Ischemie – lipiden - hartfalen Ischemie - lipiden en hartfalen Peter van der Meer Universitair Medisch Centrum Groningen University Medical Center Groningen
Ischemie – lipiden - hartfalen Male 77 years old. Did not show up for regular check ups. Now shortness of breath, atypical chest pain. Medical History: 2011: Large anterior MI, single vessel disease 2012: LVEF: 25%. Implantation of VVI-ICD Medication : ASA100mg, furosemide 40mg, Bisoprolol 10mg, Enalapril 2dd10mg, spironolactone 25mg ECG : SR 85/min QRS:122ms LBBB NYHA II – III BP 105/70mmHg Lab : K:4.8mmol/L GFR:45ml/min/1.73m 2 NT-proBNP:1645pg/mL University Medical Center Groningen
Ischemie – lipiden - hartfalen What is your next step? Start statin A) Coronary Angiogram B) Both C) None of the above D) University Medical Center Groningen
Ischemie – lipiden - hartfalen CABG vs OMT STICH 10 year follow-up • Primary Endpoint ▪ All-cause mortality • Major Secondary Endpoints ▪ Cardiovascular mortality ▪ Death (all-cause) + cardiovascular hospitalization CABG=Coronary artery bypass graft ; OMT=Optimal medical therapy; STICH=Surgical treatment for ischemic heart failure Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20 University Medical Center Groningen
Ischemie – lipiden - hartfalen Important inclusion criteria • LVEF ≤ 0.35 • CAD suitable for CABG • Eligibility for medical therapy alone ▪ Absence of left main CAD as defined by an intraluminal stenosis of ≥ 50% ▪ Absence of CCS III angina or greater (angina markedly limiting ordinary activity) LVEF=Left ventricular ejection fraction; CABG=Coronary artery bypass graft; CAD=Coronary artery disease; CCS=Canadian Cardiovascular Society University Medical Center Groningen Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20
Ischemie – lipiden - hartfalen All-cause mortality NNT = 14 CABG=Coronary artery bypass graft; MED=Medical therapy alone; NNT=Number needed to treat University Medical Center Groningen Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20
Ischemie – lipiden - hartfalen What is your next step? Start statin A) Coronary Angiogram B) Both C) None of the above D) University Medical Center Groningen
Ischemie – lipiden - hartfalen Inclusion criteria: Exclusion criteria: • • Age > 60 years Previous statin-myopathy • • LVEF <40% Myocardial infarction < 6months • • NYHA II-IV Kreat > 221 umol/L • Ischemic etiology (reported) University Medical Center Groningen
Ischemie – lipiden - hartfalen Rosuvastatin in older patients with systolic heart failure baseline NYHA=New York Heart Association Kjekshus J et al. N Engl J Med. 2007 Nov 29;357(22):2248-61 University Medical Center Groningen
Ischemie – lipiden - hartfalen Baseline University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen No effect on primary endpoint (CV death + non fatal MI / stroke) University Medical Center Groningen Kjekshus J et al. N Engl J Med. 2007 Nov 29;357(22):2248-61
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen 2nd trial with rosuvastatin in HF • GISSI-HF trial • Ischemic + non-ischemic HF University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen RCT vs real world data University Medical Center Groningen
Ischemie – lipiden - hartfalen Circ HF 2015 University Medical Center Groningen
Ischemie – lipiden - hartfalen Potential beneficial effect of statin on mortality in observational study University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen Digoxin Evaluation in Chronic heart failure: Investigational Study in Outpatients in the Netherlands: DECISION University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
2 Ischemie – lipiden - hartfalen 5 University Medical Center Groningen
Ischemie – lipiden - hartfalen University Medical Center Groningen
Ischemie – lipiden - hartfalen Conclusions: • Ischemic events are common in heart failure • CABG has a beneficial effect on the long term • 2 large RCTs do not support routine statin use in HF • ”real world ” data show some effect, but bias is likely • PCSK9 predicts outcome, no data on treatment in HF University Medical Center Groningen
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