The European Heart Journal’s / European Journal of Heart Failure’s year in cardiology

Piotr Ponikowski, MD, PhD, FESC Medical University, Centre for Heart Disease

Clinical Military HospitalWroclaw, Poland

Acute and Advanced Heart Failure

Disclosure

Consultancy fees and speaker’s honoraria from:

Vifor Pharma Ltd, Amgen, Servier, Novartis, Bayer, Pfizer, Johnson&Johnson, Abbott Vascular, Coridea, Respicardia

Research grant: Vifor Pharma Ltd, Respicardia

Heart Failure: treatable and preventable disease (?)

Landscape at the end of 20th century: HF more malignant than cancer Framingham study

Median survival:Men – 1.7 yrs, women – 3.2 yrs

Ho KKL et al., Circulation 1993;88:107-15

Hospitalizations due to HF worsening often complicate patient’s journey

Severity ofsymptoms

Death

Time

Sudden death

HospitalizationHospitalization

Hospitalization

Mild HF

Moderate-severe HF

End-stage HF

Repeated Hospitalizations

161.131 pts; mean age: 78 yrs (M:77 vs F:82); 20% ≥ 2 HHF; LOS: 10 daysIn-hospital mortality: 7.8%

Average annual change in mortality for HF (2000-12) Trends in age-standardized rates of HHF pts and proportion of readmissions (2002-12)

Year 2012

Patient characteristics by geographic region

Conclusion for designing future HHF clinical trials: region of enrolment for clinical trial as independent and strong

predictor of death

Relative risk of clinical outcomes by geographic region relative to North America

Greene SJ et al. Eur J Heart Fail 2015 (in press)

CardShock Study: 219 pts, ACS – 81%, in-hospital mortality – 37%

CardShock risk Score for risk prediction of in-hospital mortality in cardiogenic shock

Distribution of the population (red) and in-hospital mortality (blue) according to cumulative points

low risk

intermediaterisk

high risk

Simple index of diuretic response: ∆weight (kg) / 40 mg furosemide Day 4 response: differentiation in responsiveness and diuretics adjustment to clinical responsePredictors of poor diuretic response: low SBP, high BUN, diabetes, atherosclerotic disease

“This is the first guidance to insist that acute heart failure (AHF) is like acute coronary syndrome

(ACS) in that it needs urgent diagnosis and appropriate treatment. In ACS when the coronary is occluded we say ‘time is muscle’ which means that the quicker the

vessel is dilated, the more heart muscle is saved. The same principle is true for AHF.

By introducing the time to therapy concept together with new medications for AHF we hope to

achieve the reductions in mortality and morbidity seen with ACS.”

ESC WEBPAGE

„Time is muscle in acute heart failure”

Urgent treatment emphasised for the first time

in recommendations from across specialties

and continents

Alexandre Mebazaa

Mebazaa A et al. Eur J Heart Fail 2015 (in press)

Bedside assessment to identify hemodynamic profilesPatient with acute heart failure

signs/symptoms: •orthopnea, PND, breathlessness, bi-basal rales, an abnormal BP response to the Valsalva maneuver (left-sided); •symptoms of gut congestion, elevated jugular venous distention, hepato-jugular reflux, hepatomegaly, ascites, and peripheral edema (right-sided);

Presence of congestion

YES (95% of all AHF patients)

„Wet” patient

NO (5% of all AHF patients)

„Dry” patient Adequate peripheral perfusion

YES„Wet and Warm” patient

(typically elevated/normal systolic blood pressure)

NO

„Wet and Cold” patient(typically low systolic blood pressure)

•inotropes: dobutamine, levosimendan, milrinone

•vasodilators (if peripheral vasoconstriction): nitroprusside, nitrates

•diuretics

Vascular type (fluid redistribution):

•Vasodilators•diuretics (small dose)

Cardiac type (fluid accumulation):

•diuretics •ultrafiltration

(if diuretic resistance)

Ponikowski P et al. submitted

Treatment of iron deficiency: Attractive therapeutic target in heart failure ?

• Iron deficiency (ID) – frequent co-morbidity in stable CHF

• CHF complicated with ID – associated with impaired functional capacity, poor quality of life and increased mortality

• Deleterious consequences of ID in CHF are irrespective of anaemia

• Correction of ID itself as an attractive therapeutic target in CHF – hypothesis recently being tested in clinical studies

• What about iron status in Acute Heart Failure ?

Iron deficiency (new definition): •depleted body iron stores (low serum hepcidin)

•insufficient iron amount in metabolizing cells (high serum sTfR)

20%

40%

60%

80%

% of AHF pts

Preserved iron status

Isolated high sTfR

Isolated low hepcidin

Iron deficiency(↓hepcidin & ↑sTfR)

75% of AHF - impaired iron status

Iron deficiency is common and predicts poor outcomein patients hospitalized for AHF

Cumulative survival

Follow-up (months)

χ2=29.45, p<0.001

100% 93% (81-100%)85% (75-95%)

59% (47-71%)

Iron deficiency (both low hepcidin and high sTfR) (1)Isolated high sTfR (2)Isolated low hepcidin (3)Preserved iron status (4)

Jankowska EA et al. Eur Heart J 2014

Sleep disordered breathing in heart failureProblems with nomenclature and perception

Sleep Physician• obstructive sleep apnoea

• central sleep apnoeaNomenclature accepted

Prevalent and relevant for M&M and QoL

Target for intervention

Prevalent in obese & HTN pts

Snoring problem

Affecting QoL

Cardiologist

Sleep disordered breathing in heart failureProblems with nomenclature and perception

Sleep Physician• obstructive sleep apnoea

• central sleep apnoeaNomenclature accepted

Prevalent and relevant for M&M and QoL

Target for intervention

Heart Failure Specialist

Breathing abnormality

•Cheyne-Stokes respiration

•During sleep (also at rest)

Nomenclature accepted ?

Prevalent and relevant for M&M and QoL

Target for intervention ?

Prevalent in obese & HTN pts

Snoring problem

Affecting QoL

Cardiologist

Prevalence of sleep apnoea in patients with chronic HFrEF

Krawczyk M et al. Cardiol J 2013

Ominous pathophysiological and clinical consequences(progression of the disease, increased M&M)

Largest prospective evaluation of SDB in AHF: 1117 pts with HFrEFExcluded: unstable, hypoxic, unable to sleep flat; 97 % with chronic decompensated HFPrevalence: 31% central sleep apnoea, 47% obstructive sleep apnoea, 22% with nmSDB

CSA and OSA – independent risk factors for post-discharge mortality

Modification of the mortality effect with SDB treatment

Khayat R et al. Eur Heart J 2015 (in press)

The great thing in this world is not so much where we stand, as in what direction we are moving

Oliver Wendell Holmes 1841-1935