Maryam AlQaseerConsultant Cardiologist

King Fahad Specialist Hospital in Dammam

Sub-investigator in SHIFT, REVERESE, ATMOSPHERE, REPORT-HF

2 brief case histories Outline of management of HFrEF management.. What do the guidelines say.. Recent evidence and therapeutic options.. Pharmacotherapy Devices Surgical interventions Glimpse into the future outlook of heart failure

53 year old gentleman with no previous medical illnesses gets admitted via ER with a history of progressively worsening sob for 4 weeks, orthopnoea and PND.

He denied any chest pain Very good baseline effort tolerance, works as a grave digger.

Examination was positive for sinus tachycardia of 110bpm. BP128/71mmHg, SpO2 93% on room air and RR24bpm.

Elevated JVP 8cm H2O S1, S2, S3, no murmurs. Bibasal crepitations Minimal pitting pedal oedema at the level of ankles.

ECG: Sinus tachycardia with LBBB

Troponin was mildly elevated, BNP 1050, Normal RFT, CBC, Iron profile and TSH.

ECHO CAG normal coronaries.

Started on anti-failure therapy and sent home after education Regular f/u at the HFU managed to take him up to bisoprolol

10mg, spironolactone 25mg od, perindopril 10mg od, lasix40mg od, and warfarin as per INR.

3 months after OMT brought him back for an echo, LV function remains same and LV thrombus disappeared.

CRT-D implanted, and brought him back in 6 weeks after implant.

Device check was good and BiV pacing about 97% of the time. An echo was done, EF~50%. Patient is back to working 70-80 hour weeks

29 year old gentleman, smoker, history of myocarditis which improved 3 years ago lost to follow up and stopped medications.

Comes back with a history of recent URTI and was in florid pulmonary oedema.

SBP~80-90mmHg. Required NIPPV. Bloods BNP of 3450, Troponin mildly elevated, Normal RFT,

CBC, Iron, TSH, Non specific ECG changes CAG: Normal coronaries

Bisoprolol 10mg od, spironolactone25mg od, valsartan 80 mg BD, lasix 40mg BD, and warfarin as per INR.

3 months after OMT still severe LV dysfunction. Narrow QRS. ICD rejected. Recurrent admissions with heart failure 4x/year, needed inotropes

once. Right heart cath, elevated PAP. INTERMACS class 6-7 Awaiting heart transplant.

Studies working towards the upcoming ESC HF guidelines in 2016

ESC HF Guidelines 2012

1987-CONSENS

US

1991-SOLVED

1991- V HEFTII

1996-CARVEDI

LOL HEART

FAILURE GROUP

1997- DIG TRIAL

1999-RALES

2001-VAL-HEFT

2001-COPERNI

CUS

2011-EMPHASI

S HF

2014-PARADIG

M-HF

3 components: ACE-i/ARB--------- -ARN-i BB MRA

Its not only about the addition of drugs but rather achieving the

target doses of therapy

Courtesy of ESC slides 2015

1. CHRONIC STABLE HF 2. CLASS II-III3. WITHOUT SIGNIFICANT

HYPOTENSION 4. WITHOUT SIGNIFICANT RENAL

IMPAIRMENT

ARN-iCourtesy of ESC slides 2015

Iron therapy

IRONMAN TRIAL.. Results awaited..

2004-COMPANION

2005- CARE HF

2005- SCD HeFT

2009- MADIT CRT 2010- RAFT

2013- ECHO CRT

2014- MADIT CRT

TAKE HOME MSG, Consider CRT if:

Severe LV systolic dysfunction, EF < 35% despite OMT NYHA II or more LBBB Or alternatively, non LBBB preferably >150 msec

TWO CAVEATS..

If Class IV, expected to live for a year with a good functional status.

If Afib, ensure adequate BiV pacing, or else will need concomitant AVN ablation

TAKE HOME MESSAGE: Severe LV systolic dysfunction, EF < 35% despite OMT NYHA II or more Narrow QRS

CAVEAT.. The patient needs to know that this will NOT improve their symptoms but rather improve their sudden cardiac death(SCD)risk..

The patients at highest risk of SCD are those in Class II

INTERMACS Evidence of Heart Tx Evidence of MCS

Establishing a Heart Failure Unit Education to the patient Education to the staff Checklists CPGs Clinical pathways Minimize variation Start early from admission Prevention is Key.. Target those at risk before they get HF.. Stage

A HF..

ARN-i ATMOSPHERE Where do we draw line between HFpEF vs HFrEF PRADA

Courtesy of ESC slides 2015

CABG

ICD vs CRT

OMT Sinus rhythm NYHA II or more Resting HR > 70bpm Target HR ~ 50-60 bpm

State of Art Therapy in Chronic Heart FailureDisclosures:Outline of the talk..Mr. T.B.Physical examinationInvestigationsManagementSlide Number 8Mr. A.R.ECHO Sequel.. Reference guidelines..Basic RoadmapPharmacotherapyACE-i.. The first real ray of hope..BB.. The big NO became a definite YESMRA.. Extended indication from FC III-IV to IIIs it enough to start ACE-I, BB, MRA.. So now.. The foundation is set.. Is there anything else to solidify the foundation further.. Results of PARADIGM-HF..Possible change in basic building blocksAdditional supportive pharmacotherapy Evidence on iron therapyDevice managementWhat do the guidelines say.. If not a candidate for CRT, then what about an ICD??How good are we getting at improving risk of mortality..Can we do better if we shake hands with the surgeons.. How good are the outcomes with HTx?How scarce are donors..So, will we wait till they die, or is there a get-out-of-jail card?Slide Number 33Slide Number 34How will it all work??Where will the future of HF Rx goAwaiting new updates, this is where we are today.. Thanks..Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45A few words on Ivabridine..Slide Number 47Heart failure profile assessment