Disclosures I have nothing to disclose Heart Failure for the - PDF document

Disclosures I have nothing to disclose “ Heart Failure for the Hospitalist ” Ronald Witteles, M.D. Stanford University School of Medicine October 22, 2016 A Common Scenario Goals of This Talk 68 y.o. man with longstanding nonischemic • Focus on real-life clinical scenarios you will encounter • cardiomyopathy When to place an ICD? • At diagnosis: • • LVEF 20%, normal cath When to initiate/stop heart failure drugs? • • EKG: Narrow QRS, no significant abnormalities • Well-controlled DM II, otherwise healthy Now (3 years post-diagnosis): • • On stable comprehensive heart failure medication regimen • Admitted for volume overload due to excess Na intake • You have diuresed him & he feels better • LVEF 30% (stable for last 2 years) He’s getting ready for discharge, and your Cardiology • consultant wants to place a primary prevention ICD 1

What do you say? What do you say? 1) “Makes sense. He has a LVEF <35%, a life 1) “Makes sense. He has a LVEF <35%, a life expectancy >1 year, and is on a comprehensive expectancy >1 year, and is on a comprehensive medication regimen.” medication regimen.” 2) “I could take it or leave it. The evidence is 2) “I could take it or leave it. The evidence is equivocal.” equivocal.” 3) “No thanks. Primary prevention ICDs only make 3) “No thanks. Primary prevention ICDs only make sense for ischemic cardiomyopathies.” sense for ischemic cardiomyopathies.” 4) “No thanks. Primary prevention ICDs only make 4) “No thanks. Primary prevention ICDs only make sense for LVEF ≤ 25%.” sense for LVEF ≤ 25%.” 5) “Of course! I blindly listen to the consultants 5) “Of course! I blindly listen to the consultants regardless of the evidence!” regardless of the evidence!” x What do you say? What do you say? 1) “Makes sense. He has a LVEF <35%, a life 1) “Makes sense. He has a LVEF <35%, a life expectancy >1 year, and is on a comprehensive expectancy >1 year, and is on a comprehensive medication regimen.” medication regimen.” 2) “I could take it or leave it. The evidence is 2) “I could take it or leave it. The evidence is equivocal.” equivocal.” 3) “No thanks. Primary prevention ICDs only make 3) “No thanks. Primary prevention ICDs only make sense for ischemic cardiomyopathies.” sense for ischemic cardiomyopathies.” 4) “No thanks. Primary prevention ICDs only make 4) “No thanks. Primary prevention ICDs only make sense for LVEF ≤ 25%.” sense for LVEF ≤ 25%.” 5) “Of course! I blindly listen to the consultants 5) “Of course! I blindly listen to the consultants regardless of the evidence!” regardless of the evidence!” 2

A Similar Scenario What do you say? 68 y.o. man admitted with an acute MI • 1) “Makes sense. He has an LVEF <35%, an ischemic At time of admission: cardiomyopathy, a life expectancy >1 year, and is on a • • Anterior ST elevations comprehensive medication regimen. There’s good • Emergent coronary angiogram: 100% mid-LAD occlusion trial evidence recommending this practice.” • Undergoes successful PCI with placement of a DES • Has well-controlled DM II, otherwise healthy 2) “I could take it or leave it. There’s really no evidence either way.” Echocardiogram 3 days after STEMI: • • Anterior/apical wall-motion abnormalities 3) “No thanks. There’s good trial evidence • LVEF = 30% recommending against this practice.” • On beta-blocker, ACE-inhibitor, and aldosterone antagonist 4) “Of course! I blindly listen to the consultants He’s getting ready for discharge, and your Cardiology • regardless of the evidence!” consultant wants to place a primary prevention ICD What do you say? • What do you say? One Final Question… The same patient just discussed & the same • 1) “Makes sense. He has an LVEF <35%, an ischemic scenario… cardiomyopathy, a life expectancy >1 year, and is on a comprehensive medication regimen. There’s good You tell the Cardiologist that your patient is not • trial evidence recommending this practice.” going to get an ICD as there good trial evidence against it. 2) “I could take it or leave it. There’s really no evidence either way.” The Cardiologist suggests placing a Life Vest for • 3) “No thanks. There’s good trial evidence the next 3-6 months instead. recommending against this practice.” 4) “Of course! I blindly listen to the consultants regardless of the evidence!” 3

What do you say? What do you say? 1) “Makes sense. The evidence shows that Life Vests 1) “Makes sense. The evidence shows that Life Vests save lives in this scenario.” save lives in this scenario.” 2) “I could take it or leave it. The evidence is 2) “I could take it or leave it. The evidence is equivocal.” equivocal.” 3) “No thanks. There’s good trial evidence 3) “No thanks. There’s good trial evidence recommending against this practice.” recommending against this practice.” 4) “Why would my patient need a Life Vest anyway? He 4) “Why would my patient need a Life Vest anyway? He doesn’t even like boats!” doesn’t even like boats!” MADIT Trial (1996) Let’s Examine the Landmark 196 patients with following characteristics: • • Prior MI Primary Prevention ICD Trials • History of NSVT • LVEF < 35% • Inducible VT on EP study Randomized to ICD vs. conventional therapy • Mean f/u: 27 months • Primary endpoint: All-cause mortality • Adapted from Moss et al. NEJM. 1996;335:1933-40. 4

MADIT Trial: Survival CABG-Patch Trial (1997) • 900 patients undergoing elective CABG P=0.009 • Age <80 years • LVEF ≤ 35% (preoperatively) • Randomized to ICD vs. no ICD • Mean f/u: 32 months • Primary endpoint: All-cause mortality Adapted from Moss et al. NEJM. 1996;335:1933-40. CABG-Patch Trial: Survival MUSTT Trial (1999) 704 patients with following characteristics: • • Coronary artery disease • History of NSVT within last 6 months • LVEF ≤ 40% • Inducible VT on EP study Randomized to EPS-guided antiarrhythmic • therapy vs. no antiarrhythmic therapy • Patients in EPS-guided therapy arm could get ICD if could not find successful antiarrhythmic agent • 46% got an ICD on this basis Adapted from Bigger et al. NEJM. 1997;337:1569-75. 5

MUSTT Trial: All-Cause Mortality MADIT-II Trial (2002) • 1232 patients on stable medical therapy with following characteristics: • Prior MI • LVEF < 30% • Randomized to ICD vs. conventional therapy • Mean f/u: 20 months • Primary endpoint: All-cause mortality Adapted from Buxton et al. NEJM. 1999;341:1882-90. Adapted from Moss et al. NEJM. 2002;346:877-83. MADIT-II: Survival DEFINITE Trial (2004) • 458 patients (!) P=0.016 • Nonischemic cardiomyopathy • LVEF ≤ 35% • NSVT on Holter or telemetry • Randomized to ICD vs. standard therapy • Mean f/u: 29 months • Primary endpoint: All-cause mortality Adapted from Moss et al. NEJM. 2002;346:877-83. Adapted from Kadish et al. NEJM. 2004;350:2151-8. 6

Results: Not so DEFINITE Results: Not so DEFINITE Adapted from Kadish et al. NEJM. 2004;350:2151-8. Adapted from Kadish et al. NEJM. 2004;350:2151-8. DINAMIT Trial (2004) Not So DINAMIT: Mortality • 675 patients • LVEF ≤ 35% • 6-40 days after MI • Randomized to ICD vs. placebo • Mean f/u: 30 months • Primary endpoint: All-cause mortality Adapted from Hohnloser et al. NEJM. 2004;351:2481-8. 7

DINAMIT: Fewer Arrhythmic Deaths, But… Brief Interruption – A Quick Aside About Trial Names & Karma… Arrhythmic Deaths Nonarrhythmic Deaths Adapted from Hohnloser et al. NEJM. 2004;351:2481-8. They’ll Never Learn: Another BEST Trial (!) BEST Trial: Bucindolol for Heart Failure Death, MI, Stroke, or Revascularization in Multivessel CAD * No statistically significant difference *Funded by Abbott Vascular, Producer of Everolimus Stents Adapted from NEJM. 2001;344:1659-67. Adapted from Park et al. N Engl J Med. 2015;372:1204-1212. 8

They’ll Never Learn: Another BEST Trial (!) Learning From One’s Mistakes… Death, MI, Stroke, or Revascularization in Multivessel CAD “What is the optimal antiplatelet and anticoagulant therapy in patients with oral anticoagulation and coronary stenting?” *Funded by Abbott Vascular, Producer of Everolimus Stents Adapted from Park et al. N Engl J Med. 2015;372:1204-1212. Learning From One’s Mistakes… Learning From One’s Mistakes… “What is the Optimal antiplatelet and “What is the Optimal aNtiplatelet anD anticoagulant theRapy in patients wiTH anticoagulant therapy in patiEnts with oral anticoagulation and coronarY oral anticoagulation and coRonary stenting?” stenting?” 9

“WOEST” Trial Name Ever… Learning From One’s Mistakes… But the BEST Karma! “What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing?” Adapted from Dewilde et al. Lancet. 2013;381:1107-1115. IRIS Trial (2009) • 898 patients • LVEF ≤ 40% • 5-31 days after MI • HR ≥ 90 bpm at least 48h after the MI (marker Back to ICDs… for high-risk) or NSVT ≥ 150 bpm on Holter moniotring (or both) • Randomized to ICD vs. placebo • Mean f/u: 37 months • Primary endpoint: All-cause mortality 10