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Heart Failure is not a disease It is a syndrome with many causes - - PowerPoint PPT Presentation
Heart Failure is not a disease It is a syndrome with many causes - - PowerPoint PPT Presentation
Heart Failure is not a disease It is a syndrome with many causes that have common symptoms Prevalence estimates between studies varied because of differences in study population, case definition, and echocardiographic measurements applied.
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Eur J Heart Fail 2016;18:242-252
Prevalence estimates between studies varied because of differences in study population, case definition, and echocardiographic measurements applied.
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Eur J Heart Fail 2016;18:242-252
Prevalence of Heart Failure
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Eur J Heart Fail 2016;18:242-252
Prevalence of Heart Failure
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HF in the UK About 840,000 have HF £379 million annual hospitalization cost About 66,000 new cases each year 106,080 episodes / year £3,572 / episode in average 986,995 hospitalization days 13.3 days / episode in average
1.Cost of Heart Failure to the National Health Service, 2000, UK on the British Heart Foundation Website www.heartstats.org accessed on June the 13th 2006.
- 2. House of Commons Health Committee (2003), 'Sexual Health: Third Report of Session 2002-03', May, p. 46.
- 3. Dolan P. et al. Cost of breast cancer treatment in the UK. Breast. 1999 Aug; 8(4): 205-207.
- 4. Computed from Moss S. The diagnosis, management, treatment and costs of prostate cancer in England and Wales.
The Research Findings Register. Summary number 25. Retrieved 13 June 2006, from http://www.RefFeR.nhs.uk
£63 £243 £345 £629 £0 £100 £200 £300 £400 £500 £600 £700 Prostate Cancer (4) Breast Cancer (3) AIDS (2) Heart Failure (1) Million £ / Year
Cost of heart failure
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Low productivity/ mortality
Home healthcare Drugs/other medical durables
Physicians/other
professionals Nursing home Hospitalisation
$14.7
Total cost: $29.6 Billion
American Heart Association. Heart Disease and Stroke Statistics – 2006 Update
Estimated costs of heart failure
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70% of patients with HF are managed by primary care physicians
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600 500 400 300 200 100 15 12 9 6 3 Normal Heart Failure 12 6 4 2 300 250 200 150 100 50 8 6 4 2
Neurohormonal Activation in Heart Failure
Norepinephrine Renin- Angiotensin- Aldosterone Arginine Vasopressin ANP/BNP Endothelin-1
Adapted from Cohn JN. Cardiology, 1997;88:2-6
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Pharmacological therapy indicated in potentially all patients with systolic HF
Recommendations Class Level ACE inhibitor An ACE inhibitor is recommended, in addition to a beta-blocker, for all patients with an EF ≤40% to reduce the risk of HF hospitalization and the risk of premature death.
I A
Beta-blocker A beta-blocker is recommended, in addition to an ACE inhibitor (or ARB if ACE inhibitor not tolerated), for all patients with an EF ≤40% to reduce the risk of HF hospitalization and the risk of premature death.
I A
MRA An MRA is recommended for all patients with persisting symptoms (NYHA class II– IV) and an EF ≤35%, despite treatment with an ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated) and a beta-blocker, to reduce the risk of HF hospitalization and the risk of premature death.
I A
All three 1A recommendations are neurohumoral modulators
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Eur Heart J. 2016 May 20. http://dx.doi.org/10.1093/eurheartj/ehw128
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N Eng J Med 2004;351:6:543-551
HYPERKALEMIA AFTER RALES PUBLICATION
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N Engl J Med, Vol. 345, No. 23
Figure 1. The Renin–Angiotensin–Aldosterone System.
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HOPE Trial with ramipril
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Baseline Variables ATMOSPHERE (n=7063) PARADIGM (n=8399)
Diabetes mellitus, % 28% 35% Stroke, % 7% 9% Current smoker, % 13% 14% ECG findings Left bundle branch block, % 21% 20% QRS duration, ms 117 117 Pretrial use of ACEi/ARB Previous use of ACEi at screening visit, % 100% 78% Previous use of ARB at screening visit, % 2% 23% Pharmacological treatment Diuretic use, % 80% 80% Beta blocker, % 92% 93% MRA, % 37% 56% Digoxin, % 32% 30% Anticoagulant, % 30% 32% Lipid lowering, % 52% 56% Devices for HF at screening CRT, % 6% 7% ICD, % 15% 15%
All values are from the randomization visit unless otherwise stated.
ATMOSPHERE & PARADIGM: baseline characteristics (3/3)
Krum et al. Eur J Heart Fail (2015) 17, 1075–1083
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ATMOSPHERE: Primary outcome
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Aliskiren+ Enalapril (n=2340) Aliskiren (n=2340) Enalapril (n=2336) P value (1) P value (2) Hypotension n (%) Symptoms Symptoms and SBP <90mmHg 322 (13.8%) 87 (3.7%) 249 (10.6%) 31 (1.3%) 258 (11.0%) 55 (2.4%) 0.005 0.008 0.67 0.009 Renal impairment n (%) Cr ≥2.5mg/dl Cr ≥3.0mg/dl 95 (4.1%) 46 (2.0%) 63 (2.7%) 35 (1.5%) 62 (2.7%) 29 (1.2%) 0.009 0.06 1.00 0.53 Hyperkalemia n (%) K+ >5.5mmol/l K+ >6.0mmol/l 401 (17.1%) 116 (5.0%) 255 (10.9%) 70 (3.0%) 291 (12.5%) 83 (3.6%) <0.0001 0.02 0.10 0.29 Cough n (%) 290 (12.4%) 241 (10.3%) 284 (12.2%) 0.83 <0.05
ATMOSPHERE: Safety outcomes
(1) = Comparison of enalapril plus aliskiren versus enalapril; (2) = Comparison of aliskiren versus enalapril
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4187 4212 3922 3883 3663 3579 3018 2922 2257 2123 1544 1488 896 853 249 236 LCZ696 Enalapril Patients at Risk
PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)
16 32 40 24 8
Enalapril
(n=4212)
360 720 1080 180 540 900 1260 Days After Randomization
1117
Kaplan-Meier Estimate of Cumulative Rates (%)
914
LCZ696
(n=4187)
HR = 0.80 (0.73-0.87) P = 0.0000002 Number needed to treat = 21
N Engl J Med 2014;371:993-1004
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Challenges of Hyperkalemia in At-Risk Patients
- Associated with increased mortality
- Frequent visits to the emergency department or urgent
care when potassium levels increase
- Fear of hyperkalemia can prevent prescribing or optimally
dosing RAAS inhibitor therapy
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