2012 CCS HEART FAILURE UPDATE ACC Rockies 2012 Anique Ducharme, MD, - - PowerPoint PPT Presentation

2012 CCS HEART FAILURE UPDATE

ACC Rockies 2012 Anique Ducharme, MD, MSc Justin Ezekowitz, MD

Heart Failure Guidelines

Who are you ? 1. Internists 2. General Cardiologists 3. Interventionists 4. Surgeon 5. Nurse 6. Industry 7. An insane skier looking forward for more snow

Heart Failure Guidelines

Where are you practicing ? 1. Academic practice 2. Community hospital 3. Private office 4. Industry 5. Other

Heart Failure Guidelines

Agenda Agenda

• A case of mild-moderate HF (AD)
• BNP testing in ADHF (JE)
• WHF

– Cardiorenal syndrome (JE) – Palliative care (AD)

• Refractory HF

– UF (JE) – LVAD (AD)

Heart Failure Guidelines

• 61 years old female,

previous MI, stage B-C HF, stable NYHA III, LVEF 29%

• On optimal dose of

lisinopril and bisoprolol,

• ccasional diuretics
• Has not been assessed

for device Rx

• BP 99/67 mmHg, HR 76

bpm

• K, 4.7 mEq/L; NT-proBNP

4500 pg/mL

• EKG: old anterior MI, LBBB

QRS 145 ms.

Heart Failure Guidelines

Would you consider treating this patient with mild symptoms of HF and low ejection fraction with 1. Angiotensin receptor blocker? 2. Aldosterone receptor blocker? 3. ICD? 4. CRT? 5. CRT + ICD (CRT-D)

Heart Failure Guidelines

• 55 years old, NYHA II
• LVEF≤30% (if > 30%-35%, a

QRS duration of ≥130 ms)

• ACE) inhibitor and/or ARB,

and β-blockers (if indicated)

• < 6 months of hospitalization

for CVD reasons; if > 6 months for hospitalization, BNP needed to be ≥ 250 pg/mL or NT-pro-BNP ≥ 500 pg/mL in men and ≥ 750 pg/mL in women.

10.1056/NEJMoa1009492

Heart Failure Guidelines

Recommendation We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged >55 years with LV systolic dysfunction (LVEF≤ 30%, or if LVEF> 30% and ≤ 35% with QRS duration ≥130 ms), and recent hospitalization for CVD or elevated BNP/NT-pro-BNP levels, who are on standard HF therapy (Strong Recommendation, High-Quality Evidence). Practical Tip Key exclusion criteria in the EMPHASIS study included a serum K >5.0 mmol/L and an estimated eGFR of <30 mL/min/1.73 m2. Therefore, it is important to monitor these laboratory variables and to not use eplerenone in those patients who exceed these levels for K and eGFR.

Heart Failure Guidelines

You started treating this patient with mild symptoms

• f HF and low ejection fraction with epleronone as
• recommended. Dosage was increased up to 50 mg

without side effects. What do you do next? 1. Angiotensin receptor blocker? 2. ICD? 3. CRT? 4. CRT + ICD (CRT-D) ? 5. Lake Louise or Sunshine: That is the real question.

Heart Failure Guidelines

MADIT-CRT EF≤30, NYHA I-II, QRS ≥130 RAFT EF≤30, NYHA II-II, QRS ≥120

Heart Failure Guidelines

Heart Failure Guidelines

Recommendation

• We recommend the use of CRT in combination with an implantable

cardioverter defibrillator (ICD) for HF patients on optimal medical therapy with NYHA II HF symptoms, LVEF ≤ 30% and QRS duration ≥150 ms. (strong recommendation, high quality of evidence) Practical Tip

• The use of 150 ms as a cut point for QRS duration was based on a pre-

specified subgroup analysis of the data

• MADIT-CRT included QRS ≥ 130 ms
• RAFT included QRS ≥ 120 ms

In practice the selection of patients should be individualized and based

• n other risk features.

Heart Failure Guidelines

Case # 2

Heart Failure Guidelines

• 78 year old male presented to ER with worsening

dyspnea for 2 days

• PMH: hypertension, type-2 diabetes, COPD, CAD

with previous CABG and permanent AF

• Chronic dyspnea, no chest pain, was told to have

‘normal heart function’

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

Meds

• ASA, metformin, candesartan and warfarin

Physical examination

• Appeared distressed
• BP 155/90 mm Hg; RR 22/min; HR 116 bpm
• JVP difficult to assess
• No S3, scattered crackles
• Trace ankle edema

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

Investigations

• pH 7.35; pO2 89; pCO2 39; Sat.Art 0.96
• BUN 14 mmol/L (39.2 mg/dL)
• creatinine 165 mol/L (1.87 mg/dL)
• Na 138 mmol/L
• Hb 110 g/L
• Troponin I 0.06 ug/L

EKG: AF with HR 110, LBBB, no acute changes

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

1.

Exacerbation of COPD

2.

Acute heart failure

3.

Acute coronary syndrome

4.

Lung infection

5.

Pulmonary embolism

6.

Obesity and deconditioning

7.

Anxiety

8.

Combinations of above

Question : Differential Diagnoses

Heart Failure Guidelines

Doe Does s BNP BNP ad add to d to clin clinica ical l assessment? assessment?

McCullough, Circulation 2002; Moe Circulation 2006

BNP study IMPROVE study (Canadian)

Heart Failure Guidelines

Which exam would you consider ordering for this patient for immediate diagnostic purpose? 1. EP study 2. MUGA 3. BNP / NT-proBNP 4. Coronary angiogram 5. Cardiac MRI 6. A one day chairlift ticket

Heart Failure Guidelines

• BNP/NT-proBNP levels should be measured to help

confirm or rule out a diagnosis of heart failure in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (class I, level A)

• Measurement of BNP/NT-proBNP levels may be

considered in patients with an established diagnosis

• f heart failure for prognostic stratification (class IIa,

level A)

• Sequential measurements of BNP/NT-proBNP levels

may be considered to guide the therapy of patients with heart failure (class IIb, level B)

BNP/NT-proBNP Recs

Heart Failure Guidelines

BNP/NT-proBNP … should be measured to … confirm or rule out a diagnosis of heart failure in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt. (class I, level A)

BNP NP (CC (CCS S 20 2007 07)

Age

(years)

Heart failure is unlikely Heart failure possible but other diagnoses must be considered Heart failure is very likely BNP All < 100 pg/ml 100-500 pg/ml > 500 pg/ml NT-proBNP < 50 < 300 pg/ml 300-450 pg/ml > 450 pg/ml 50 - 75 < 300 pg/ml 450-900 pg/ml > 900 pg/ml > 75 < 300 pg/ml 900 - 1800 pg/ml > 1800 pg/ml

Heart Failure Guidelines

AHF Dx Scoring systems

Baggish AL, et al. Am Heart J 2006; 151: 48-54].

Predictor Points Our Case Elevated NT-proBNP 4 4 Interstitial edema on CXR 2 2 Orthopnea 2

• Absence of fever

2 2 Current loop diuretic use 1

• Age > 75 years

1 1 Rales on lung examination 1 1 Absence of cough 1 1 Interpretation 11

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93

Heart Failure Guidelines

Investigations

• NT-proBNP = 9872 pg/mL

Using a scoring system can help, e.g. PRIDE score

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

Investigations

• NT-proBNP = 9872 pg/mL

Using a scoring system can help, e.g. PRIDE score

Case: Use of Natriuretic Peptide Testing in Acute HF

Heart Failure Guidelines

Case # 3

Heart Failure Guidelines

• 69 years old male
• stage “C” HF
• stable NYHA II-III
• LVEF 29%
• Meds: evidenced-based doses of enalapril,

carvedilol and eplerenone and diuretic

• Device: CRT-D
• Prior labs:
• Stable clinic serum Cr 120 mol/L
• NT-proBNP4000 pg/mL

Case: Worsening HF

Heart Failure Guidelines

• Recently R with NSAID by GP for back pain

–  dyspnea – wt gain of 6 kg in 1 week

• Physical examination: ++ congestion,

– BP 102/56, HR 65

• Labs: Cr 152 mol/L, NT-proBNP 8670 pg/mL
• Your R:

– oral diuretics x 5 days – still congested  admitted to hospital

Case: Worsening HF

Heart Failure Guidelines

• R with high doses of bolus furosemide
• Diuresed, wt. 2 kg, less peripheral edema,

JVP decreased but still at 8 cm; BP 115/70

• Labs:
• Cr incr to 283 mol/L
• NT-proBNP, 7654 pg/mL

Case: Worsening HF

Heart Failure Guidelines

• Residents decided to hold all diuretics and

cautiously administered fluids

• Subsequent examination revealed higher

JVP and now diffuse fine crackles

• Labs:

– Cr increased further to 313 mol/L – NT-proBNP to 9458 pg/mL

Case: Worsening HF

Heart Failure Guidelines

• What is the reason for the rising

serum creatinine during the R for HF with hospital admission?

• What now?

Question

Heart Failure Guidelines

• Intensivist:
• “Low cardiac output, cardiogenic

shock”

– (add pressors)

• Nephrologist
• Dehydration, “over diuresis”

– (stop NSAIDS and add UF)

• Cardiologist:
• “Ongoing circulatory congestion

leading to CVP and intra- abdominal pressure and abnormal interventricular interaction”

– (do echo, diurese more)

Written in the consults notes…

Heart Failure Guidelines

Cardiorenal Syndrome (CRS) Acute HF

Kidney Disease

Increased risk of WRF and death in patients with AHF Increased risk of AHF and death in patients with renal insufficiency

McCullough PA. Rev Cardiovasc Med. 2002;3:71-76. Bock JS, Gottlieb SS. Cardiorenal syndrome: new perspectives. Circulation 2010;121:2592-600

Pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of one organ induces acute or chronic dysfunction of the other.

Heart Failure Guidelines

Mechanisms

Venous Congestion  CVP  RAP IVS to LV side  CO  Perfusion  Renal vein pressure  Filtration fraction

 GFR

Heart Failure Guidelines

Dammen W, et al. J Am Coll Cardiol. 2009;53:582–88

Increased CVP, renal function and mortality

Heart Failure Guidelines

Impact of Venous Congestion on Glomerular Net Filtration Pressure

Jessup M, et al. J Am Coll Cardiol 2009; 53:597-9

Heart Failure Guidelines

• Increased dose of metolazone, furosemide

infusion started for 2 days

• JVP declined, wt.  6 kg, no more crackles,

minimal peripheral edema

• Labs:

– Cr decreased from 313 to 198 mol/L – NT-proBNP decreased from 9458 to 4600 pg/mL

Case: Resolution

Heart Failure Guidelines

Cardiorenal Syndrome

Recommendation We recommend that patients with the CRS should be managed by a multispecialty team with experience and expertise. (Strong Recommendation, Low-Quality Evidence).

Heart Failure Guidelines

Cardiorenal Syndrome

Practical tip Careful assessment of all clinical indicators of fluid status is mandatory as changes in body weight may relate to changes in concurrent changes in fluid status or to muscle or fat content. When evaluating patients, attention should be paid to the evolution of symptoms, renal function, body weight, and fluid status to aid management. Overaggressive fluid removal should be avoided, especially in advanced biventricular HF and severe chronic kidney disease.

Heart Failure Guidelines

What is the reason for the rising serum creatinine during Rx for HF following admission? 1. Low cardiac output, cardiogenic shock? 2. “Over diuresis”, dehydration? 3. CVP and intra-abdominal pressure?

Heart Failure Guidelines

Case # 4

Heart Failure Guidelines

• 49 year old male

– Stage ‘D’ HF

PMH:

• DM, previous MI’s
• Recurrent admissions for decompensating HF

Meds:

– low dose of hydralazine/nitrates, bisoprolol, high doses of diuretics, CRT-D in place

• Deemed not suitable for cardiac transplant

Case: Refractory Heart Failure

Heart Failure Guidelines

Labs:

– Cr = 300 – 400 mol/L – NT-proBNP = 15,000 to 20,000 pg/mL

• Increasing congestion and edema,  5 kg

in 5 days, no precipitants identified

– Did not respond to higher doses of furosemide and metolazone – Admitted, – Limited diuretic response to repeated high bolus dose and 15 mg/hr dose of IV furosemide

Case: Refractory Heart Failure

Heart Failure Guidelines

• In patients with decompensated HF who

are resistant to IV diuretics with hyponatremia, what are the therapeutic

• ptions?

Question

Heart Failure Guidelines

1. Still higher doses of diuretics? 2. IV Nitroglycerin? 3. IV Nesiritide? 4. Tolvaptan? 5. Ultrafiltration?

Question Therapeutic Options?

Heart Failure Guidelines UFT removes fluid from the blood at the same rate that fluid can be “naturally” recruited from the tissue The transient removal of blood elicits a compensatory mechanism, called plasma

• r intravascular refill (PR),

aimed at minimizing this reduction in intravascular volume

Fluid Removal by Ultrafiltration

• 1. Lauer et al. Arch Intern Med. 1983;99:455-460.
• 2. Marenzi et al. J Am Coll Cardiol. 2001;38:4.

Vascular Space

UF

Vascular Space

Interstitial Space (Edema)

Na Na Na Na K

P H2O

K

P

PR

Heart Failure Guidelines

Costanzo MR et al. J Am Coll Cardiol 2007;49:675-83.

Heart Failure Guidelines

Costanzo MR et al. J Am Coll Cardiol 2007;49:675-83.

Heart Failure Guidelines

Role of Ultrafiltration HF

Recommendation We suggest that in patients with acute decompensated heart failure (ADHF) and diuretic resistance, UF may be considered for volume management and to be performed in centers by clinicians with experience and expertise in its use. (Weak recommendation, low quality of evidence)

Heart Failure Guidelines

Practical Tip

• Careful assessment of all clinical indicators of fluid status

is mandatory as changes in body weight may relate to changes in concurrent changes in fluid status or to muscle or fat content.

• When evaluating patients, attention should be paid to the

evolution of symptoms, renal function, body weight, and fluid status to aid management.

• Overaggressive fluid removal should be avoided,

especially

• in advanced biventricular HF and severe chronic kidney

disease.

CCS HF guideline

Heart Failure Guidelines

CASE # 5

Heart Failure Guidelines

Case - 69 yo male with ischemic CMP

• Referred 2009 for cardiac transplantation evaluation.
• CAD & CABG (1998); chronic AF; Diabetes;
• Primary prev. ICD (turned down for CRT);
• s/p multiple hospital admissions for ADHF, including a

recent one with cardio-renal syndrome requiring CVVH and milrinone.

• Seen at the HF clinic for deterioration.

– NYHA ¾ with mainly symptoms of fatigue and gained 5Kg. – Meds: needed to be reduce because of symptoms

• ACE, BB, Furosemide 160 die, metolazone,

spironolactone 25, atorvastatin, ASA,

Heart Failure Guidelines

Case - 69 yo male with ischemic CMP (2)

• Physical Examination

– Looks older & cachexia, HR 60, paced, BP 79/55 – JVP angle of jaw – Parasternal lift +, ↑/displaced apex – 2/6 SEM, mid systolic; increased P2; S3+ – decreased BS @ bases – 3+ LLE,

• Labs:

– Na 129 - K 4.5

• Tropo: 0.05
• NT-proBNP: 15 850

– Creatinine 192 (125 at discharge)

• CXR:

– Cardiomegaly, pacemaker dual lead and sternal wires

Heart Failure Guidelines

Case - 69 yo male with ischemic CMP (3)

• Recent Echocardiogram :

– LVEDD 78 mm, LVEF about 15-20% – RVSP 60, RV normal, biatrial enlargement – moderate TR moderate MR (2/4)

• Recent cath:

– Grafts all open (Lima- LAD and SVGX 3)

• Pressures:

– RA 15, RV 64/18, PA 66/28 -42, PCWP v= 45, mean 32 – CO 4.0 l/min PVR: 2.5 No constriction

Heart Failure Guidelines

69 year old male

• Second hospitalization for heart failure in 6

months

• Long history of AF, CAD and previous CABG
• No other comorbidities
• Presented with exertional dyspnea,
• rthopnea, PND
• Excellent response to diuretics
• Angiogram: grafts patent -> medical

management

• Discharged home: NYHA II-III

Heart Failure Guidelines

69 year old male: investigations

• Echocardiogram: EF 30%
• ECG: LVH, RBBB QRS 136 msec
• Labs (all stable):

– creatinine 87 – Na 137 – K 4.4

• Meds: optimized ACE, BB, Furosemide 20

mg/day, spironolactone 12.5 mg daily, atorvastatin, ASA,

Heart Failure Guidelines

Question Does this man require palliative care?

• 1. Yes
• 2. No
• 3. Need more information

Heart Failure Guidelines

WHAT WHAT IS IS PALLIATIVE PALLIATIVE CARE? CARE?

Heart Failure Guidelines

Palliative care is a patient-centred and family-centred approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. It is applicable early, as well as later, in the course of illness, in conjunction with

• ther therapies that are intended to prolong life, including

but not limited to in the setting of heart failure, oral pharmacotherapy, surgery, implantable device therapy, hemofiltration or dialysis, the use of intravenous inotropic agents, and Ventricular Assist Devices.

Adapted from the WHO definition for palliative care, http://www.who.int/cancer/palliative/definition/en

Heart Failure Guidelines

Palliative care in Canada

• In Canada:

– 30% die from Cancer – cancer patients represent 90% of hospice palliative care recipients

• Why?

– Multiple reasons including illness trajectory

Heart Failure Guidelines

End-of-life trajectories

• Cancer trajectory

– Relatively easy to predict life-expectancy once advanced – Admission criteria for palliative care based on known limited life expectancy

Heart Failure Guidelines

The course of Heart Failure

From: Goodlin, JACC 2009;54:386

Heart Failure Guidelines

The problem with HF

(and many chronic non-malignant diseases)

• Existing palliative services developed based on

cancer model

• Difficult to predict timing of death for individuals

– often denied palliative care

• Focus on prognosis often at the expense of

assessing symptoms which can be present for months or years before death

• Prognostic uncertainty leads to hesitancy

around discussing advance care plans

Heart Failure Guidelines

Recommendation We recommend that the provision of palliative care to patients with HF should be based on a thorough assessment of needs and symptoms, rather than on individual estimate of remaining life expectancy. (Strong recommendation, low quality of evidence)

Heart Failure Guidelines

What are the symptoms of HF?

Symptom class Examples Physical Dyspnea, chest pain, edema, fatigue, exercise intolerance; Gout, pruritus, muscle cramps, pain, anorexia, nausea, constipation; Social / functional Falls, incontinence, trouble walking, loss of independence in performing activities of daily living Psychological Panic attacks, anxiety, depression, cognitive impairment, insomnia, loss of confidence, feelings of uselessness or hopelessness

Heart Failure Guidelines

Heart Failure specific symptom assessment tools Tool Name Description Minnesota Living with Heart Failure Questionnaire (MLHFQ) 21 item, Likert scale, self-administered, overall rating, physical (8) and emotional (5) Kansas City Cardiomyopathy Questionnaire (KCCQ) 23 item, Likert scale, self-administered, physical function (6), symptoms (8) social function (4), self- efficacy (2) and quality of life (3) Quality of Life Questionnaire for Severe Heart Failure (QLQ-SHF) 26 item, visual analogue scale and Likert scale, self- administered, psychological (7), physical function (7), life-dissatisfaction (5), somatic symptoms (7) Chronic Heart Failure Questionnaire (CHFQ) 16 item, Likert scale, interviewer administered, dyspnea (5), fatigue (4), emotional (7) Left Ventricular Dysfunction (LVD-36) 36 item, dichotomous (true/false), self administered, physical domain Memorial Symptom Assessment Scale (modified for HF) 32 items reflecting symptoms in last 7 days, each rated according to frequency, severity, and associated distress; domains assessed include HF symptoms, other physical symptoms and psychological symptoms

Heart Failure Guidelines

ADVANCE ADVANCE CARE CARE PLANNING PLANNING

Heart Failure Guidelines

Advanced care directives allow you to

• 1. Identify a substitute decision maker
• 2. Direct your care when you are no

longer mentally capable of doing so

• 3. Enhance communication between

you, your family and your healthcare provider

• 4. Have a Level 1 Grade C

recommendation

• 5. All of the above

Question

Heart Failure Guidelines

Advance care planning (ACP) is a process whereby a patient, in conversation and reflection with family members, important

• thers and health care providers, makes decisions about future

health care. ACP is a process of reflection on and communication of a person’s goals, values and preferences for future healthcare, to be used should they become incapable of giving informed consent. ACP can encompass rich conversations, which go beyond "to resuscitate or not to resuscitate" and may include meanings and fears around illness and dying, preferences for after death rituals and spirituality.

Heart Failure Guidelines

When should these be discussed?

• Difficult decision but need to consider that

mortality from HF is high in the first year after diagnosis

• Ontario data:

– 33% at one year – Over 60% if comorbidity (Jong et alArch Int Med 04)

Heart Failure Guidelines

How should discussions about end-of-life planning and palliative care be conducted? Recommendation

• We recommend that clinicians looking after HF patients should initiate and

facilitate regular discussions with patients and family regarding advance care

• planning. (Strong recommendation, low quality of evidence)

Practical tips

• The timing of discussions should strongly consider the high mortality rate in

the year following a first HF hospitalization;

• A surrogate decision-maker should be identified early and regularly

participate in these discussions;

Heart Failure Guidelines

How should we approach the topic of ACP?

• Balance hope with honesty
• Assess readiness: many patients willing to talk

about it but expect physicians to initiate conversation

• If ready

– Identify surrogate decision-maker early – Clarify and articulate patients’ values over time – Establish leeway in surrogate decision making

Heart Failure Guidelines

Practical tips

• Triggers for initiating discussions include:

– a new HF diagnosis; – an important clinical event (e.g. Hospitalization) – identification that a patient is at high risk of adverse outcomes according to one of several prognostic tools – when considering an invasive intervention; – if patient requests and expectations are at variance with clinical judgement.

Heart Failure Guidelines

More practical tips

• Topics to address include:

– uncertainty of the HF trajectory and prognosis; – patients’ values and preferences for advance care planning (ACP) and treatment goals including comorbidities and frailty in determining prognosis – acknowledging that decisions are made in the context of a process that will evolve as the clinical state and wishes of the patient change.

Heart Failure Guidelines

Examples of “opening lines”

• “You have developed heart failure. Heart failure is a very

serious disease, from which many patients ultimately die. Thankfully we have some extremely good treatments to manage heart failure and to make you feel much better and for longer.”

• “If you were to get very sick, is there anyone you trust to

make medical decisions for you, and have you talked with this person about what is important to you? Can we talk about this today?”

• Lots more in the paper!

Heart Failure Guidelines

Back to the case

• He is now 70 years old

– Followed in a HF clinic for frequent admissions, IV lasix in ER – Optimal ACEi, Beta-blocker, Spironolactone, Digoxin, Furosemide 120 mg od, prn metolazone – Not revascularization candidate – EF 20%, creatinine 185, sodium 133

Heart Failure Guidelines

Question What does he require?

• 1. Referral to HF specialist?
• 2. Referral to Palliative care specialist?
• 3. Referral to a Geriatrician?
• 4. Closer involvement of the family doctor?
• 5. All of the above?

Heart Failure Guidelines

Recommendation We recommend that the presence of persistent advanced HF symptoms (NYHA III-IV) despite optimal therapy be confirmed, ideally by an inter-disciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and

• ptimized, in the context of patient goals and co-
• morbidities. (Strong recommendation, low quality of

evidence)

Heart Failure Guidelines

How should the care of patients with HF be

• rganized?

Recommendation We recommend an inter-disciplinary chronic care model (CCM) for the organization and delivery of palliative care to patients with advanced HF. (Strong recommendation, low quality of evidence)

Heart Failure Guidelines

Practical tips

• At minimum, the care model should include the primary

care team and access to providers with specialty knowledge of HF and palliative care;

• Other providers could include allied health (occupational

therapy, speech therapy, and physiotherapy, pharmacy, home care, social work, spiritual care), and specialists in psychiatry, geriatric or internal medicine;

• Formal and integrated protocols promoting seamless

communication among various providers are required to ensure optimal patient care

Heart Failure Guidelines

Advance HF: Preference for Life vs. Symptoms

10 20 30 40 50 60 70 80 90 FC II FC III FC IV Life Utility Score

Would trade almost all time to feel better Would take any risk to feel better Don’t want to trade time Don’t want risk of dying

Lewis et al, JHLT, 2001

Heart Failure Guidelines

Question What options are available for this patient ?

• 1. Cardiac Transplantation
• 2. Palliative Care
• 3. Mechanical Circulatory support
• 4. Moving to Banff in a log cabin
• 5. All of the above

Heart Failure Guidelines

Do the Math!

• 5% of 500,000 Canadians with HF Stage D
• 25,000 patients with advanced heart failure

~ 180 Transplants/year ~ 80 VAD’s per year

• Majority elderly i.e. >70

Hunt et al Circ 2009; Kirklin et al, JHLT 2010; 29:1-10; www.unos.org

48,740 pts with advanced HF and no life saving therapeutic

• ption

Heart Failure Guidelines

www.thecarenet.ca

Heart Failure Guidelines

• 1. We are all getting older and will need it
• 2. We have lots of money left over from the oil

sands

• 3. Evidence supports better outcomes for DT

therapy versus medical therapy in selected patients

• 4. You have stock in HeartWare and Thoratec

Question Health Canada should fund Destination Therapy in Canada because

• H. Ross

Heart Failure Guidelines

ADULT HEART TRANSPLANTATION

Kaplan-Meier Survival by Age Group

(Transplants: 1/1982-6/2008)

20 40 60 80 100 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years Survival (%)

18-29 (N=4,957) 30-39 (N= 6,968) 40-49 (N=15,772) 50-59 (N=27,900) 60-69 (N=15,269) 70+ (N=453) HALF-LIFE 18-29: 11.5 years; 30-39: 11.5 years; 40-49: 10.8 years; 50-59: 9.7 years; 60-69: 8.8 years; 70+: 7.1 years All pair-wise comparisons are statistically significant at p < 0.04 except for 18-29 vs 30-39 p=0.1856

2010

ISHLT

J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

Heart Failure Guidelines

10 20 30 40 50 60 70 80 90 100 3 6 9 12 15 18 21 24

June 2006 – September 2010: Adult Primary LVADs, Destination Therapy: n=389 Months after Implant % Survival Age < 70 years, n=273, deaths=69 70+ years, n=116, deaths=25 Event: Death (censored at transplant or explant due to recovery)

• verall p = .68

By Age Groups

Courtesy of Dr. D. Naftel and J. Kirklin; INTERMACS

Heart Failure Guidelines

Case - 67 yo male with ischemic CMP the sequel

• Referred 2009 for cardiac transplantation evaluation.
• CAD & CABG (1998); chronic AF; Diabetes;
• Primary prev. ICD (turned down for CRT);
• s/p multiple hospital admissions for ADHF, including a

recent one with cardio-renal syndrome requiring CVVH and milrinone.

• Seen at the HF clinic for deterioration.

– NYHA ¾ with mainly symptoms of fatigue and gained 5Kg. – Meds: needed to be reduce because of symptoms

• ACE, BB, Furosemide 160 die, metolazone,

spironolactone 25, atorvastatin, ASA,

Heart Failure Guidelines

Case - 67 yo male with ischemic CMP (2)

• Physical Examination

– Looks older & cachexia, HR 60, paced, BP 79/55 – JVP angle of jaw – Parasternal lift +, ↑/displaced apex – 2/6 SEM, mid systolic; increased P2; S3+ – decreased BS @ bases – 3+ LLE,

• Labs:

– Na 129 - K 4.5

• Tropo: 0.05
• NT-proBNP: 15 850

– Creatinine 192 (125 at discharge)

• CXR:

– Cardiomegaly, pacemaker dual lead and sternal wires

Heart Failure Guidelines

Case - 67 yo male with ischemic CMP (3)

• Recent Echocardiogram :

– LVEDD 78 mm, LVEF about 15-20% – RVSP 60, RV normal, biatrial enlargement – moderate TR moderate MR (2/4)

• Recent cath:

– Grafts all open (Lima- LAD and SVGX 3)

• Pressures:

– RA 15, RV 64/18, PA 66/28 -42, PCWP v= 45, mean 32 – CO 4.0 l/min PVR: 2.5 No constriction

Heart Failure Guidelines

69 year old male

• Second hospitalization for heart failure in 6

months

• Long history of AF, CAD and previous CABG
• No other comorbidities
• Presented with exertional dyspnea,
• rthopnea, PND
• Excellent response to diuretics
• Angiogram: grafts patent -> medical

management

• Discharged home: NYHA II-III

Heart Failure Guidelines

69 year old male: investigations

• Echocardiogram: EF 30%
• ECG: LVH, RBBB QRS 136 msec
• Labs (all stable):

– creatinine 87 – Na 137 – K 4.4

• Meds: optimized ACE, BB, Furosemide 20

mg/day, spironolactone 12.5 mg daily, atorvastatin, ASA,

Heart Failure Guidelines

Patient with refractory heart failure

• After an initial response

to UFT, one week later, the patient retained fluid again, and continued to deteriorate and went into low output state

• Cr climbed up to 320

mol/L, NT-proBNP to 24,500 pg/mL

• Consideration of ICD, CRT, cardiac Tx,

MCS

• Seen by Hepatology who suggested end

stage liver disease secondary to HF

• Respirology did not find active

pulmonary issues

• RAP 24, PAP 64/25, PCWP 28, CO 3.8
• Put on dobutamine with slight

improvement in creatinine, volume status, electrolytes, abdominal girth, weight and exercise capacity

Heart Failure Guidelines

Question What are the Clues to the Presence of Truly Intractable Heart Failure

1. Hyponatremia (Na <135 mmol/l) 2. Relative hypotension (<100 mmHg) 3. Age > 75 Years 4. Renal Insufficiency (>2.5 mg/ml) 5. Intolerance to ACEI and BB 6. Continuing Functional Class IV 7. Inotropes dependence 8. All of the above

And it is OK to consult for options

Heart Failure Guidelines

Question Should the patient be referred for consideration of a VAD (ventricular assist device)?

• 1. Yes
• 2. No

Heart Failure Guidelines

What is destination therapy?

Destination therapy with a left ventricular assist device (LVAD) has the potential to effectively treat a large number of patients with advanced heart failure who are not eligible for heart transplantation With the advent of continuous-flow LVADs, safe and effective long-term circulatory support is available for properly identified candidates

Destination therapy with left ventricular assist devices: patient selection and outcomes Slaughter, Mark Sa; Meyer, Anna La; Birks, Emma Jb, Current Opinion in Cardiology: May 2011 - Volume 26

Heart Failure Guidelines

Mortality in REMATCH

Heart Failure Guidelines

Heart Failure Guidelines

Destination therapy with a left ventricular assist device (LVAD)

HeartMate II HeartWare

Heart Failure Guidelines

“Advanced” HF Populations

CONCENSUS (ACEI) PROMISE (oral Milrinone) COPERNICUS (Carvedilol) REMATCH (No Inotropes) REMATCH (IV Inotropes) SPB (mmHg) 119 115 125 105 97 LVEF (%) 21 20 17 17 Na (mmol/L) 138 139 137 137 134 6 month mortality 24% 32% (class IV) 10% 39% 61% Adapted from Stevenson LW

Heart Failure Guidelines

Slaughter et al, NEJM 2009

Heart Failure Guidelines

Mechanical Circulatory Support (MCS)

RECOMMENDATION

• We recommend that patients with either acute severe or chronic

advanced HF and with an otherwise good life expectancy be referred to a fully equipped cardiac centre for assessment and management by a team with expertise in the treatment of severe HF, including MCS (Strong Recommendation, Moderate-Quality Evidence).

• We recommend MCS be considered for patients who are listed for

cardiac transplantation and who deteriorate or are otherwise not likely to survive until a suitable donor organ is found (Strong Recommendation, Moderate-Quality Evidence).

• We recommend that MCS be considered for patients for whom there is

a contraindication for cardiac transplantation but may, via MCS, be rendered transplant eligible (Strong Recommendation, Low-Quality Evidence).

Heart Failure Guidelines

Practical Tips

Candidacy for MCS

Patients with advanced HF including those, despite optimal treatment, continuing to exhibit NYHA IIIB or IV HF symptoms AND accompanied by > ONE of the following: 1. LVEF < 25%, and if measured, peak exercise oxygen consumption <14 ml/kg/min; 2. Evidence of progressive end organ dysfunction due to reduced perfusion not due to inadequate ventricular filling pressures; 3. Recurrent HF hospitalizations (> 3 in 1 year) not due to a clearly reversible cause; 4. Need to progressively reduce or eliminate evidence-based HF therapies such as ACE inhibitors or beta blockers, due to symptomatic hypotension or worsening renal function; 5. Requirement for inotropic support.

Heart Failure Guidelines

Practical Tips (continued)

MCS performing centers

• Cardiac centers that perform MCS should have adequate

manpower and resources for support of patients requiring MCS support. These include: – An identified and adequately trained multidisciplinary MCS team; – Access to the full array of Medical and Surgical consultative support, and institutional administrative and financial support; – Expertise in MCS implantation, follow up and explantation.

Heart Failure Guidelines PROFILE-LEVEL # Pts Yr 1 Official Shorthand General time frame for support INTERMACS LEVEL 1 82 “Crash and burn” Hours INTERMACS LEVEL 2 81 “Sliding fast” Days to week INTERMACS LEVEL 3 18 Stable but Dependent Weeks INTERMACS LEVEL 4 9 “Frequent flyer” Weeks to few months, if baseline restored INTERMACS LEVEL 5 4 “Housebound” Weeks to months INTERMACS LEVEL 6 3 “Walking wounded” Months, if nutrition and activity maintained INTERMACS LEVEL 7 4 Advanced Class III MCS not currently indicated

Heart Failure Guidelines

Mechanical Circulatory Support (MCS)

RECOMMENDATION

• We recommend that patients with fulminant HF be

considered for temporary MCS to afford an opportunity for evaluation for long-term options (Strong Recommendation, Moderate-Quality Evidence) .

• We recommend permanent MCS be considered for highly

selected transplant ineligible patients (Weak Recommendation, Moderate-Quality Evidence).

Heart Failure Guidelines

CCS Guidelines (2011) Mechanical Circulatory Support (MCS)

RECOMMENDATION

• We recommend that ambulatory patients with MCS therapy who

are discharged from hospital, and who have had minimal HF symptoms or ventricular arrhythmias for a period of at least one month, be considered candidates for operation of a personal motor vehicle for a period not exceeding two thirds of the known battery charge time. (Weak Recommendation, Low Quality Evidence)

• Values and preferences. This recommendation places a high

value on the potential variability of patient preference as well as the need to interact with the patient to ensure the choice reflects the patient’s values, with less value on the effectiveness

• f therapy.

Heart Failure Guidelines

Please fill out your evaluations