Heart Failure For the Family Medicine Physician

Heart Failure For the Family

Medicine PhysicianCT Academy of Family Physicians Annual Symposium

Sara R Tabtabai MD

October 17, 2019

Outline

• Heart failure classification

• Evaluation

• Prevention and treatment

• Specific cardiomyopathies

Case Presentation

• A 62 year old male presents with complaint of

shortness of breath for the past 4 weeks

– Also reports ankle edema

– History of coronary artery disease and atrial fibrillation

Case Continued

• Echocardiogram performed, left ventricular ejection

fraction 35%

Epidemiology

• Lifetime risk of developing HF is 20% for Americans

> 40 yrs

• >650,000 new HF cases diagnosed annually

• Increased number of cases as the population ages

Classification

• Based on etiology: Primary vs. secondary

• Based on ejection fraction: HF reduced EF, HF

preserved EF

Classification

Circulation. 2006;113:1807-1816.

Classification

Am Fam Physician. 2017 Nov 15;96(10):640-646.

Definitions of HFrEF and HFpEF

Yancy et al. 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary

HF Prevalence by Age and SexNational Health and Nutrition Examination Survey: 2007-2010

Recent Trends in Heart Failure-related Mortality:

United States, 2000-2014

NCHS Data Brief No 231 Dec 2015

Recent Trends in Heart Failure-related Mortality:

United States, 2000-2014

NCHS Data Brief No 231 Dec 2015

Pathophysiology

Adapted from HFSA board review course

Heart Failure Evaluation

Recommended Evaluation of the

Patient Presenting with Heart Failure

Evaluation of the Patient Presenting

with Heart Failure

2-Minute Hemodynamic Assessment

AHA Scientific Council Statement, Circulation 2000

The Goal of Therapy

Adapted from Dr. Stevenson

Biomarkers in the Evaluation of HF

Han-Na Kim, and James L. Januzzi, Jr Circulation.

2011;123:2015-2019


• BNP and NT-proBNP useful to support clinical

judgement for:

– Diagnosis or exclusion of HF

– Chronic ambulatory HF

– Acute decompensated HF

– Unclear etiology of dyspnea – negative predictive value

– Useful to rule out HF if < 100






Recommended Components of Follow-

up Visits

Prevention and Treatment

Prevention

Lifestyle Interventions

• Most evidence for benefit in established heart

failure:

– Exercise training

• Most evidence for prevention:

– Achieving and maintaining high levels of fitness and

maintenance of normal body weight

Revised Staging System for HF

Stages of HF and Treatment

Treatment of Stage C Heart Failure

Aldosterone Receptor Antagonists

• Landmark RALES trial (Randomized AldactoneEvaluation Study)– 30% reduction all-cause mortality, reduced risk SCD and HF

hospitalizations with spironolactone in patients with chronic HFrEF and LVEF < 35%

– Eplerenone shown to reduced all-cause deaths, CV deaths, or HF hospitalizations

• Inappropriate use of aldosterone receptor antagonists potentially harmful– Life-threatening hyperkalemia or renal insufficiency when serum

creatinine greater than• 2.5mg/dL in men

• 2.0mg/dL in women

• And/or serum potassium greater than 5.0 mEq/L

Aldosterone Receptor Antagonists

Benefit of Medical Therapy

Medications to Avoid:

• Thiazolidinediones– Increase insulin sensitivity by activating nuclear peroxisome proliferator-activated

receptor gamma, which also regulates sodium reabsorption in the collecting ducts of the kidney

– Increased incident of HF events, including those without prior history of HF

• NSAIDs– Inhibit synthesis of renal prostaglandins which mediate vasodilation in kidneys

– Can cause sodium and water retention and blunt the effects of diuretics

– Increased M&M with either nonselective or selective NSAIDs

• Calcium channel blockers – Myocardial depressant activity

– Amlodipine generally well tolerated, neutral effects on M&M

Indications for Cardiac Resynchronization

Therapy

CRT

Stage D Heart Failure

ARNI should NOT be administered with

ACE inhibitors or within 36 hrs of last

dose of ACE inhibitor

ARNI should NOT be administered to

patients with a history of angioedema

2017 Updates:

Drug Therapy for Stage C HFrEF

2017 Updates:

Drug Therapy for Stage C HFrEF

Case Presentation

• An 82 year old female presents with complaint of

decreased functional capacity

Secular Trends in Survival among Patients with Heart

Failure and Preserved or Reduced Ejection Fraction

Owan TE et al. N Engl J Med 2006;355:251-259.

Improved

survival in

HFrEF over time

No improvement

in survival in

HFpEF over

time

Cause of Death in Patients with

HFpEF

Redfield, M MD. Braunwald’s Heart Disease 9th Ed.

Non-

cardiovascular

death

Pathophysiology• Ventricular diastolic dysfunction

– Impaired relaxation, increased diastolic stiffness

– Present at rest or induced by stress

• EF normal at rest

– Does not increase appropriately with stress

• Endothelial dysfunction, arterial stiffening, and increased ventricular

systolic stiffness

– Heightened sensitivity to changes in load

Rapid onset pulmonary edema with increases in load

Excessive hypotension with decreases in load

Redfield, M MD. NEJM 2016

How Do We Make the Diagnosis of

HFpEF?

Circulation 2018

Heart Failure with Preserved EF

HFpEF• ‘Trials using comparable and efficacious agents for HFrEF have

generally been disappointing when used in patients with HFpEF’

– Most recommended therapies for HFpEF are directed at symptoms,

comorbidities, and risk factors that may worsen cardiovascular disease

• Blood pressure control – ACE and ARB first-line

• Diuretics – relief from volume overload

• Management of atrial fibrillation

• Use of ARBs Class IIb – decreased hospitalizations

Pharmacologic Treatments for

HFpEF

• Blood pressure control → ACE and ARB first-line

• Diuretics → relief from volume overload

• Management of coronary artery disease and atrial fibrillation

• Use of ARBs Class IIb → decreased hospitalizations

Proven Therapies for HFpEF

ESC HF Guidelines 2016

Don’t miss ‘non-HFpEF’ causes of

HFpEF

Adapted from Borlaug, B. HFSA Review Course 2016

Updates on Comorbidities

• Anemia and HF– Treatment with IV iron repletion - improved functional status and QoL

– Ongoing studies for efficacy of oral repletion

– Erythropoietin-stimulating agents should not be used

• Hypertension– Stage A HF – optimal blood pressure target less than 130/80 mmHg

(SPRINT trial)

• Sleep apnea– Sleep study is reasonable

– Distinguish between central and obstructive sleep apnea

– CPAP can be helpful for obstructive sleep apnea (improve sleep quality and daytime sleepiness)

– Central sleep apnea – adaptive servo-ventilation causes harm

Specific Cardiomyopathies

Hypertrophic Cardiomyopathy

• Common autosomal dominant

• 1:500 of general population for phenotype recognized by

echocardiography

• Most common cause of sudden cardiac death in the

young

Arrhythmogenic Right Ventricular

Dysplasia

• Typically present from teens to 40s

• Prevalence 1:5000

• Male : Female 3:1

• 4 phases of disease– Concealed – asymptomatic but increased risk of SCD

– Overt – symptomatic arrhythmias

– Signs and symptoms RV failure

– Biventricular heart failure and arrhythmias

Left Ventricular Noncompaction

• May present with palpitations, heart failure

• Evidence for genetic predisposition

• Increased risk for LV dysfunction, arrhythmia, and

thrombotic stroke

• Implications for family screening, consideration for ICD,

anticoagulation

Evidence for Genetic Testing

Thank you!

Treatment of Stage A Heart Failure

• Hypertension and lipid disorders should be

controlled in accordance with contemporary

guidelines

• Other conditions that may lead to or contribute to

HF: obesity, DM, tobacco use, cardiotoxic agents,

should be controlled or avoided

Treatment of Stage B Heart Failure

Treatment of Stage C Heart Failure

ANY Updates for HFpEF?

TOPCAT Trial

Substudy

analysis

focused on

the Americas

ANY Updates for HFpEF?

Routine use of phosphodiesterase-5

inhibitors to increase activity or QoL is

ineffective

NEAT HFpEF and RELAX – negative

RCTs

Documents

Heart Failure For the Family Medicine Physician