HOW TO PREVENT CARDIAC DECOMPENSATION Burcu Balam YAVUZ, MD, Assoc Prof Hacettepe University Faculty of Medicine Department of Internal Medicine, Division of Geriatric Medicine Ankara, TURKEY bbdogu@gmail.com
CONFLICT OF IN INTEREST DIS ISCLOSURE I have no potential conflict of interest to report
• Heart failure (HF) and geriatric age • Decompensated HF (DHF) • Definition • Causes • Predisposing - precipitating factors • Prevention • DHF – association with Geriatric Syndromes • Comprehensive Geriatric Assessment and Cardiogeriatric care • THM
HEART FAILURE AND GERIATRIC AGE Differences from younger patients: Atypical Physiological presentation of Geriatric changes diseases Comorbidities syndromes Decreased reserves Atypical subtle symptoms Different type of Different HF predominant Difficult Worse clinical (HFpEF) diagnosis prognosis characteristics (Diastolic HF) 2016 ESC Guidelines Upadhya et al. Journal of Molecular and Cellular Cardiology 2015;83:73-- ‐87 Komadja et al. Eur Heart J 2007;28:1310-- ‐8 2012 ESC Guidelines. Eur Heart J 2012;33
• Incidence of HF increases with age • Prevalence of HF and LV dysfunction increases steeply with age • Prevalence of HF with a preserved EF (HFpEF) increases with age • The estimated prevalence of diastolic dysfunction among patients with HF Age <50: 15% Age 50-70: 33% Age >70: 50% J Am Coll Cardiol 1995; 26:1565 The Rotterdam Study. Eur Heart J 2004; 25:1614 The Framingham Study. Am J Cardiol 1992: 70:1180 Am Heart J 2002; 143:412 J Am Coll Cardiol 2003; 41:217
HFpEF in Geriatric Age • Predominant type of HF • 567 patients, ≥80 years: • Isolated diastolic dysfunction: 51.3% • Systolic dysfuncion (EF ≤50%): 5.8% Vaes et al. Int J Cardiol 2012;155:134 Upadhya et al. Journal of Molecular and Cellular Cardiology 2015;83:73
HEART FAILURE AND GERIATRIC AGE Differences from younger patients: Atypical Physiological presentation of Geriatric changes diseases Comorbidities syndromes Decreased reserves Atypical subtle symptoms Different type of Different HF Difficult Worse clinical (HFpEF) diagnosis prognosis characteristics (Diastolic HF) Upadhya et al. Journal of Molecular and Cellular Cardiology 2015;83:73-- ‐87 Komadja et al. Eur Heart J 2007;28:1310-- ‐8 2012 ESC Guidelines. Eur Heart J 2012;33 2016 ESC guidelines
• Clinical manifestations of decompensation is atypical in geriatric age • Subtle • Weakness/exhaustion • Somnolence • Delirium • Falls • Decline in oral intake • Decline in general condition
HEART FAILURE AND GERIATRIC AGE Differences from younger patients: Atypical Physiological presentation of Geriatric changes diseases Comorbidities syndromes Decreased reserves Atypical subtle symptoms Different type of Different HF Difficult Worse clinical (HFpEF) diagnosis prognosis characteristics (Diastolic HF) Upadhya et al. Journal of Molecular and Cellular Cardiology 2015;83:73-- ‐87 Komadja et al. Eur Heart J 2007;28:1310-- ‐8 2012 ESC Guidelines. Eur Heart J 2012;33 2016 ESC guidelines
• Multiple comorbidities complicate the management • Closer monitoring is required • Higher risk of side effects • High risk of drug-- ‐drug interactions • Higher prevalance of nonadherence to treatment Increased rate of decompensation Increased rate of hospitalisations Increased rate of mortality Hamada et al, Geriatr Gerontol Int 2017 Sargento et al. Curr Heart Fail Rep 2014 Komajda et al. Eur Heart J 2007;28:1310
• The outcome for older HF patients depends on • Disease severity • Non-cardiac comorbidities associated with worse clinical outcome These comorbidities effect functioning, qol, selfcare, adherence • Hypertension • DM • Renal disease • Chronic obstructive pulmonary diseases • Geriatric syndromes • Cognitive dysfunction • Depressive disorders • Malnutrition • Frailty • Psychological factors, social environmental factors Hamada et al, Geriatr Gerontol Int 2017 Sargento et al. Curr Heart Fail Rep 2014
Vicious cycle Chronic HF Cognitive decline Functional decline Depressive symptoms Weight loss Malnutrition Worsen HF Frailty Increase decompensation Worsen prognosis
A Major Pitfall : Evidence based medicine? • Most RCTs in HF exclude patients with comorbidities/ frailty/ very old • Difficult to carry out evidence based therapies in older patients • Difficult to apply guidelines to older patients Patient Based 2013 ACCF/AHA Heart Failure Guideline. Circulation 2013;128:e240-- ‐e327
Diagnosis of HF ESC 2016
ESC 2016
• 2013 by an American College of Cardiology/American Heart Association (ACC/AHA) task force • Stage A – At high risk for HF but without structural heart disease or symptoms of HF • Stage B – Structural heart disease but without signs or symptoms of HF • Stage C – Structural heart disease with prior or current symptoms of HF • Stage D – Refractory HF requiring specialized interventions
Cardiac Decompensation • Decompansated heart failure (DHF) • Acute • Chronic • Predisposing factors + precipitant factors = cardiac decompansation
Comorbidities Predisposant Factors Physiological changes Decreased reserves Atypical presentation of diseases Atypical subtle Polypharmacy symptoms Precipitant factors Geriatric syndromes Nonadherence to treatment
ADHF – Acute Decompensated Heart Failure Definition • Common and potentially fatal cause of acute respiratory distress • Generally associated with rapid accumulation of fluid within the lung's interstitial and alveolar spaces • Presentation: • Cardiogenic pulmonary edema (the result of acutely elevated cardiac filling pressures) • Dyspnea without pulmonary edema (elevated left ventricular filling pressures) • Acute cardiogenic shock, severe hypotension • Respiratory failure • Dyspnea, Cough, Fatigue, Peripheral edema which rapidly become more severe, Chest discomfort • Atypical presentation in older age N Engl J Med 2005; 353:2788
ADHF - Causes LV systolic or diastolic dysfunction ± additional cardiac pathology Cardiogenic pulmonary edema Non-Cardiogenic pulmonary edema • Cardiac pathology: • Permeability due to • CAD (acute coronary syndrome) • ARDS: major cause • Valve abnormality • Pulmonary embolism • Elevated pulmonary capillary • Reperfusion pulmonary edema wedge pressure in the absence of • Re-expansion pulmonary edema heart disease • High altitude • Primary fluid overload (eg, excessive • Neurogenic pulmonary edema fluid and sodium intake, due to nonadherence, blood transfusion, iv • Drugs: opiate overdose, salicylate fluid, TPN...) toxicity* • Severe hypertension (particularly • Transfusion-related acute lung injury renovascular hypertension) • Viral infections • Severe renal disease • Pulmonary veno-occlusive disease
• In the large majority of patients who present with ADHF • A prior history of episodes of decompensation exists • While approaching the episode of ADHF • Information regarding the precipitating factors • Workup for HF, the elements of successful therapy for prior episodes • Approppriate longterm treatment • Important to prevent decompensation especially in older adults as it is associated with higher rates of mortality
PREDISPOSING FACTORS • Systolic dysfunction • Diastolic dysfunction* • CAD • LV hypertrophy • HT • Hypertrophic and restrictive cardiomyopathies • Valvular heart disease • Acutely with ischemia and acute • Idiopathic dilated cardiomyopathy hypertensive crisis • Cardiotoxic agents (eg, anthracyclines) • Primary intrinsic abnormalities of LV • Metabolic disorders (eg, hypothyroidism) diastolic function • Viral myocarditis (eg, Coxsackie B virus or • Volume overload (as in renal failure) echovirus infection). • Increased afterload (as in hypertensive crisis) • Tachycardia (eg, AF with rapid ventricular response
PREDISPOSING FACTOR (cont.) • Left ventricular outflow • Renovascular hypertension* obstruction • Association between recurrent • Critical aortic stenosis pulmonary edema and renovascular hypertension (including supravalvular and • Flash pulmonary edema more subvalvular stenosis), common in patients with bilateral • Hypertrophic cardiomyopathy renal artery stenosis and/or severe systemic hypertension. • Limited evidence is available on the efficacy of revascularization to • Mitral stenosis prevent decompensation Lancet 1988; 2:551; Am J Hypertens 1999; 12:1 Eur Heart J 2011; 32:2231; Blood Press 2011; 20:15
PRECIPITATING FACTORS 1. Adherence and care issues** 2. Cardiac 3. Noncardiac Blood AJ, et al. Progress in Cardiovascular Diseases 2017 (Article in Press) 2013 American College of Cardiology/AHA Heart Failure Guideline Wu et al. Am J Crit Care. 2016;26:62-69 J Card Fail 2010; 16:e1 Eur Heart J 2008; 29:2388 Circulation 2009; 119:e391 Can J Cardiol 2006; 22:23 J Am Coll Cardiol 2009; 53:254
Precipitating Factors - 1 1. Adherence and care issues: • Especially important in geriatric age • Geriatric syndromes affect adherence: • Functionality • Cognitive function • Mood • Frailty • Socio-economical factors
1. Adherence and care issues: • Dietary noncompliance (fluid and sodium restriction) • Nonadherence to medications • Volume overload (by patient or iatrogenic) • Significant drug interactions and side effects
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