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GP symposium
2 April 2016
Dr Dinna Soon
Consultant Cardiologist, Department of Cardiology
Case presentation
• 76 years old male, chronic smoker, hypertension, previous MI
• 3/7 SOB and chest tightness
• BP : 170/90
• CVS- no murmur
• Chest -few wheeze
• ECG- sinus tachycardia, Q waves in anterior leads.
• CXR- ?Cardiomegaly, hyper inflated lungs, increased broncho- vascular markings.
• Normal initial lab results
Diagnostic Dilemma
• 1.ACS
• 2.Acute exacerbation of COPD
• 3. Acute PE
• 4. Acute Heart Failure (LVF)
Aspirin + Bronchodilator + Clexane + Diuretic
( ‘ABCD’ treatment)
More information…
• Orthopnoea, PND
• Cold peripheries, leg swelling, fine inspiratory crackles at lung bases , JVP elevated 6cm
• S3 Gallop
• BNP – markedly elevated
• ECHO- Dilated LV , severe LV systolic dysfunction- EF 20%
Organs that may be involved in development of shortness of breath
Biykem Bozkurt, and Douglas L. Mann Circulation.
2003;108:e11-e13
Lungs:
Asthma/COPD/Emphysema
Pneumonia
Pneumothorax
Cancer
Pulmonary embolism
Asbestosis/ systemic illness
(Rheumatoid arthritis)
Heart:
Heart failure
Angina equivalent
Systemic illness:
Anaemia
Hyperthroidism
Renal failure/liver failure
Nervous and
Musculoskeletal system:
Brain tumour/stroke
Muscle disorders
Heart Failure
• “A complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the ability
of the ventricle to fill with or eject blood”
-American Heart Association and American College of Cardiology
Hunt SA et al.2009.Circulation.2009;119(14):e391-e479
Accuracy of Initial Evaluation Findings in Diagnosing Heart Failure
Ruling in Heart Failure
Michael K. Am Fam Physician.2012;85(12):1161-1168
Framingham Diagnostic Criteria for Heart Failure
• Paroxysmal nocturnal dyspnea/orthopnoea
• Neck vein distension
• Rales
• Cardiomegaly
• Acute pulmonary oedema
• S3 gallop
• Hepatojugular reflux
• Ankle edema
• Dyspnea on exertion
• Hepatomegaly
• Nocturnal cough
• Pleural effusion
• Tachycardia (>120 beats per
minute)
• Major Criteria • Minor Criteria
Heart failure is diagnosed when 2 major criteria or 1 major and 2 minor criteria are met
Patrick A. McKee et al. The Natural History of Congestive Heart Failure: The
Framingham Study.N Engl J Med 1971; 285:1441-1446
• To validate Framingham diagnostic criteria using echocardiography as the reference standard
to diagnose heart failure
• Framingham clinical criteria - very sensitive for systolic HF (92% compared with 89% for
diastolic HF) and moderately specific (79%)
• Absence of the Framingham clinical criteria rules out the diagnosis of HF
• However the presence of these criteria do not necessarily confirm the diagnosis, which may be
based in echocardiography Journal of Evaluation in Clinical Practice.2009;15(1):55-61
BNP & NT-pro BNP
• Secreted by atria and ventricles in response to stretching or increased wall tension1
• Normal BNP/NT-pro BNP effectively rules out HF2 (high negative predictive value)
No HF Further evaluation HF
BNP < 100 (NNV 96%) 100-400 > 400
NT-pro BNP <400 (NNP99%) 400-2000 >2000
Levels in pg/ml
1.Chen WC. Biomarkers in heart failure.Heart 2010;96(4):314-320
2.Balion C et al. Evid Rep Technol Assess 2006;(142) 1-147
3.Han-Na Kim et al. Natriuretic Peptide testing in HF.Circulation
2011;123: 2015-2019
WHO ARE AT RISK?
Risk Factors for Heart Failure
• Coronary artery
disease
• Hypertension (LVH)
• Valvular heart disease
• Alcoholism
• Infection (viral)
• Diabetes
• Congenital heart defects
• Other:
– Obesity
– Age
– Smoking
– Obstructive Sleep Apnea
Evaluation for IHD
• Warranted in patients with HF, especially if angina is present, given that
CAD is the cause for HF in approximately two-thirds of the patients1
• Coronary angiography has been shown to improve symptoms and
survival in patients with angina and reduced ejection fraction 2
1.Ghoerghiade M et al. Chronic HF in US: a manifestation of CAD.
Circulation.1998;97(3):282-289
2.Hunt SA et al.2009 focused update incorporated into the ACC/AHA
2005 guidelines for diagnosis and management of HF in
adults.Circulation.2009;119(14):e391-e479
MK et al. American
Family
Physician.2012;85(12):11
61-1168
Identify alternative/reversible
causes and treat Suspected Heart Failure
Framingham criteria not met
OR
Normal BNP
Referral and approach to care NICE (UK) GUIDELINES
• Refer patients to the specialist multidisciplinary heart failure team in the
following situations:
• Initial diagnosis of heart failure
• Management of severe heart failure (NHYA III-IV)
• Heart failure not responding to treatment
• Heart failure due to valve disease
• Patient who is pregnant or planning to get pregnant
NICE UK 2010 Chronic HF in adults
TREATMENT
Entresto: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression
Current therapies are unable to fully address neurohormonal imbalance
in Heart Failure:
ENTRESTO is a new alternative to an ACEI or ARBs in patients with HFrEF1
1. McMurray et al. Eur J Heart Fail 2013;15:1062–73
Figure references: Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy
2002;22:27–42
Kemp & Conte. Cardiovascular Pathology 2012;365–71
Schrier & Abraham. N Engl J Med 2009;341:577–85
SNS
RAAS
Vasoconstriction Blood pressure
Sympathetic tone Aldosterone Hypertrophy
Fibrosis
Ang II AT1R
HF SYMPTOMS &
PROGRESSION
INACTIVE
FRAGMENTS
NP system
Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy
NPRs NPs
Epinephrine
Norepinephrine α1, β1, β2
receptors
Vasoconstriction RAAS activity
Vasopressin Heart rate
Contractility
Neprilysin
inhibitors
RAAS inhibitors
(ACEI, ARB, MRA)
β-blockers
ENTRESTO
NEJM SEP 2014. 371;11
20 21 20 % reduction in
CV death or HF
hospitalization
P<0.001
% reduction in HF
hospitalization
P<0.001
% reduction in
CV mortality
P<0.001
PARADIGM-HF: Efficacy of ENTRESTO over Enalapril
% reduction in all-cause mortality
p<0.001 16
LCZ696 superior to enalapril in reducing
symptoms and physical limitations of HF
(indicated by KCCQ score)
KCCQ, Kansas City Cardiomyopathy Questionnaire
Impact of ENTRESTO in improving QoL in HF Patients
Death imputed as zero. The analysis included all patients with at least one KCCQ data point
Significantly fewer patients treated with Entresto had a 5-point deterioration in KCCQ
scores at Month 8, compared with enalapril and the effect was consistent for all sub-
domains of KCCQ; also the effect was consistent at Months 8, 12 and 24.1
Summary
• Heart failure is primarily a clinical diagnosis.
• The initial evaluation of patients with SOB/suspected HF should include a
history and physical examination, laboratory assessment, CXR and ECG.
ECHO can confirm the diagnosis.
• A displaced cardiac apex, a third heart sound, and CXR findings of
pulmonary venous congestion or interstitial edema are good predictors to
rule in the diagnosis of HF
• Systolic heart failure can be effectively ruled out with a normal B-type
natriuretic peptide or N-terminal pro-B-type natriuretic peptide level
• Systolic heart failure can be effectively ruled out when Framingham
criteria are not met.
• Current treatments (beta-blocker, ACEi/ARB, MRA) mainly focus on
blocking the detrimental effects of neurohormonal activation, and largely
ignore the physiological compensatory effect of the natriuretic peptide
system.
• Inhibition of neprilysin (ARNI) results in an increase in the activity of
natriuretic peptides and other vasoactive peptides that can potentially
exert favourable long-term compensatory effects.
THANK YOU