Congestive Heart Failure CHF: Nik Nikam, M.D

SUGAR LAND
Congestive Heart Failure CHF
HEART CENTER
By Nik Nikam, M.D.

Interventional Cardiologist Sugar Land Texas May 2010
SUGAR LAND

Epidemiology
Approximately 4.9 million people have CHF More than 550,000 cases detected annually Account for 5 to 10% of all hospitalizations 250,000 deaths per year related to CHF Five year mortality as high as 60% in men & 45% in women Median survival is 3.5 years for men and 5.4 years for women
HEART CENTER
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CHF precipitating factors Non Compliance with Meds and Diet Acute MI Arrhythmia Pneumonia Increased Sodium Diet (Holiday Failure) Anxiety Pregnancy
HEART CENTER
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Rhythm problems leading to CHF
HEART CENTER
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Pathophysiology
HEART CENTER
Hemodynamic changes
Neurohormonal changes Cellular changes
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Neurohormonal changes in CHF
Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Initial fall in LV performance, wall stress
Activation of RAAS and SNS
HEART CENTER
Remodeling and progressive worsening of LV function
Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity
Peripheral vasoconstriction Hemodynamic alterations
Morbidity and mortality Arrhythmias Pump failure
Heart failure symptoms Fatigue Activity altered Chest congestion Edema Shortness of breath
RAS, renin-angiotensin system; SNS, sympathetic nervous system.
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Neurohormonal changes
N/H changes
Sympathetic activity Renin-Angiotensin Aldosterone Vasopressin interleukins &TNF
HEART CENTER
Favorable effect
HR , contractility, vasoconst. V return, filling Salt & water retention VR
Unfavor. effect
Arteriolar constriction After load workload O2 consumption Vasoconstriction after load Same effect
Same effect
May have roles in myocyte hypertrophy Vasoconstriction VR
Apoptosis
Endothelin
After load
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Cardiovascular physiology Frank-Starling
Length: Tension Ratio
HEART CENTER
Ejection Fraction
End diastolic volume/end systolic volume
Cardiac Output
Stroke volume x heart rate
Preload
Volume of blood delivered to heart during diastole
Afterload
Peripheral vascular resistance
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Causes of CHF Volume overload: Pressure overload: Loss of muscles:
Regurgitate valve High output status Systemic hypertension Outflow obstructionAS Post MI, Chronic ischemia Connective tissue diseases Infection, Poisons
(alcohol,cobalt,Doxorubicin)
HEART CENTER
Restricted Filling:
Pericardial diseases, Restrictive cardiomyopathy Tachyarrhythmia
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Types of CHF Systolic & Diastolic
High Output Failure
Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagets disease
HEART CENTER
Low Output Failure Acute
large MI, aortic valve dysfunction-- Chronic
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Types of CHF
Right v. Left sided heart failure Right sided heart failure : Most common cause is left sided failure Other causes included : Pulmonary embolisms Other causes of pulmonary HTN RV infarction MS Usually presents with: LL edema, ascities Hepatic congestion Cardiac cirrhosis (on the long run)
HEART CENTER
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New York Heart Association (NYHA)
Functional Classification
HEART CENTER
Class
I
% of pts
35%
Symptoms
No symptoms or limitations in ordinary physical activity Mild symptoms and slight limitation during ordinary activity Marked limitation in activity even during minimal activity. Comfortable only at rest Severe limitation. Experiences symptoms even at rest
II
35%
III
25%
IV
5%
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Physical Exam
Anxious Pale Clammy Tachypnea Confusion Edema Hypertension Diaphoretic
HEART CENTER
Rales Rhonchi Tachycardia S3 Gallop JVD Pink Frothy Sputum Cyanosis Displaced PMI
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Measurement of Jugular Venous pressure
HEART CENTER
Jugular Venous Distention not directly related to LVF.
Comes from back pressure building from right heart into venous circulation
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Framingham Criteria for CHF
HEART CENTER
Major Criteria:
PND JVD Rales Cardiomegaly Acute Pulmonary Edema S3 Gallop Positive hepatic Jugular reflex venous pressure >16 cm H2O
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Lab Tests Anemia Hyperthyroid Chronic renal insuffiency Electrolyte abnormality-Na, K, Mag, Calcium Pre-renal azotemia Hemochromatosis BNP TSH HgA1c
HEART CENTER
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EKG Old MI or recent MI Arrhythmia Some forms of Cardiomyopathy are tachycardia related LBBBmay help in management Heart Block
HEART CENTER
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Chest X-ray
HEART CENTER
Look for Heart size Pulmonary vascular markings COPD, pneumonia, Pneumothorax, widened mediastinum Pleural effusions
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Echocardiogram
HEART CENTER
Function of both ventricles Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pericardial effusion Restrictive pericarditis Pulmonary hypertension
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Cardiac Catheterization
HEART CENTER
Coronary artery disease Dilated ventricle Hyperdynamic small ventricle Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pulmonary hypertension
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Differential Diagnosis of CHF
HEART CENTER
Pericardial diseases Liver diseases Nephrotic syndrome Protein losing enteropathy
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COPD CHF Pneumonia
HEART CENTER
Cough
Wheeze Sputum Hemoptysis PND
Frequent
Frequent Thick Occasionally Sometimes after a few hours
Occasional
Occasional Thin/white Pink frothy Often within 1 hour
Frequent
Frequent Thick/yellow/ brown occasionally Rare
Smoking
Pedal edema
Common
Occasional
Less common
Common with chronic
Less common
none
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COPD Onset Chest Pain Often URI with cough pleuritic CHF Orthopnea at night Substernal, crushing Pneumonia Gradual with fever, cough Pleuritic, often localized
HEART CENTER
Clubbing
Cyanosis Diaphoresis Pursed Lips
Often
Rare
Rare
Often and severe Initially mild but May be present progresses May be present Often Mild to heavy Rare Dry to moist Rare unless COPD
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HFSA 2006 Comprehensive Heart Failure Practice Guideline
HEART CENTER
Strength of Evidence
A B
Randomized controlled trials
May be assigned on results of 1 trial
Cohort and case control studies

Includes sub group analyses, metaanalyses, observational studies, registries
Expert opinion
Includes observational, epidemiological findings; in-practice safety reporting
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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Goals for CHF management in a hospital
1. Relieve symptoms rapidly
2. Reverse hemodynamic abnormalities 3. Prevent end-organ dysfunction 4. Initiate patient education and survival-enhancing medications before discharge 5. Optimize survival-enhancing oral medications (ACE inhibitor, beta blocker, aldosterone receptor antagonist) 6. Optimize patient education and HF disease management
HEART CENTER
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CHF treatment-Acute
HEART CENTER
NTG- SL and IV infusion Morphine sulfate: 2-6 mg IV Lasix 40-80 mg IV O2High flow O2 CPAP Foley catheter
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CHF Management
Bi-Vv pacing if sxs CRT
HEART CENTER
Hydralazine/nitrate or ARB if BP allows + sxs Digoxin to reduce hospitalizations Aldosterone antagonists in select patient
Diuretics for fluid retention Beta Blocker ACE-I (or ARB if ACE intolerant) Regular exercise program Sodium restriction
ICD
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Treatment of CHF
Correction of reversible causes Medications Diuretics, ACE inhibitors, beta blokers etc. Ischemia Arrhythmia: A fib, flutter, PJRT Valvular heart disease Thyrotoxicosis and other high output status Shunts
HEART CENTER
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CHF treatment-Acute
Pharmacological
Morphine sulfate Nitrates Diuretics ACE inhibitors Beta blockers Aspirin therapy statins Vasodilators Neurohormonal antagonists Anticoagulant therapy Antiarrhymics
HEART CENTER
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Diet and Activity
HEART CENTER
Salt restriction (2 grams per day) Fluid restriction (Less than 1-2 liters per day) Daily weight (tailor therapy) Gradual exercise programs Blood sugar monitoring
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Sodium Equivalents
Salt tsp tsp tsp 1 tsp Sodium Chloride 1550 mg 3100 mg 4650 mg 6100 mg Sodium 600 mg 1200 mg 1800 mg 2400 mg
HEART CENTER
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Diuretics The most effective symptomatic relief Mild symptoms
HCTZ Chlorthalidone Metolazone Block Na reabsorbtion in loop of henle and distal convoluted tubules Thiazides are ineffective with GFR < 30 --/min
HEART CENTER
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HEART CENTER
Thiazide Diuretics
Agent Chlorothiazide Initial Daily Max Total Elimination Dose Daily Dose 250-500 mg qd or bid 1000 mg 100 mg Renal 65% Renal, 10% into Bile, 25% Unknown Renal 80% Renal, 10% into Bile, 10% Unknown Metabolic Duration of Action 6-12 hrs 24-72 hrs
Chlorthalidone 12.5-25 mg qd Hydrochlorothiazide Metolazone 25 mg qd or bid 2.5 mg qd
200 mg 20 mg
6-12 hrs 12-24 hrs
Idapamide
2.5 mg qd
5 mg
36 hrs
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Diuretics
Loop diuretics for more severe heart failure Lasix Bumex Torsemide
(20 320 mg QD), Furosemide (Bumetanide 1-8mg) (20-200mg)
HEART CENTER
Mechanism of action: Inhibit chloride reabsortion in ascending limb of loop of Henle results in natriuresis, kaliuresis and metabolic alkalosis
Adverse reaction: pre-renal azotemia Hypokalemia Skin rash Ototoxicity
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HEART CENTER
Loop Diuretics
Agent Initial Daily Dose 20-40mg qd or bid 0.5-1.0 mg qd or bid 10-20 mg qd 25-50 mg qd or bid Max Total Daily Dose 600 mg Elimination: Duration of Renal Met. Action 65%R/35%M 4-6 hrs
Furosemide
Bumetanide
10 mg
62%R/38%M 6-8 hrs
Torsemide Ethacrynic acid
200 mg 200 mg
20%R/80%M 12-16 hrs 67%R/33%M 6 hrs
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Diuretics
HEART CENTER
Side Effects
Pre-renal azotemia
Skin rashes Neutropenia Thrombocytopenia Hyperglycemia
Uric Acid
Hepatic dysfunction Loss of K and Mag
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Diuretics K sparing diuretics
Triamterene Amiloride acts on distal tubules to K secretion Spironolactone (Aldosterone inhibitor)
HEART CENTER
Recent evidence suggests that it may improve survival in CHF

patients due to the effect on renin-angiotensin-aldosterone system with subsequent effect on myocardial remodeling and fibrosis
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HEART CENTER
Potassium-Sparing Diuretics
Agent Spironolactone Eplerenone Initial Daily Dose 12.5-25 mg qd 25-50 mg qd 5 mg qd 50-75 mg bid Max Total Daily Dose 50 mg 100 mg Elimination Metabolic Renal, Metabolic Renal Metabolic 24 hrs 7-9 hrs Duration of Action 48-72 hrs
Amilioride Triamterene
20 mg 200 mg
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LV size and thickness in CHF
HEART CENTER
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CPAP Mechanism
Increases pressure within airway.
HEART CENTER
Airways at risk for collapse from excess fluid are kept open. Gas exchange minimizes the Increased work of breathing.
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CPAP Mechanism
CPAP Non-invasive Easily discontinued Easily adjusted Does not require sedation Comfortable Intubation Invasive Potential for infection Traumatic
HEART CENTER
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Renin, angiotensin, aldasterone blockers
HEART CENTER
Renin-angiotensin-aldosterone system is activation early in the course of heart failure and plays an important role in the progression of the syndrome:
Angiotensin converting enzyme inhibitors (ACE inhibitors) Angiotensin receptors blockers (ARBS) Spironolactone
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Renin Angiotensin Blockers
HEART CENTER
Common ACE inhibitors Captopril
Lisinopril
Vasotec Monopril Accupril
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Renin-angiotensin blockers They block the R-A-A system by inhibiting the conversion of angiotensin I to angiotensin II: Vasodilation Na retention Decreased Bradykinin degradation its level PG secretion & nitric oxide Ace Inhibitors improve survival in CHF patients
Delay onset & progression of HF in pts with asymptomatic LV dysfunction cardiac remodeling
HEART CENTER
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Renin-angiotensin blockers
HEART CENTER
Side Effects of ACE inhibitors

Angioedema Hypotension Renal insuffiency Rash cough
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Sleep related problems in CHF
Affects 40-50% of pts with systolic HF
Central sleep apnea Cheyne Stokes respiration Does not correlate with ejection fraction Overnight oximetry- easy diagnostic test Treatment with supplemental oxygen May also need mild sleeping pills, acetazolamide May need Full sleep study -BiPap Nocturnal 02 lowers BNP and catecholamine levels
HEART CENTER
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Beta Blockers
Has been traditionally contraindicated in pts with CHF
Now they are the main stay in treatment on CHF & may be the only medication that shows substantial improvement in LV function In addition to improved LV function multiple studies show improved survival The only contraindication is severe decompensated CHF
HEART CENTER
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Beta Blocker therapy outcomes
Adjusted* hazard ratios (95% CI) for one-year outcomes, beta blocker therapy vs no beta blocker therapy, by LV functional status
End point Mortality Readmission Mortality or readmission LV systolic dysfunction, n=3001 0.77 (0.680.87) 0.89 (0.800.99) 0.87 (0.790.96) Preserved LV systolic function, n=4153 0.94 (0.841.07) 0.98 (0.901.06) 0.98 (0.911.06)
HEART CENTER
*Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of diabetes and cardiovascular, neurological, pulmonary, and renal diseases
Hernandez AF et al. J Am Coll Cardiol 2009; 53:184-192.
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Inotropic agents-Digoxin The role of digitalis has declined somewhat because of safety concern Recent studies have shown that digitals does not affect mortality in CHF patients but causes significant
HEART CENTER
Reduction in hospitalization Reduction in symptoms of HF Rate control in At fib.
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Inotropic agent-Digoxin action +ve inotropic effect by intracellular Ca & enhancing actin-myosin cross bride formation (binds to the Na-K ATPase inhibits Na pump intracellular Na Na-Ca exchange Vagotonic effect Arrhythmogenic effect
HEART CENTER
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Inotropic agent-Digitalis toxicity Cardiac manifestations
Sinus bradycardia and arrest A/V block (usually 2nd degree) Atrial tachycardia with A/V Block Development of junctional rhythm in patients with a fib PVCs, VT/ V fib (bi-directional VT)
HEART CENTER
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Inotropic agent-Digitalis toxicity Narrow therapeutic to toxic ratio Non cardiac manifestations
Anorexia,
HEART CENTER
Nausea, vomiting, Headache, Xanthopsia sotoma, Disorientation

Treatment: Digibind (Fab antibody)
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Antiarrhythmics
HEART CENTER
Most common cause of SCD in these patients is ventricular tachyarrhythmia

Patients with h/o sustained VT or SCD ICD implant Patients with CHF with an ejection fraction of less than 30% may receive ICD implant Amiodarone for patients with frequent VPCs and at fib Dranedone for patients with recurrent paroxysmal at fib.
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VasodilatorsHydralazine and Nitrates
HEART CENTER
Reduction of afterload by arteriolar vasodilatation (hydralazin) reduce LVEDP, O2 consumption,improve

myocardial perfusion, stroke volume and COP
Reduction of preload By venous dilation ( Nitrate) the venous return the load on both
ventricles.
Usually the maximum benefit is achieved by using agents with both action.
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Anticoagulation
HEART CENTER
Atrial fibrillation H/o embolic episodes Left ventricular apical thrombus Low LV ejection fraction
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Inotropic Agents
HEART CENTER
These are the drugs that improve myocardial contractility ( adrenergic agonists, dopaminergic agents,
phosphodiesterase inhibitors),
Dopamine
Dobutamine Milrinone, Aamrinone

Several studies showed mortality with oral inotropic agents So the only use for them now is in acute sittings such as cardiogenic shock
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ICD placement
HFSA 2006 Practice Guideline (9.1, 9.4)
HEART CENTER
Device Therapy:
Prophylactic ICD Placement
In patients on optimal medical therapy (ideally 3-6 months) with or without concomitant coronary artery disease (including a prior MI > 1 month ago):
Prophylactic ICD placement should be considered in those with NYHA II-III HF (LVEF 30%) Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%) Strength of Evidence = A
Concomitant placement should be considered in NYHA IIIIV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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New Treatment Choices
HEART CENTER
Implantable ventricular assist devices Biventricular pacing (only in patient with
LBBB & CHF)

Artificial Heart
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Achieving Cardiac Resynchronization
Mechanical Goal: Atrial-synchronized bi-ventricular pacing Standard pacing lead in RA Standard pacing or defibrillation lead in RV Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus
HEART CENTER
Right Atrial Lead
Left Ventricular Lead
Right Ventricular Lead
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CHFLong term prognosis
100 Probability of Survival (%) 90 80 70 60 50 Women (N = 230) Men (N = 237)
HEART CENTER
80% of men and 70% of women who have CHF will die within 8 years.2
40
30 20 10 0 0 2 4 6 8 Time After CHF Diagnosis (Years) 10
2 American
Framingham Heart Study (1948-1988) in Atlas of Heart Diseases. Heart Association. Heart Disease and Stroke Statistics2005 Update.
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Cardiac transplant
HEART CENTER
It has become more widely used since the advances in immunosuppressive treatment Survival rate
1 year 80% - 90% 5 years 70%
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Prognosis
HEART CENTER
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
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Modes of death in CHF based on NYHA class
NYHA II CHF 12% CHF Other Sudden Death
(N = 103)
HEART CENTER
NYHA III
26% 59% 15%
Other
Sudden Death
(N = 103)
64%
24%
NYHA IV CHF Other 56% 11%

1 MERIT-HF
33%
Sudden Death
(N = 27)
Study Group. LANCET. 1999;353:2001-2007.
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Predictors of Mortality Based on Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis of ADHERE data shows: Three variables are the strongest predictors of mortality in hospitalized ADHF patients:
HEART CENTER
BUN BUN> >43 43mg/dL mg/dL Systolic Systolicblood bloodpressure pressure< <115 115mmHg mmHg Serum Serumcreatinine creatinine> >2.75 2.75mg/dL mg/dL
Fonarow GC et al. JAMA 2005;293:572-80.
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CHF Prognosis based on BUN
HEART CENTER
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CHF Prognosis based on Serum sodium
HEART CENTER
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Diastolic CHF
HEART CENTER
Impaired LV relaxation Increase passive LV stiffness Endocardial and pericardial disordersw Microvascular flow Myocardial turgor Neurohormonal regulation
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Diagnosis of diastolic CHF
Increased ventricular filling pressure with normal systolic function
Incresed ventricular pressure with preserved systolic function and normal ventricular volumes Increased left atrial and pulmonary capillary wedge pressure Clinical symptoms and signs.
HEART CENTER
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Treatment of diastolic CHF
Diuretics provide the most symptoms relief if fluid retentionn is a future ACE inhibitors and Blockers complement diuretics well Central sympatholytics hypertensive episodes Nitrates preventing ischemia Trimetazidine as a metabolic support
HEART CENTER
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Treatment of diastolic CHF
HEART CENTER
Benefits of Calcium Channel Blockers

Slowing of heart rate Reduction of MVO2 Control of BP Regression of LVH Dilation of coronary microcirculation Amelioration of intracellular calcium overload
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HEART CENTER
HFSA 2006 Practice Guideline

NonpharmacologicFluid Intake
Recommendation 6.3
Restriction of daily fluid intake to < 2 liters:

Is recommended in patients with severe hyponatremia (serum sodium < 130 mEq/L) Should be considered for all patients demonstrating fluid retention that is difficult to control despite high doses of diuretic and sodium restriction.
Strength of Evidence = C
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HEART CENTER

NonpharmacologicVitamins
Recommendation 6.5
Patients with HF, especially those on diuretic therapy and restricted diets, should be considered for daily multivitaminmineral supplementation to ensure adequate intake of the recommended daily value of essential nutrients.
Evaluation for specific vitamin or nutrient deficiencies is rarely necessary.
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HEART CENTER

Beta BlockersSummary of Recommendations
General Initiate at low doses Up-titrate gradually, generally no sooner than at 2 week intervals Use target doses shown to be effective in clinical trials Aim to achieve target dose in 8-12 weeks Maintain at maximum tolerated dose Considerations if symptoms worsen or other side effects appear Considerations if up-titration continues to be difficult Adjust dose of diuretic and/or other concomitant vasoactive medication Continue titration to target dose once symptoms return to baseline Prolong titration interval Reduce target dose Consider referral to a HF specialist If an acute exacerbation of chronic HF occurs Maintain therapy if possible Reduce dosage if necessary Avoid abrupt discontinuation If discontinued or reduced, reinstate gradually before discharge
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HEART CENTER

ICD Placement
Recommendation 9.5
ICD placement is not recommended in chronic, severe refractory HF when there is no reasonable expectation for improvement.
Pacing
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HEART CENTER

Biventricular Pacing
Recommendation 9.7
Biventricular pacing therapy should be considered for patients with all of the following:
Sinus rhythm A widened QRS interval (? 120 ms) Severe LV systolic dysfunction (LVEF < 35% with LV dilation > 5.5 cm) Persistent, moderate to severe HF (NYHA III) despite optimal medical therapy. Strength of Evidence = A
Pacing
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HEART CENTER

Biventricular Pacing
Recommendation 9.9
Biventricular pacing therapy is not recommended in patients who are asymptomatic or have mild HF symptoms.
Pacing
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HEART CENTER

HF in African Americans
Recommendation 15.9
A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy in addition to betablockers and ACE-inhibitors for African Americans with LV systolic dysfunction and:
NYHA III-IV HF NYHA II HF
Vasodilator s
Strength of Evidence = A Strength of Evidence = B
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CHF treatment-Nursing Initiates
1. Recommend smoking cessation counseling
2. Initiate LV function determination 3. Patient education
HEART CENTER
4. Instructional video, printed materials

5. Vaccination initiatives
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HEART CENTER
Aldosterone Antagonists in HF
RALES (Advanced HF)
1.00 0.90 0.80 0.70 0.60 0.50 0.40 0 3 6 9 12 15 18 21 24 27 30 33 36 1.00 0.90 0.80
EPHESUS (Post-MI)
Probability of Survival
Epleronone
Spironolactone
Placebo
0.70 0.60 0.50 0.40 0 3 6 9 12 15 18 21 24 27 30 33 36
Placebo
RR = 0.70 P < 0.001
RR = 0.85 P < 0.008
Months
Months
Pitt B. N Engl J Med 1999;341:709-17. Pitt B. N Engl J Med 2003;348:1309-21.
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HEART CENTER
MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%)

1.0
Probability of Survival
.9 .8 .7 .6 0 0 1
503 (.91) 329 (.90)
Defibrillator
Conventional Therapy
3
110 (.78) 65 (.69)
4
9 3
Number at Risk Defibrillator Conventional
Year
742 490 274 (.84) 170 (.78)
Moss AJ et al. N Engl J Med 2002;346:877-83.
Pacing
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Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF
100
HEART CENTER
% Event-Free Survival
75
CRT Medical Therapy
50
25 HR = 0.64 (95% CI = .48-.85) p = .0019 0 0

409 404 376 365
500
351 321
Number at risk CRT Medical Therapy
Days
213 192
1,000
89 71 8 5
1,500
Cleland JG et al. N Engl J Med 2005;352:1539-49.
Pacing
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HEART CENTER
CRT Improves Quality of Life and NYHA Functional Class

Average Change in Score (MLWHF) 0 -5 -10 -15 -20
LE RA C CD CD
NYHA: Proportion Improving by 1 or More Class 80 60
* *
(%) 40 *
SR MU ST IC
*
CO NT AK
*
EI
*
CL
20 0
MIRACLE CONTAK MIRACLE CD ICD
MI
Control
CRT
* P < .05
Abraham WT et al. Circulation 2003;108:2596-2603.
Pacing
MI RA
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ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat
HR 97.5% Cl .86-1.30 .62-.96 P Value .53 .007
HEART CENTER
.4
Amiodarone vs Placebo ICD vs Placebo
1.06 .77
.3
Mortality
22%
.2
17%
.1 Amiodarone ICD Therapy Placebo 0 0 6 12 18 24 30 36 42 48 54 60
Months of Follow-Up
Bardy GH et al. N Engl J Med 2005;352:225-37.
Pacing
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HEART CENTER
A-HeFT All-Cause Mortality

100
43% Decrease in Mortality

Fixed Dose ISDN/HDZN
Survival %
95
90
Placebo P = 0.01
85 0 100 200 300 400 500 600

Days Since Baseline Visit
Taylor AL et al. N Engl J Med 2004;351:2049-57.
ISDN/HDZ
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ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative
100
HEART CENTER
Val-HeFT
Valsartan
50
CHARM-Alternative
Placebo
90
CV Death or HF Hosp %
40
Survival %
80
30
Placebo
70
Candesartan
20
60
10
p = 0.017
50 0 3 6 9 12 15 18 21 24 27 0 0
HR 0.77, p = 0.0004
9 18 27 36 42
Months
Months
Maggioni AP et al. JACC 2002;40:1422-4. Granger CB et al. Lancet 2003;362:772-6.
ARBS
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Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD
Study US Carvedilol1 CIBIS-II2 MERIT-HF3 COPERNICUS4 CAPRICORN5 Drug carvedilol bisoprolol metoprolol succinate carvedilol carvedilol HF Severity mild/ moderate moderate/ severe mild/ moderate severe post-MI LVD Target Dose (mg) 6.2525 BID 10 QD 200 QD 25 BID 25 BID Outcome 48% disease progression (p= .007) 34% mortality (p <.0001) 34% mortality (p = .0062) 35% mortality (p = .0014) 23% mortality (p =.031)
HEART CENTER
4. Packer M et al. N Engl J Med 2001;3441651-8. 1. Colucci WS et al. Circulation 1196;94:2800-6. 5. The CAPRICORN Investigators. Lancet 2001;357:1385-90. 2. CIBIS II Investigators. Lancet 1999;353:9-13. 3. MERIT-HF Study Group. Lancet 1999;353:2001-7.
BBs
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Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF 40%)
SAVE Study
All-cause mortality 19% CV mortality 21% HF development 37% Recurrent MI 25%
Mortality Rate
0.1 0.3
HEART CENTER
Placebo
0.2
Captopril
19% relative risk reduction p = 0.019

0 0 0.5 1 1.5 2 2.5 3 3.5 4
Years
Pfeffer et al. NEJM 1992;327:669-77.
ARBS
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HEART CENTER
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CHF prognosis based on rhythm
HEART CENTER
Arrhythmias
SOLVD Investigators: J Am Coll Cardiol. 1998;32:695-703. From: Shivkumar, Weiss, Fonarow, and Narula; eds. Braunwalds Atlas of EP in HF.
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CHF Management-long term
HEART CENTER
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HEART CENTER

HypertensionPreserved EF
Recommendation 14.1 In patients with symptomatic or symptomatic LV hypertrophy or LV dysfunction without LV dilation (Preserved EF):
It is recommended that blood pressure be aggressively treated to lower systolic and usually diastolic levels. Target resting levels should be <130/<80 mmHg, if tolerated. Strength of Evidence = C
SUGAR LAND

CHF treatment-7 Core measures
1. 2. 3. 4. 5. 6. 7. Do you have a left ventricular function measurement? If LVEF<40% is the patient on ACE inhibitors or ARBS? CHF and atrial fib: Is the patient on anticoagulants? Did the patient get influenza vaccination? Did the patient receive pneumococcal vaccination? Did the patient receive smoking cessation counseling? Discharge instructions: Diet Activity level Medicines Weight monitoring What to do if symptoms worsen
HEART CENTER
SUGAR LAND

HFSA 2006 Practice Guideline (8.13)
HEART CENTER
Sleep related problems in CHF
End-of-Life Care in Heart Failure

End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy, as evidenced by one or more of the following:
Frequent hospitalizations (3 or more per year) Chronic poor quality of life with inability to accomplish activities of daily living Need for intermittent or continuous intravenous support Consideration of assist devices as destination therapy
SUGAR LAND
HEART CENTER
The End
By Nik Nikam, M.D.
Interventional Cardiologist

Congestive Heart Failure CHF: Nik Nikam, M.D

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SUGAR LAND

Congestive Heart Failure CHF

By Nik Nikam, M.D.

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Remodeling and progressive worsening of LV function

Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity

Peripheral vasoconstriction Hemodynamic alterations

Morbidity and mortality Arrhythmias Pump failure

RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Congestive Heart Failure CHF

May have roles in myocyte hypertrophy Vasoconstriction VR

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Pericardial diseases, Restrictive cardiomyopathy Tachyarrhythmia

Congestive Heart Failure CHF

Low Output Failure Acute

large MI, aortic valve dysfunction-- Chronic

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Jugular Venous Distention not directly related to LVF.

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Pericardial diseases Liver diseases Nephrotic syndrome Protein losing enteropathy

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Cohort and case control studies

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Chlorthalidone 12.5-25 mg qd Hydrochlorothiazide Metolazone 25 mg qd or bid 2.5 mg qd

6-12 hrs 12-24 hrs

Congestive Heart Failure CHF

Congestive Heart Failure CHF

62%R/38%M 6-8 hrs

Torsemide Ethacrynic acid

20%R/80%M 12-16 hrs 67%R/33%M 6 hrs

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Recent evidence suggests that it may improve survival in CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF

Congestive Heart Failure CHF