Heart Failure Review and Update Mark Garcia, MD Assistant Professor University of New Mexico School of Medicine Division of Cardiology No disclosures Learning Objectives
Outpatient therapy focused Understand gaps in HF therapy Review HF classification and stages Review HF therapies and guideline updates Understand the importance of medication
titration and guideline adherence Heart failure is the price we pay for the successful treatment of heart disease. - Eugene Braunwald, MD Lecture 2017: The war on heart failure A common and serious condition: 6.5 million Americans adults have HF
Will increase to >8 million by 2030 Lifetime risk of developing HF for both men and women is 1 in 5 ~50% of people diagnosed with HF will die within 5 years HF is the leading cause of hospitalizations annually Benjamin et al. Heart disease and stroke statisticsHeart Disease and Stroke Statistics - 2018 update: A report from the American Heart Association. Circulation 2018; 137:e67e492.
Gaps in Heart Failure Treatment Cleland JG, Cohen-Solal A, Aguilar JC, et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002;360:1631-1639. The Gap in Applying Guidelines James E. Calvin, MD; Sujata Shanbhag, MD; Elizabeth Avery, MS; John Kane, MS; Dejuran Richardson, PhD; Lynda Powell, PhD. Adherence to Evidence-Based Guidelines for Heart Failure in Physicians and Their Patients: Lessons From the Heart Failure Adherence Retention Trial (HART). Congest Heart Fail. 2012;18:7378.
Guarnaccia Francoa, Fimiani Biagioa, Zito Giovanni Battistaa, De Simone Antoniob, Stabile Giuseppeb, Bossone Edoardoc,d, Volpe Ercolee, Bosso Giorgiof, Sacca` Luigif, Oliviero Ugof, and the ALERT-HF Investigators. ALERT-HF: adherence to guidelines in the treatment of patients with chronic heart failure. J Cardiovasc Med 2014, 15:491497 Heart Failure Definition Heart Failure (HF): syndrome that results from structural or functional impairment of ventricular filling or ejection of blood Cardinal features of HF: Dyspnea and fatigue which limit exercise tolerance
Fluid retention which may lead to pulmonary and/or systemic congestion Clinical diagnosis mostly based on history and physical exam with no single diagnostic test Classifications of HF by Ejection Fraction Heart Failure with reduced Ejection
Fraction (HFrEF) Left ventricular Ejection Fraction (EF) <40% Heart Failure with preserved Ejection Fraction (HFpEF) EF >50% HFpEF borderline EF 41 to 49%
HFpEF improved EF >40% (previously reduced EF) HF Stages Stage A At risk for heart failure (HTN, CAD, cardiotoxins) No structural disease Stage B Structural disease/reduced EF
No heart failure symptoms Stage C Heart failure symptoms Stage D End-stage disease (recurrent hosp, need for Tx/LVAD) Functional Classification New York Heart Association Functional Class (NYHA)
NYHA class I No physical limitations NYHA class II Slight limitation of physical activity NYHA class III Marked limitation of physical activity
NYHA class IV Symptoms at rest Brent N. Reed and Carla A. Sueta. A Practical Guide for the Treatment of Symptomatic Heart Failure with Reduced Ejection Fraction (HFrEF). Current Cardiology Reviews, 2015, 11, 23-32 Pathology to therapy Neurohumoral activation leads to: Vasoconstriction Sodium retention
Maladaptive remodeling Therapeutic interventions combat neurohumoral activation: Reverse remodeling Improve survival, symptoms, and QOL Therapy by stage Stage A (at risk) Treat BP to <130/80mmHg (new update) Treat lipid disorders according to existing
guidelines Address/treat obesity, DM, tobacco use Avoid/control cardiotoxic agents Therapy by stage Stage B (reduced EF, no HF) ACEi or ARB and evidence-based beta blockers Reduce mortality (post-MI) and prevent HF
Statins according to existing guidelines ICD in EF <30% while on appropriate guideline therapy and >40 days post-MI Reduce mortality Therapy by stage Stage C HFrEF and HFpEF Initial labs CBC, electrolytes, BUN/Cr, LFTs, lipid panel, TSH
Screen for hemochromatosis and HIV New onset HF obtain CXR and TTE BNP or NT-proBNP Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;
Diuretic dosing in HF Stage C HFrEF and HFpEF Use diuretics to relieve volume overload Sodium restriction Generic name and dosing range Bumetanide 0.510 mg daily in one or two doses Furosemide 20600 mg daily in one or two doses Torsemide 10200 mg once daily
Therapy by stage Stage C HFrEF ACEi/ARB, evidence based beta blockers Aldosterone antagonist ICD/CRT Other therapies ARNI ACE-I and ARBs for managing HF Stage C HFrEF
Reduce mortality and hospitalizations Improve symptoms Asymptomatic LV dysfunction (LVEF < 40%) to class IV symptoms ARBs are not superior to ACEi Reasonable substitute if not tolerant to ACEi Use with caution when Cr>3, SBP<80mmHg, and K>5
ACE-I for managing HF Stage C HFrEF Generic name and dosing range Benazepril 540 mg once a day Captopril 6.550 mg three times a day Enalapril 2.520 mg twice a day Fosinopril 540 mg once a day Lisinopril 2.540 mg once a day Quinapril 520 mg once a day Ramipril 1.2510 mg once a day
Trandolapril 14 mg once a day ARBs for managing HF Stage C HFrEF Generic name and dosing range Candesartan 432 mg once a day Losartan 25150 mg once a day Valsartan 20160 mg twice a day Beta-blockers for managing HF
Stage C HFrEF Reduce mortality and hospitalizations Improve symptoms Asymptomatic LV dysfunction (LVEF < 40%) to class IV symptoms In new onset HF, initiate beta blocker once congestion is resolved Beta-blockers for managing HF Stage C HFrEF
Generic name and dosing range Carvedilol 3.12525mg twice a day (50mg if >85Kg) Metoprolol succinate 12.5200 mg once a day Bisoprolol 1.2510 mg once a day Dose Does Matter: Importance of titration Stage C HFrEF Lisinopril titrated to trial doses decreased hospitalizations and fewer CV events
No change in mortality with higher dose Beta blocker benefit increases relative to the degree of heart rate reduction Reduced mortality and hospitalizations Aldosterone receptor antagonists for managing HF Stage C HFrEF Reduce mortality and hospitalizations
NYHA II-IV and EF < 35% Class II with prior hospitalization or BNP elevation Post acute MI and EF < 40% with HF or DM Cr <2.5 in men or <2.0 in women, K<5.0 Aldosterone receptor antagonists for managing HF Stage C HFrEF Generic name and dosing range
Spironolactone 12.525 mg once a day Eplerenone 2550 mg once a day Gregg C. Fonarow, MD. How Well Are Chronic Heart Failure Patients Being Managed? Rev Cardiovasc Med. 2006;7(suppl 1):S3-S11. Device Therapy in HF Stage C HFrEF Implantable Cardioverter-Defibrillator (ICD) for primary prevention of sudden cardiac death (SCD)
Reduce mortality EF <35% and NYHA class II or III On chronic guideline therapy Dilated cardiomyopathy Ischemic cardiomyopathy >40 days post-MI Life expectancy >1 yr Device Therapy in HF Stage C HFrEF Cardiac Resynchronization Therapy (CRT)
EF <35% and NYHA II-IV on guideline therapy LBBB (QRS duration >150ms) Reduce mortality and hospitalizations Improve EF and reverse remodeling Additional Therapies Stage C HFrEF Hydralazine-Nitrate combination Hydralazine and isosorbide dinitrate
Reduce HF mortality and morbidity NYHA Class III-IV symptoms Self described as African American Already on optimal ACEi and beta blocker ACEi/ARB intolerant Additional Therapies Stage C HFrEF Digoxin can be beneficial to decrease HF
hospitalizations ASA and statin (based on primary and secondary prevention recommendations) Omega-3 polyunsaturated fatty acid (PUFA) for NYHA class IIIV symptoms (IIa) May reduce mortality and CV hospitalizations New Therapy Stage C HFrEF Angiotensin-neprilysin inhibition (ARNI)
Further reduce mortality and morbidity ACEi and ARB class I indication Head to head comparison to ACEi resulted in ARNI being superior (further reduced mortality and hospitalizations) NYHA class II or III who tolerate ACEi/ARB Angiotensin-neprilysin inhibition
Scott A. Hubers, MD; Nancy J. Brown, MD. Combined Angiotensin Receptor Antagonism and Neprilysin Inhibition. Circulation. 2016;133:1115-1124. Angiotensin-neprilysin inhibition (ARNI) for managing HF Stage C HFrEF Do not administer with ACEi Do not give if history or angioedema Angiotensin-neprilysin inhibition for managing heart failure
Stage C HFrEF Generic name and dosing range Sacubitril-valsartan 2426 mg, 4951 mg, or 97103 mg twice daily Recommend to replace ACEi/ARB with sacubitril-valsartan for further reduction of morbidity and mortality (class I indication) If tolerated for 24 weeks, double the daily dose until target dose of 97103 mg twice daily is reached For patients converting from an ACEi, start 36 hours after discontinuation of the ACEi
Additional Therapies Stage C HFrEF and HFpEF Exercise in HF is safe and recommended Cardiac rehab Improve functional capacity, QOL, and mortality Clinically stable patients Additional Therapies
Stage C HFrEF and HFpEF Sleep disordered breathing (new update) NYHA class II-IV and suspicion of sleep disordered breathing Referral for sleep evaluation Obstructive sleep apnea CPAP beneficial Central sleep apnea and NYHA II-IV HFrEF Adaptive servo-ventilation can be harmful
Therapy by stage Stage C HFpEF Hypertension treat according to GDMT and titrated to attain SBP <130 mm Hg (new update) Omega-3 polyunsaturated fatty acid (PUFA) for NYHA class IIIV symptoms (IIa) May reduce mortality and CV hospitalizations
Therapy by stage Stage C HFpEF (new update IIb) Aldosterone receptor antagonist EF 45% Elevated BNP levels or HF admission within 1 year GFR >30 mL/min or creatinine <2.5 mg/dL and potassium <5.0 mEq/L Consider Spironolactone to decrease hospitalizations
Drugs to avoid in HF Verapamil, diltiazem, nicardipine NSAIDs Thiazolidinediones Therapy by stage Stage D (End-stage disease) >2 Hospitalization in the past year Persistent symptoms with ADLs Weight loss (cardiac cachexia)
Intolerance to ACEi or beta blockers Frequent SBP <90mmHg Decline in serum sodium (<133) Progressive decline in renal function Frequent ICD shocks Therapy by stage Stage D (End-stage disease) In carefully selected patients consider advanced options:
Ionotropic support Mechanical circulatory support Transplant Palliative care and hospice ICD deactivation Strategies for success Closely monitor vital signs (include postural changes), renal function, and electrolytes
Continual education of patients and families Use a multidisciplinary team Continual assessment and management of comorbidities DM, depression, COPD, etc. Strategies for success Reducing HF readmissions: In-hospital initiation of HF therapies
Resolution of congestion HF education Medication titration and adherence Close monitoring and follow up References
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240e327.ABCs of Heart Failure Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017
Ike S. Okwuosa, MD , Oluseyi Princewill, MD, MPH , Chiemeke Nwabueze, MD , Lena Mathews, MD , Steven Hsu, MD , Nisha A. Gilotra, MD , Sabra Lewsey, MD, MPH , Roger S. Blumenthal, MD, Stuart D. Russell, MD. The ABCs of managing systolic heart failure: Past, present, and future. Cleveland Clinic Journal of Medicine. 2016 October;83(10):753-765 Benjamin et al, Heart Disease and Stroke Statistics2018 Update: A Report From the American Heart Association Circulation. 2018;137:e67e492. Gregg C. Fonarow, MD, FACC, FAHA. How Well Are Chronic Heart Failure Patients Being Managed? Rev Cardiovasc Med. 2006;7(suppl 1):S3-S11 John J.V. McMurray, M.D., Milton Packer, M.D., Akshay S. Desai, M.D., M.P.H., Jianjian Gong, Ph.D., Martin P. Lefkowitz, M.D., Adel R. Rizkala, Pharm.D., Jean L. Rouleau, M.D., Victor C. Shi, M.D., Scott D. Solomon, M.D., Karl Swedberg, M.D., Ph.D., and Michael R. Zile, M.D., AngiotensinNeprilysin Inhibition versus Enalapril in Heart Failure. N Engl J Med
2014;371:993-1004. Clyde W. Yancy, MD, Comprehensive Treatment of Heart Failure: State-of-the-Art Medical Therapy. Rev Cardiovasc Med. 2005;6(suppl 2):S43-S57 Bozkurt B. What is new in Heart Failure Management in 2017? Update on ACC/AHA Heart Failure Guidelines. Current Cardiology Reports 2018; 20: 39. Hartley-Rayner E. et al Update on the management of acute heart failure. Current Opinion in Cardiology 2018; 33:225231.
