Chronic Heart FailureLatest Guidance 2013

Dr Geraint H. JenkinsConsultant CardiologistConsultant Cardiologist

Regional Cardiac Centre, Swansea

Heart Failure Epidemiologyp gy• Heart failure is common

– prevalence 2-4%prevalence 2 4%– incidence 1% per year

• True incidence and prevalence unknown• True incidence and prevalence unknown• 10,000 new cases per year in SW Wales• 30,000 patients requiring ongoing treatment• 3,000 new cases per year in Swanseap y• 2,800 discharges in ABMULHB in 2011• Mortality 60% in first year after an admission• Mortality 60% in first year after an admission• Outlook much better with modern treatment

Admission to Hammersmith Hospital pwith Heart Failure 1999-2000

100

80

60

Freq

uenc

y 60

40F 40

2020

0

Std. Dev = 12.68 Mean = 75

N = 473.00

Age (years)

1009080706050403020100

Inpatient Stay in Heart Failure

Digestive

GU

Injury & po isoning

Bladder cancer

Nervous sytem

Respiratory

Cancer

Colorectal cancer

Lung cancer

Breast cancer

iag

no

sis

Ch i CHD

Heart failure

Stroke

Diabetes

Ma

in d

CHD

Angina

Acute M I

Chronic CHD

All

Circulatory

0 5 10 15 20 25 30Number of inpatient days

Causes of Heart Failure

• Coronary artery disease• Hypertension• Valvular heart disease• Valvular heart disease• Dilated cardiomyopathy• Tachycardia / Bradycardia

Oth• Other

Chest X-Ray

LVRVV

LARA

Dilated Cardiomyopathyy p y

Amyloid Cardiomyopathy

ACC/AHA Staging of Heart FailureStage Patient Description

A High risk for • Coronary artery diseasegdeveloping heart failure (HF)

y y• Hypertension• Diabetes mellitus• Family history of cardiomyopathyy y y p y

B Asymptomatic HF

• Previous myocardial infarction• Left ventricular systolic dysfunction• Asymptomatic valvular diseasey p

C Symptomatic HF • Known structural heart disease• Shortness of breath and fatigue• Reduced exercise tolerance

D Refractory end-stage HF

• Marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalised or cannot be safely discharged from hospital without specialised interventions)

Quality of life in Heart FailureQuality of life in Heart FailureNYHA Definition Diagnosed functional class HF cases

%

Class I No limitation: ordinary physical exercise does not cause dyspnoea. 0

Class II (s) Slight limitation of physical activity: dyspnoea on walking more than 200 yards or on stairs; M d t li it ti f h i l ti it d lki l

69

Class II (m) Moderate limitation of physical activity: dyspnoea walking less than 200 yards.

Class III Marked limitation of physical activity: comfortable at rest but dyspnoea washing and dressing or walking from room to room

15dyspnoea washing and dressing, or walking from room to room.

Class IV Severe limitation of physical activity: dyspnoea at rest with 16Class IV Severe limitation of physical activity: dyspnoea at rest, with increased symptoms with any level of physical activity.

16

Symptoms v. severity of disease

Conditions that may mimic heart failure

• Lung diseaseOb i

• HypoalbuminaemiaR l h i di• Obesity

• Venous insufficiency i l li b

• Renal or hepatic disease• Pulmonary embolism

i d/ iin lower limbs• Drug induced ankle

d

• Depression and/or anxiety disordersS ioedema

• Drug induced fluid i

• Severe anaemia• Thyroid disease

Bil t l l tretention • Bilateral renal artery stenosis

(or coexist with heart failure)

Diagnosing Heart Failure

in the Community

Based on NICE 2010

Principles of Heart Failure ManagementConfirm presence of clinical heart failure– Confirm presence of clinical heart failure

– Institute simple treatmentIdentify cause e g aortic stenosis echo and other tests– Identify cause e.g. aortic stenosis – echo and other tests

– Identify• precipitating factors e g new AF UTI LRTI anaemia• precipitating factors e.g new AF, UTI, LRTI, anaemia• Exacerbating factors e.g. salt intake, medication• Concomitant disease e.g. COPD, renal failureg ,

– Simple medical therapy – Diuretic, B-Blocker, ACE, MRA

– Optimal medical therapyp py– Definitive treatment – drugs, surgery, devices– Assess and re-asses symptom severityy p y– Estimation of prognosis

Aims of treatment

• Improve symptoms• Improve prognosis• Cure (in a few)• Cure (in a few)• Treatment directed at cause• Almost all drug trials are in patients with

heart failure due to LV dysfunctionheart failure due to LV dysfunction• Treat overall patient not the test

Non-Pharmacological Management

• Low salt intakeW i h d i

• Daily weightEd i• Weight reduction

• Exercise• Education• Self-management• Nurse advice

Pharmacological Management

Prognosis Symptoms• ACE Inhibitors

B Bl k• Diuretics

Di i• B-Blockers• Mineralcorticoid

• Digoxin• Hydralazine / Nitrates

Receptor Antagonists• AIIRB

• Ivabradine

Device / Surgical Management

Devices Surgery

• Simple Pacemakers • Valve repair / replacement• Biventricular

Pacemakersreplacement

• Revascularisation• Defibrillators• Balloon pumps

• Volume reduction surgeryp p

• LV assist devices • Transplantation

ESC Guidelines for Management of Chronic Heart Failure

2012

Maximal doses of B-blockersand ACE Inhibitors are important

Triple Therapy forTriple Therapy for most patients – ACE, B-Blocker and MRA

ACE Inhibitors

Trials of ACEI in Heart FailureTrials of ACEI in Heart Failure(20-25% reduction in mortality)

Patients Mean NYHA LVEF Effects on(n) Follow-

upClass (%) all-cause mortality

HF

CONSENSUS 253 188 days IV N/A All-cause mortality:At 6 months↓ 40%(p=0.002)

SOLVD-T t t

2569 3.4yrs II–III ≤35 All-cause mortality:↓ 16% (p<0 0036)Treatment ↓ 16% (p<0.0036)

SOLVD-Prevention

4228 3.1yrs N/A ≤35 All-cause mortality↓8% (p=0.30)

P t MI HFPost-MI HF

SAVE 2231 3.5yrs N/A ≤40 All-cause mortality:↓ 19%(p=0.019)

AIRE 2006 1 25 I III N/A All liAIRE 2006 1.25yrs I–III N/A All-cause mortality: ↓ 27%(p=0.002)

TRACE 1749 2-4.2yrs N/A ≤ 35 All-cause mortality:↓ 22%(p=0.001)(p )

Avoid stopping ACEI because of cough

B-Blockers

i l f bl k d i ilTrials of B-blockade in Heart Failure(30-35% reduction in mortality)

n MeanFollow-up

NYHAClass

LVEF(%)

Effects onall-cause mortality

HF

CIBIS 641 1.9yrs III-IV <40 All-cause mortality:↓ 20% (p=0.22)

CIBIS-II 2647 1.3yrs III-IV ≤35 All-cause mortality:↓ 34% (p<0.0001)

MERIT-HF 3991 1yr II–IV ≤40 All-cause mortality: ↓ 34% (p=0 0062)↓ 34% (p 0.0062)

US Carvedilol HF Study

1094 6.5mths II–IV ≤35 All-cause mortality:↓ 65% (p<0.001)

COMET 3029 4.9yrs II-IV <35 All-cause mortality: y y↓ 17%(p=0.0017)

Post-MI HF

CAPRICORN 1959 1.25yrs N/A <40 All-cause mortality:CAPRICORN 1959 1.25yrs N/A <40 All cause mortality:↓23%(p=0.03)

B Blockade in Heart FailureB-Blockade in Heart Failure

Heart 2001

Ald t R tAldosterone Receptor AntagonistsAntagonists

(ARA or MRA)( )

Spironolactone in Heart FailureRALES: All-Cause Mortality

0.90

0.95

1.00

Risk reduction 30%95% CI (18%-40%)

0 001

of su

rviv

al

0.75

0.80

0.85 p < 0.001

Aldosterone receptor antagonist + ACE inhibitor + loop diuretic ± digitalis

Prob

abili

ty

0.60

0.65

0.70ACE inhibitor + loop diuretic ± digitalis

Placebo + ACE inhibitor + loop diuretic ± digitalis

0.45

0.50

0.55loop diuretic ± digitalis

Months0 3 6 9 12 15 18 21 24 27 30 33 36

54Pitt B et al, N Engl J Med 1999; 341: 709-717

EPLERENONE

• Selective Aldosterone Receptor Antagonist(SARA)

• Short half life 3-5 hoursShort half life 3 5 hours• No sex steroid side effects of Spironolactone• Ephesus study shows clear benefit in heart

failure post MIfailure post MI• Expensive

EPHESUS

Primary Endpoint: All-Cause Mortality222018

Cumulative PlaceboEplerenone

161412

Incidence (%)Eplerenone12

1086

RR = 0.85 (95% CI, 0.75-0.96) P = 0.008

02

64

Months Since Randomisation002993237091213180124182830298330643313Placebo

03633302724211815129630

0001103367281260185724632896304431253319Eplerenone

Pitt B et al. N Eng J Med 2003; 348: 1309-1321

EPHESUS

Sudden Cardiac Death10

98

All Patients

Cumulative

8765

Placebo

Cumulative Incidence

(%)

543

RR = 0 79 (95% CI 0 64

Eplerenone

210

RR = 0.79 (95% CI, 0.64-0.97)P = 0.03

Months Since Randomisation

0 3 6 9 12 15 18 21 24 27 30 33 36

Pitt B et al. N Eng J Med 2003; 348: 1309-1321

Emphasis HF - Summary

• Age >55yrs, • NYHA Class II heart failure• EF <30%• EF <30%• B-Blocker, ACE and/or ARB• Cardiovascular admission within 6/12

• Reduced hospitalisation / death co-endpoint p pby 37% overall, 54% in diabetics

Angiotension II R t Bl kReceptor Blockers

Angiotensin II Receptor Blockers• Usually used in ACE intolerant patients• May be small additional benefit on top ofMay be small additional benefit on top of

ACE, B-blocker and SpironolactoneV lH FT– ValHeFT

– CHARM• Alternative• Added• Preserved• Low

– VALIANT

Ivabradine

• Inhibits If current in Sinoatrial node• Slows heart rate in sinus rhythm• Higher heart rate is associated with higher• Higher heart rate is associated with higher

mortality in heart failure

Shift StudyShift Study• Class II-IV Heart Failure• LV EF <35%• Heart Rate >70• Heart Rate >70• Sinus rhythm• Hospitalised with heart failure in preceding

12 months12 months• 90% on B-blockers, 91% on ACEI, 83%

Diuretics, 59% ARA

Shift StudyShift Study

Shift Death or HospitalisationShift – Death or Hospitalisation for HFfor HF

4.2% absolute reduction

Shift – Hospitalisation for HF

Shift Outcomes

Maximal Heart Failure Management%

)100

Maximal Heart Failure Managemental

ity (%

8080

100

Feels better

mor

ta

6060

80 Feels better

1 ye

ar

3926 22

40

1 2615

2220 (?)

0Diuretic Add

C

Add AddSpironolactone

AddIvabradine

AddCRT

£19.11 £14.99 £19.66 £552.33 £8000 +FU

£10.04

ACEI B-blocker Spironolactone Ivabradine CRT

Four most effective drugs £63.80 per annum (BNF March 2013, drug cost only)

Optimal Drug Doses in LV Systolic Dysfunction

Cardiac Resynchronisation Therapyy py• 30% of heart failure patients have incoordinate LV

i i ( d ll l h )activation (and usually also have LBBB)– Adverse effect on LV ejection– Adverse haemodynamic effects– Associated with Increased mortality

• Cardiac resynchronisation in patients with poor LV, LBBB and NYHA III-IV heart failure– Improves symptoms and exercise tolerance– Reduces hospitalisation for heart failurep– Reduces mortality when combined with ICD

LBBB

Cardiac Resynchronisation

NICE 2007

59% of all heart failure59% of all heart failure admissions

37076 patients admitted pwith heart failure of which 4170 were readmissions

Mandatory in Wales since April 2012

National Heart Failure Audit 2012National Heart Failure Audit 2012

2011

National Heart Failure AuditNational Heart Failure Audit 20122012

Inpatient Care Cardiology Ward Medical Ward Other Ward% of Total 48 41 11% of Total 48 41 11Length of Stay (d) 12.7 13.1 14.7Inpatient Mortality % 7.8 13.2 17.4

Cardiology patients were younger and more malesgy p y gCardiology patients were more likely to be on prognostic drugs

Mortality reduction on cardiology wards remains significant when confounding factors are taken into accountare taken into account

National Heart Failure Audit 2012National Heart Failure Audit 2012

National Heart Failure Audit 2012National Heart Failure Audit 2012

National Heart Failure Audit 2012

National Heart Failure Audit 2012

Issues

• Lack of– Echo services– Clinical expertise– Cardiologists– Heart Failure Nurses

• Pressure to reduce length of stay• Every patient with heart failure should be• Every patient with heart failure should be

seen by a cardiologist ( or GPwSI)

New Swansea Service

• British Heart Foundation & LHB Funding– 7 Community Heart Failure Nurses– Heart Failure Nurse CoordinatorHeart Failure Nurse Coordinator– 1 Hospital based Heart Failure Nurse

H t F il A dit T– Heart Failure Audit Team

• Training of Nurses• Development of Referral Pathways• Development of Referral Pathways

Refer to Tertiary Cardiologist if:YoungV l l diValvular diseaseAcute coronary syndromesCo-existing anginaDifficulty optimising treatment in secondary careDifficulty optimising treatment in secondary careCandidate for conventional pacingS i i l d h i h LBBBSymptomatic on maximum tolerated therapy with LBBBTransplant or device candidate

Take Home Message

• Low threshold for considering heart failure• BNP screening if not clear• Echocardiography for all heart failure patients• Echocardiography for all heart failure patients• Basic triple therapy for all LVSD (ACE, BB, MRA)

• All patients should see a cardiologistC di l f ll i t d ith• Cardiology follow up associated with improved outcome.