MANAGEMENT OF HEART FAILURE DR S MAZHAR CONSULTANT

MANAGEMENT OF HEART FAILURE DR S MAZHAR CONSULTANT CARDIOLOGIST SOUTHEND UNIVERSITY HOSPITAL

SCALE OF THE PROBLEM • MORE THE 900, 000 PATIENTS IN UK KNOWN TO HAVE HEART FAILURE AND ALMOST SAME NUMBER HAVE ‘DAMAGED HEART, BUT AS YET, ASYMPTOMATIC • PREVALENCE OF HEART FAILURE ON THE RISE • PREDOMINANTLY A CONDITION OF ELDERLY WITH AVERAGE OF 76 YEARS AT THE TIME OF DIAGNOSIS • POOR PROGNOSIS WITH 30 -40% PATIENTS DYING WITHIN A YEAR OF DIAGNOSIS • PATIENTS ON GP HF REGISTERS HAVE 5 YEAR SURVIVAL OF 58% (93% FOR AGE- AND SEX- MATCHED GENERAL POPULATION) • 1 MILLION INPATIENT BED DAYS AND 6 -7% OF ALL ACUTE ADMISSIONS

• SURVIVAL BENEFITS WITH ALMOST ALLPROGNOSTIC MEDICATIONS SEEN MOST IN THE YOUNG AGE GROUP (AGE <65 YEARS) • MOST STUDIES SHOW MINIMAL SURVIVAL YEARS • BENEFITIN AGE >80 CONSISTENT WITH EXPERT OPINION ADVISING EMPHASIS ON QUALITY OF LIFE BUT NOT MORTALITY IN THIS SUBGROUP

HFREF (REDUCED EJECTION FRACTION) VS HFPEF (PRESERVEDEF) 65% VS 35% (? ) • ALMOST ALL THE EVIDENCE ON TREATMENT IS FORHFREF

PLASMA BNP IN PRIMARY CARE 1 -NOT A SUBSTITUE FOR GOOD CLINICAL ASSESSMENT 2 - ALWAYS HAVE AN UPDATED ECG BEFORE REQUESTING PLASMA BNP 3 - DO NOT CHECK BNP IF THE PATIENT HAS CLINICAL SIGNS OF HEART FAILLURE OR LOW LIKELIHOOD OF HEART FAILURE ON CLINICAL ASSESSMENT 4 - GP SHOULD BE AWARE OF THE ‘PLASMA BNP’ JOURNEY OVER THE LAST 15 YEARS – (NG/L) – 150 – 250 – 300 – 450 - ? 600 5 - ROLE OF SERIAL/UPDATED BNP IN PATIENTS WITH KNOWN HEART FAILURE 6 - ‘ONE STOP HEART FAILURE CLINIC’ AND THE IMPACT OF AUTOMATIC INAPPROPRIAE PLASMA BNP LEVEL GUIDED REFERRAL

FINDINGS OF AN AUDIT OF 100 CONSECUTIVE IN ONE STOP HF CLINIC • 65% PATIENTS WITH PLASMABNP >600 NG/L HAD SINUS RHYTHM, NORMAL/NEAR NORMAL ECHOCARDIOGRAM AND NO CLINICAL SIGNS OF HEART FAILURE. • 29 PATIENTS HAD PLASMABNP IN THE 300 -600 RANGE. 1 (3. 4%) HAD ABNORMAL ECHOCARDIOGRAM. NORMAL AGE ADJUSTED ECHOCARDIOGRAM AND CLINICAL EXAMINATION IN 28 PATIENTS • ONE OFF NT PROBNP HAS NO SIGNIFICANT ROLE IN DIAGNOSIS OF HEART FAILURE IN AF – MEAN BNP OF 800 NG/L IN PATIENTS WITH NORMAL LVEF AND NO VALVE ABNORMALITIES)

AUDIT NEAR COMPLETION AT SOUTHEND HOSPITAL • 100 CONSECUTIVE PATIENTS WITH PLASMA BNP 300(450) - 600 NG/L SEEN IN THEONE STOP HF CLINIC. • LV DYSFUNCTION/VOLUME OVER LOAD/SIGNIFICANT VALVULAR ABNORMALITIES IDENTIFIED IN 7 PATIENTS. FINAL RESULTS AWAITED – MAY LEAD TO FURTHER RAISING OF THE PLASMA BNP CUT OFF VALUE FOR AUTOMATIC REFERRAL TOONE STOP HF CLINIC.

MEDICAL MANAGEMENT 1. ACE INHIBITORS • WHICH IS THE BEST ACE INHIBITOR? • RULE OF THUMB-NO SIGNIFICANT DIFFERENCE BETWEENRAMIPRIL, PERINDOPRIL, LISINOPRIL AND ENALAPRIL – EMPHASIS SHOULD BE ON DOSE OPTIMISATION AND NOT BRANDSELECTION 2. ARB • CANDESARTAN, LOSARTAN, VALSARTAN • NB: CONCOMITANT USE OF ACE INHIBITORS AND ARB NOT RECOMMENDED

3. B BLOCKERS • BISOPROLOL, CARVEDILOL, METOPROLOL AND NEBIVOLOL • (DIFFERENCES BETWEEN THESE B BLOCKERS ARE USUALLY OF NO PRACTICAL SIGNIFICANCE) • B BLOCKERS IN COPD AND ASTHMA • WHAT SHOULD BE STARTED FIRST? ACEI/ARB ORB BLOCKER

4. MRAS (MINERALOCORTICOID RECEPTOR ANTAGONIST) • SPIRONOLACTONE AND EPLERONONE • ALL PATIENTS INNYHA CLASS 3 (ESTABLISHED ONACEI/ARB AND B BLOCKERS) SHOULD BE CONSIDERED FORMRAS. • ONLY EPLERONONE FOR NYHA CLASS 2 PATIENTS • WHICH MRA TO USE?

5. IVABRADINE IN HFREF • PATIENTS MUST BE IN SINUS RHYTHM • RESTING HEART RATE NO LESS THAN 70 (5)/MIN AT THE START OF THERAPY • LVEF <40% • NYHA CLASS 2 -4 • IDEALLY AS AN ADD ON TOB BLOCKER BUT AS A SUBSTITUTE IF B BLOCKER NOT TOLERATED/CONTRAINDICATED

NEW KID ON THE BLOCK 6. SACUBUTRIL/VALSARTAN (ENTRESTO) • CLASS 2 -4 PATIENTS WITHLVEF <35% ON OPTIMAL DOSES OF ACEI/ARB AND OTHER APPROPRIATE MEDICATIONS • PARADIGM-HF TRIAL • • LARGEST HF CLINICAL TRIAL EVER CONDUCTED ENALAPRIL 10 BD VS SACUBUTRIL/VALSARTAN 97/103 BD (8442 PATIENTS, PRIMARY ENDPOINT DEATH OR HF HOSPITALISATION, MEDIAN FOLLOW UP 27 MONTHS, TRIAL STOPPED EARLY

POINTS TO PONDER WHILE CONSIDERING PATIENTS FOR SACUBUTRIL/VALSARTAN 1. AVERAGE OF 64 YEARS IN PARADIGM TRIAL WHILE IN UK COMMUNITY HF CLINICS AVERAGE IS 76 YEARS (MALE) AND 81 YEARS (FEMALE) – HENCE NOT A SIMPLE MATTER OF EXTRAPOLATION 2. TARGET VALSARTAN DOSE OF 103 MG BD ALMOST NEVER USED IN CLINICAL PRACTICE. 3. STARTED BY HOSPITAL BASED SPECIALIST AFTER MDT. DOSE UPTITRATION BY COMMUNITY HF CLINIC OR GPSI 4. SYMPTOMATIC HYPOTENSION AND DETERIORATION OF RENAL FUNCTION IMPORTANT SIDE EFFECTS

FLOW CHART ADULT WITH CHRONIC HEART FAILURE DUE TO LEFT VENTRICULAR SYSTOLIC DYSFUNCTION AND LVEF LESS THAN 35% ON TTE IN THE LAST 12 MONTHS OR ON REPEAT TTE AFTER RECENT CHANGES IN HF TREATMENT AND AT MAXIMUM TOLERATED EVIDENCE BASED DOSE FOR AT LEAST 4 WEEKS ON ACEI OR ARB + BB FIRST LINE AND ON MR ANTAGONIST AND INVABRADINE (if SR and HR more than 75 bpm, in addition to BB or in place if BB contradicted or not tolerated SECOND LINE STILL SYMPTOMATIC NYHA CLASS II-IV REPLACE ACEI OR ARB WITH ARNI THIRD LINE

CRT AND HFREF “ I KNOW SOMEONE WITH HEART PROBLEMS SIMILAR TO MINE WHO HAS BEEN FITTED WITH DEFIBRILLATOR/SPECIAL PACEMAKER – WHY HAVEN’T I GOT ONE? ”

LBBB

CARDIAC DYSSYNCHRONY – ELECTRICAL VS MECHANICAL DEVICE THERAPY IN HEART FAILURE “ SOMEONE WITH HEART CONDITION SIMILAR TO MINE HAS A DEFIBRILLATOR/SPECIAL PACEMAKER. I WOULD ALSO LIKE TO HAVE ONE”. NORMAL ECG

LBBB

RBBB

IVCD

RATIONALE FOR CRT ‘PRESENCE OF BUNDLE BRANCH BLOCK CAN WORSEN HF DUE TO SYSTOLIC DYSFUNCTION BY CAUSING VENTRICULAR DYSSYNCHRONY, THEREBY INDUCING REGIONAL LOADING DISPARITIES AND REDUCING THE EFFICIENCY OF CONTRACTION. A VARIETY OF HEMODYNAMIC BENEFITS FOLLOW THE CORRECTION OF DYSSYNCHRONY WITH CRT. ’

META ANALYSIS OF RANDOMISED CONTROLLED TRIALS FOR CRT

CURRENT GUIDELINES FOR CRT • WITH LVEF <35% NICE, ESC AND ACC GUIDELINES RECOMMEND: • • CRT-D FOR NYHA CLASS 1 TO 3 PATIENTS WITH QRSD >150 MSEC CRT-D FOR CLASS 2 AND 3 PATIENTS WITH LBBB AND QRSD 130 -149 MSEC STAND ALONE CRT-P IN NYHA CLASS 4 PATIENTS WITH ECG CRITERIA AS ABOVE ROLE OF ECHO – DURING WORKUP LIMITED TO LVEF ASSESSMENT. SOME ROLE OF ECHO IN INTRAVENTRICULAR DYSSYNCHRONY ASSESSMENT IN LBBB WITHQRSD 120 -130 MSEC POST IMPLANT – ECHO HAS ROLE IN CRT OPTIMISATION

CRT AND ATRIAL FIBRILLATION • THE PREVALENCE OF ATRIAL FIBRILLATION (AF) VARIES WITH SEVERITY OF HEART FAILURE, RANGING FROM 5% IN PATIENTS WITH NYHA FUNCTIONAL CLASSI HF TO 40% IN PATIENTS WITH NYHA CLASSIV HF. • NICE, ESC AND ACC CONSENSUS : • CRT CAN BE USEFUL IN PATIENTS WITH AF WHO HAVE A LEFT VENTRICULAR EJECTION FRACTION (LVEF) ≤ 35% ON GUIDELINEDIRECTED MEDICAL THERAPY IF: • THE PATIENT REQUIRES VENTRICULAR PACING OR OTHERWISE MEETS CRT CRITERIA AND • AV NODAL ABLATION OR PHARMACOLOGIC RATE CONTROL WILL ALLOW NEAR 100 PERCENT VENTRICULAR PACING WITH CRT.

EXPANDING CRT INDICATION • BLOCK HF TRIAL • RECOMMENDATIONS OF BLOCK-HF TRIAL HAVE BEEN WIDELY ACCEPTED AND APPLIED TO OUR PATIENTS • DANISH TRIAL • CURRENT PRACTICE IN LINE WITH THE TRIAL RESULT – THE GUIDELINES ARE LAGGING BEHIND

EVOLVING CARE OF HF PATIENTS • DISCONNECT BETWEEN THE IMAGING SPECIALISTS (WHO ALSO FREQUENTLY SUPERVISE THE HF SERVICE) AND IMPLANTERS (HISTORICALLY CARDIAC ELECTROPHYSIOLOGISTS) • 1 ST GENERATION OF HF SPECIALISTS NOW COMING THROUGH – WILL RESULT IN COMPREHENSIVE MANAGEMENT UNDER THE SUPERVISION OF ONE SPECIALIST

ELEPHANT IN THE ROOM HFPEF SOME IMPORTANT FACTS TO TAKE HOME: 1. CRITICAL TO DIFFERENTIATE BETWEEN ASYMPTOMATIC LV DIASTOLIC DYSFUNCTION FROM A SYNDROME OF SYMPTOMS AND SIGNS OF HEART FAILURE, LVEF >50% (EXCLUDING WELL DEFINED CLINICAL ENTITIES) AND EVIDENCE OF LV DIASTOLIC DYSFUNCTION ON ECHOCARDIOGRAM OR CARDIAC CATHETERISATION.

2. HYPERTENSION, DIABETES, CORONARY ARTERY DISEASE, OBESITY, SLEEP APNEA, CKD, AGE >70 YEARS – AT LEAST TWO ENTITIES PRESENT IN ‘ALMOST’ ALL PATIENTS. 3. HFREF VS HFPEF - NO MAJOR DIFFERENCES IN MEDICAL MANAGEMENT BUT NO CLEAR PROGNOSTIC BENEFIT IN HFPEF. 4. NO ROLE OF IVABRADINE INHFPEF. 5. NO ROLE OF CRT INHFPEF 6. BETTER PROGNOSIS OF HFPEF

EVOLVING COMMUNITY HEART FAILURE SERVICE IN SOUTHEND 1 - THE COMMUNITY HF SERVICE IS NOW FUNDED TO MANAGE HFPEF PATIENTS – COMMENCEMENT DATE 15 TH OCTOBER 2018. 2 - INTRAVENOUS DIURETIC THERAPY IN COMMUNITY IS NOW FULLY OPERATIONAL –THE REFERRAL PATHWAYS ARE IN PLACE AND GPS CAN DIRECTLY REFER THE PATIENTS TO THE SERVICE 3 - WEEKLY HEART FAILURE MDT BETWEEN THE COMMUNITY HF TEAM AND HOSPITAL BASED SPECIALISTS IS NOW FULLY FUNCTIONAL

CHALLENGES OF LONG TERM PRIMARY CARE FOLLOWUP OF ‘STABLE HEART FAILURE’ • 1 - ADHERENCE TO NICE GUIDELINES REGARDING FOLLOWUP. • 2 - GOOD UNDERSTANDING OF LATEST ADVANCES IN MANAGEMEMT AS THE ‘STABLE’ PATIENTS MAY BENEFIT FROM NEW MEDICINES/TECHNOLOGY. • 3 - SEAMLESS TRANSITION TO INCREASED PALLIATION IN APPROPRATE PATIENTS

CASE HISTORY 48 YEAR OLD MAN, BMI 27, NON DIABETIC, NON SMOKER, TREATED FOR HYPERTENSION (142/90), ASYMPTOMATIC, PLASTERER FH , OF CHD, TC: HDL 4. 9 - 10 YEAR CHD RISK OF 11% WHAT SHOULD WE DO WITH THE PATIENT? NOTE: THERE IS POOR CORRELATION BETWEENFH & RAISED PLASMA CHOLESTEROL AND MI PREDICTION

1 - PROVIDE LIFE STYLE MODIFICATION ADVISE AND DISCHARGE? 2 - COMMENCE HIM ON ‘CHEAPEST AVAILABLE / FLAVOUR OF THE MONTH STATIN’ AND ? ASPIRIN AND OPTIMISE ANTIHYPERTENSIVE RX 3 - REFER TO CARDIOLOGIST FOR FUNCTIONAL TESTS OF MYOCARDIAL ISCHAEMIA? 4 - GO DIRECTLY FOR THE C ‘ ONCLUSIVE DIAGNOSIS’ AND CT OR INVASIVE CORONARY ANGIOGRAM? ARRANGE

CT CORONARY CALCIUM SCORE

• 1 - IN NON DIABETIC ASYMPTOMATIC PATIENTS AGED >40 YEARS WITH CT CORONARY CALCIUM SCORE (CAC) OF 0, IRRESPECTIVE OF PLASMA CHOLESTEROL LEVEL, 549 PATIENTS REQUIRE TREATMENT WITH STATINS FOR 5 YEARS TO PREVENT 1 MI • WITH CAC SCORE >100, 24 PATIENTS REQUIRE TREATMENT TO PREVENT 1 MI IN 5 YEARS

RECENT ADVANCES IN CAC ( 10 MINS, LOW RADIATION AND LOW COST ) MAKES IT A PARTICULARLY ‘USER FRIENDLY’ TEST. IN OTHERWISE ASYMPTOMATIC INDIVIDUALS IT SHOULD BE LIMITED TO: A) PRESENCE OF NO MORE THAN 1 RISK FACTOR FORCAD (I. E HTN) B) MEN >45 YEARS OLD AND WOMEN >55 YEARS OLD C) FH OF PREMATURE CAD CAC SCORING IN MOST USEFUL IN ASYMPTOMATIC INTERMEDIATE RISK PATIENTS AS THE CT SCORE EITHER UPGRADES THE INDIVIDUAL TO LOW RISK (NOSTATIN REQUIRED) OR DOWNGRADES TO HIGH RISK (STATIN REQUIRED)

• IN THE PRESENCE OF CHEST PAIN THE INDICATIONS FOR CAC SCORECT /T C ANGIOGRAM ARE MUCH MORE CLEARLY DEFINED

ASPIRIN AND OTHER ANTIPLATELET AGENTS PRIMARY VS SECONDARY PREVENTION - JOINT BRITISH SOCIETIES GUIDANCE ON PRIMARY PREVENTION – ASPIRIN SHOULD BE PRESCRIBED TO ALL PATIENTS AGED OVER 50 YEARS WITH 10 YEARS CHD RISK OF 20% OR MORE - ABSOLUTE RISK REDUCTION IN PRIMARY PREVENTION IS MODEST AT BEST - >550 ALL COMERS AGED OVER 50 YEARS NEED TO BE PRESCRIBED ASPIRIN FOR OVER 8 YEARS TO PREVENT A SINGLE CVD EVENT

CURRENTLY, BALANCE OF EVIDENCE DOES NOT SUPPORT WIDESPREAD USE OF ANTIPLATELETS FOR PRIMARY PREVENTION OF CVD, INCLUDING IN DIABETES AND HYPERTENSION

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