

Ø  Semi-urgent referral within 6 weeks l  BNP 100-400 pg/mL l  NT-pro BNP 400-2000 pg/mL

Ø  Remember that heart failure excluded if l  BNP < 100 pg/mL l  NT-proBNP < 300 pg/mL

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NYHA Classification of Heart Failure

New York Heart Association Classification (NYHA)

l  Class I •  No limitation of ordinary physical activity

l  Class II •  Slight limitation (fatigue, dyspnoea) of

ordinary physical activity l  Class III

•  Marked limitation of ordinary physical activity

l  Class IV •  Unable to carry out any physical activity

without discomfort

asymptomatic LV dysfunction

Severe

CHF Moderate

Mild

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NYHA Classification

Class % of patients

Symptoms

I 35% No symptoms or limitations in ordinary physical activity

II 35% Mild symptoms and slight limitation during ordinary activity

III 25% Marked limitation in activity even during minimal activity. Comfortable only at rest

IV 5% Severe limitation. Experiences symptoms even at rest

Treatment of Heart Failure

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Treatment Goals

Ø Reduce mortality

Ø Reduce morbidity

Ø Prevent further cardiac damage

What Are The Treatments for Heart Failure?

Experts recommend:

•  Diuretics - help control symptoms •  Digoxin - helps control symptoms •  ACE Inhibitors - can slow disease progression •  Beta Blockers - can slow disease progression

This combination of medications has been proven to save lives and keep people out of the hospital.

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Non-pharmacological treatment …1

Ø Education, discussion, counselling l  Multi-disciplinary management program l  Weight control (report 2kg gain in 2 days)

Ø Smoking cessation Ø Caffeine reduction Ø Reduce stress Ø Treat sleep apnoea Ø Vaccination Ø Avoid pregnancy

Non-pharmacological treatment …2

Ø Exercise and rehabilitation l  Keep active exercise program for CHF l  Improves functional capacity and symptoms

•  20-30min/day •  3-5 days/week •  low intensity (60-80% peak HR)

Ø Dietary measures l  Salt avoidance (mainly class III/IV) l  Fluid restriction ~ 1.5L/day (mainly class III/IV) l  Alcohol reduction (1-2/day with alcohol free days)

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Pharmacological treatment …1

Ø Depends on NYHA class Ø Regimen adjusted and adapted depending

on fluid status Ø Cornerstone are ACEi and heart-failure

specific beta blockers

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ACE inhibitors

Ø Reduce symptoms Ø Reduce mortality

•  CONSENSUS 1987, AIRE 1993, V-HEFT 1991, SOLVD 1991

Ø  Indicated for NYHA I – IV CHF

Angiotensin II Receptor Blockers (ARBs)

Ø Used instead of ACE inhibitors, if intolerant

Ø Reduces symptoms (equal to ACEi) Ø Reduced side effects (compared to ACEi) Ø No mortality benefit over ACEi Ø Reduces CV mortality and morbidity

•  CHARM alternative 2003

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Beta Blockers

Ø  Improve symptoms l  May have initial worsening

•  Start when euvolaemic •  Start low and up-titration should be slow

Ø Reduces mortality •  US Carvedilol Study 1996 •  CIBIS II 1999 (Bisoprolol) •  MERIT-HF 1999 (Metoprolol XL) •  SENIORS 2005 (Nebivolol)

Ø  Indicated for NYHA II- IV

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Diuretics (loop)

Ø Reduce symptoms •  Wilson et al Am J Med 1981

Ø Requires dose adjustments

Ø  Indicated for Class III-IV and often Class II

Digoxin

Ø  In CHF with atrial fibrillation l  Improves LV function and symptoms

l  Khand et al Eur Heart Journal 2000

Ø  In CHF with sinus rhythm l  Reduces symptoms l  Neutral effect on total mortality

l  DIG trial 1997

Ø  Indicated for NYHA II-IV

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Aldosterone Antagonists

Ø Spironolactone l  Reduces symptoms l  Reduces mortality

l  RALES 1999

l  Indicated for NYHA III/IV

Ø Eplerenone l  Start 30 days post infarct with LV failure l  Reduces mortality and hospitalisations

l  EPHESUS 2003

Nitrates

Ø Venous > arterial vasodilatation Ø Reduces symptoms Ø  Indicated for

l  Pulmonary congestion •  APO, orthopnoea, PND

l  CHF with ischaemia

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Ivabradine

Ø Selective sinus node inhibitor Ø Lowers resting heart rate Ø  Indicated for symptomatic HF with resting

HR > 70bpm despite maximal tolerated beta blocker

Ø Reduces death due to heart failure and hospitalisations

l  SHIFT 2010

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NYHA-based recommendations for CHF treatment

NYHA IV

NYHA III

NYHA II

NYHA I

diuretics + digoxin + nitrates tolerated + temporary inotropic support

+ diuretics + ARB + digoxin

+/- diuretic depending on fluid retention +ARB

reduce / stop diuretic

For Symptoms

ACE inhibitor β-blockade spironolactone +/-ARB

ACE inhibitor and β-blockade + ARB + spironolactone

ACE inhibitor and β-blocker

ACE inhibitor, add β-blocker if post MI

For Survival/Morbidity mandatory therapy if Intolerance to ACE inhibition

ARB if ACE inhibitor intolerant

ARB if ACE inhibitor intolerant

ARB if ACE inhibitor intolerant

ARB if ACE inhibitor intolerant

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Monitoring clinical signs of heart failure

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Ø  Complex syndrome Ø  Complex and varied treatment modalities Ø  Disease characterised by fluctuating

relapse/remitting course

CHF: Natural History

Lynn et al JAMA97

Monitoring CHF …1

Ø  All patients with CHF require monitoring Ø  Clinical assessment

l  Functional capacity (NYHA class) •  Exercise tolerance, orthopnoea, PND, fatigue

l  Cardiac rhythm (pulse +/- ECG) l  Cognitive status

•  Depression, Delirium (compliance issues)

l  Nutritional status l  Weight pattern

Ø  Examination l  JVP, crepitations, peripheral oedema, ascites

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Monitoring CHF …2

Ø Medication review l  Changes based on fluid status and possible side effects

Ø Biochemical profile l  Routine FBE, ECU, eGFR l  LFTs, INR, TFTs, CRP as required

Identifying decompensation

Ø Weight gain > 2kg in 48 hr period l  Patient educated to contact HF service for

guidance or implement action plan

Ø Reduced urine output Ø Orthopnoea Ø Paroxysmal nocturnal dyspnoea Ø  Increasing peripheral oedema

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Mechanisms of decompensation …1

Ø Cardiac issues l  Ischaemia l  Arrhythmia l  Valvular dysfunction

Ø Patient issues l  Non-compliance with drugs or advice

Ø  Drug issues l  Water and salt retention l  Negative inotropes

Mechanism of decompensation …2

Ø  Drugs to avoid / use with caution l  Antiarrhythmics (except HF beta blockers and

amiodarone) l  Calcium antagonists (non-dihydropyridines eg

verapamil and diltiazem) l  Tricyclic antidepressants l  NSAIDs / COX II inhibitors l  Corticosteroids l  Thiazolidinediones (rosiglitazone)

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Mechanism of decompensation …3

Ø Co-morbid conditions

l  Infection l  Renal failure l  Anaemia l  Thyroid dysfunction

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When to refer to HF specialist clinic

Ø  Initial diagnosis of heart failure Ø Management of severe (NYHA IV) heart

failure Ø Management of heart failure that does not

respond to usual treatments Ø Heart failure that can no longer be

managed at home (ie needs admission or specialist HF nursing outreach)

Heart failure clinics

Ø Heart failure nurse l  Point of contact for advice, education, drug

titration Ø Heart failure cardiologist

l  Increased adherence to treatment guidelines Ø Physiotherapist

l  Heart failure exercise program Ø Achieves reduction in risk of death and

hospital readmission l  Azevedo et al Eur J Heart Failure 2002

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Thank you