Optimizing Treatment Of Optimizing Treatment Of Heart Failure for individual Heart Failure for individual

patientspatientsByBy

Prof. Mansoor Ahmad FRCPProf. Mansoor Ahmad FRCP

Consultant CardiologistConsultant Cardiologist

Introduction Introduction

A clinical syndrome characterized by progressive weakening of the heart as a pump, causing complex changes in processes at systemic, organ and cellular levels, finally leading to premature myocardial cell death. This leads to salt and water retention with classical symptoms and physical signs.

Heart failureHeart failure• Prevalence of symptomatic HF 0.4-2.0%,

6-10% in people over 65 years• Disease of the elderly (mean age > 70 years)

• Prevalence is rising• Bad prognosis: 5-year survival rate < 50%• Mortality (even if age adjusted) is increasing

Laszlo L. Tornoci, Inst. Pathophysiology, Semmelweis University

PrognosisPrognosis

• Annual mortality rate depends on patients symptoms and LV function

• 5% in patients with mild symptoms and mild ↓ in LV function

• 30% to 50% in patient with advances LV dysfunction and severe symptoms

• 40% – 50% of death is due to SCD

Causes of heart failureCauses of heart failure

• Underlying (true) causes

• Precipitating causes (which make the clinical condition worse, ‘decompensate’ the patient)

Underlying causesUnderlying causes

• Ischemic heart disease

• Hypertension

• Valvular heart disease

• Cardiomyopathies

• Other

Precipitating causes 1.Precipitating causes 1.

Increased workload

•Increased cardiac output

–metabolic need

(fever, infection, hyperthyroidism)

–volume overload

(renal failure, high sodium intake)

•Pressure overload

–high BP

–pulmonary embolism

Precipitating causes 2.Precipitating causes 2.

Same workload, but weaker heart

• Cardiac ischemia

• Decreased efficiency (arrhythmias)

• Drug effect

• Endocarditis, myocarditis

Precipitating causes 3Precipitating causes 3

• Drugs• Non Steroidal Anti Inflammatory Drugs• Steroids• IV fluids• Hydralazine• Beta blockers• Angioedema

Summary of drug therapySummary of drug therapy

drugcontrol

fluid retention

alleviate symptom

s

prolong survival

diuretic ++ + ?

ACE inhibitor

+ + ++

-blocker* (0) (+) ++

digitalis + ++ 0

*: long term effects are in parentheses

Heart failure Heart failure

• Treatment is evidence based eg.

• CONSENSUS 1987 (ACEI)

• CHARM 2004 (ARB)

• MERIT HF and COPERNICUS (beta blocker)

MERIT-HF and COPERNICUS: Severe Heart FailureMERIT-HF and COPERNICUS: Severe Heart Failure

Number of Patients to Number of Patients to Treat 1 Year Treat 1 Year

in Order to Save One Lifein Order to Save One Life

MERIT-HF:MERIT-HF: 1313

COPERNICUS: COPERNICUS: 1515

COPERNICUSCOPERNICUS Inclusion Criteria Defining Heart FailureInclusion Criteria Defining Heart Failure

EF <0.25 within 6 months prior to randomizationEF <0.25 within 6 months prior to randomizationSymptoms of dyspnea and/or fatigue at rest or on Symptoms of dyspnea and/or fatigue at rest or on minimal exertion for at least 2 monthsminimal exertion for at least 2 monthsNo pulmonary rales and no ascites at No pulmonary rales and no ascites at randomizationrandomizationNo or only trace (minimal) oedema of the No or only trace (minimal) oedema of the peripheral limbs at randomization (patients with peripheral limbs at randomization (patients with mild oedema may be enrolled if the oedema is mild oedema may be enrolled if the oedema is due to a venous disorder)due to a venous disorder)

Heart failure?Heart failure?

• Most of the studies use highly selected patients.

• On an average 12 to 20% of patients are selected out of total screened.

• Where do the rest of the patients fit??

Intolerance to drugs Intolerance to drugs

• Approximately 15% withdrawal rate for blocker.

MERIT-HFMERIT-HF

Severe Heart Failure (NYHA III/IV and EF<0.25)Severe Heart Failure (NYHA III/IV and EF<0.25)

All cause Adverse events

Wosening CHF

p=0.027p=0.027 p=0.012p=0.012p=0.018p=0.018No. ofNo. of

withdrawwithdrawalsals

86/6286/62 66/4266/42 34/1834/18

Goldstein S et al, JACC 2001;38:932-8

MERIT-HF and COPERNICUS: Severe Heart FailureMERIT-HF and COPERNICUS: Severe Heart Failure

Yearly Withdrawal Rate of Yearly Withdrawal Rate of Study MedicineStudy Medicine

Placebo Placebo Meto Meto ΔΔ p-valuep-valueCR/XLCR/XL

MERIT-HF1MERIT-HF1 21.721.7%% 15.5%15.5% -31%-31% 0.027 0.027 COPERNICUSCOPERNICUS 18.5%18.5% 14.8%14.8% -23%-23% 0.020.02

Goldstein S et al, JACC 2001;38:932-8Packer et al, NEJM 2001;344:1651-8

Heart failureHeart failure

• A variety of patients are seen in day to day practice who will not fit completely for the prescribed GUIDELINES.

•

Blood Pressure levelsBlood Pressure levels

• Patients with low Blood Pressure levels tend to tolerate ACE inhibitor, Angiotensin Receptor Blocker and blocker less well.

MERIT-HFMERIT-HF

Severe Heart Failure (NYHA III/IV and EF<0.25)Severe Heart Failure (NYHA III/IV and EF<0.25)

Baseline Blood Pressure and Heart RateBaseline Blood Pressure and Heart Rate

Variable Variable Placebo Placebo Meto Meto

CR/XL CR/XL n=396 n=396 n=399 n=399

Systolic blood pressureSystolic blood pressure 124 124 125125Diastolic blood pressure Diastolic blood pressure 7777 7777Heart rate Heart rate 85 85 8585

Goldstein S et al, JACC 2001;38:932-8

MERIT-HF and COPERNICUS: Severe Heart FailureMERIT-HF and COPERNICUS: Severe Heart Failure

Baseline Blood Pressure and Heart RateBaseline Blood Pressure and Heart Rate

MERIT-HF1MERIT-HF1 COPERNICUSCOPERNICUSVariable Variable Placebo Placebo Meto CR/XL Meto CR/XL Placebo Placebo Carvedilol Carvedilol

n=396n=396 n=399 n=399 n=1133n=1133 n=1156n=1156

SBPSBP 124124 125125 123 123 123123DBPDBP 7777 7777 76 76 7676HRHR 8585 8585 80 80 8080

Chronic Obstructive Airway Chronic Obstructive Airway DiseaseDisease

blocker

Chronic kidney diseaseChronic kidney disease

• Caution with ACE inhibitor and Angiotensin Receptor Blocker.

• BP control

Hyperkalemia Hyperkalemia

• Hyperkalemia is the commonest reason for temporary pacing.

• ACE inhibitor

• Angiotensin Receptor Blocker

• Spiranolactone

• Possibly blocker.

Heart failureHeart failure

• Maintain symptomatic control

• Control fluid retension

• Use diuretics

• Serum potassium.

Heart failureHeart failure

• Add ACE inhibitors/ Angiotensin Receptor blocker early

• Build up the dose over weeks if blood pressure is low

• Watch out for• cough (upto 20%)• Serum potassium• Serum creatinine

Heart failureHeart failure

• Add beta blocker after the fluid overload is controlled

• Build up the dose slowly

• Watch out for brochospasm, worsening failure??

Heart failureHeart failure

• Use digoxin appropriately and cautiously

• Main indication is Fast Atrial Fibrillation with failure

• Serum potassium

• Toxicity

DIAL: Randomized Trial of DIAL: Randomized Trial of Telephonic Intervention in Chronic Telephonic Intervention in Chronic

Heart Failure Heart Failure

DIAL: primary endpoint: all-cause mortality/heart failure hospitalizations

DIAL: heart failure hospitalization

Summary Summary

• Tailor treatment to individual needs of thepatients

• Dosage to tolerability levels• Support care as much as possible• Advise on possible precipitating factors

eg. Flu vaccination in autumn for COAD patients

SummarySummary

• Treat cause whenever possible eg. Revascularization, Valve replacement.

• Control arrythmias• Close watch on patients even if they are well, as

Sudden Cardiac Death is common in all• CRT and ICD in appropriate cases (both clinical

and financial)• Transplant• Artificial heart