Outline Chronic Heart Failure: Diagnosis and Staging Effective - PowerPoint PPT Presentation

Outline Chronic Heart Failure: • Diagnosis and Staging Effective Diagnosis, • Diastolic Heart Failure Treatment and Monitoring • Systolic Heart Failure Medications • Devices and End-Stage Heart Failure Michael G. Shlipak, MD, MPH Scientific Director , Kidney Health Research Collaborative Professor of Medicine, Epidemiology & Biostatistics University of California, San Francisco Associate Chief of Medicine for Research Development San Francisco VA Medical Center 2013 ACC/AHA Guideline for the Heart Failure Epidemiology Management of Heart Failure A Report of the American College of Cardiology • Only cardiovascular outcome that continues to increase Foundation/American Heart Association • Lifetime risk ~20% CIRCULATION, 2013 • Complicated to manage with multiple other comorbidities 2016 ACC/AHA/HFS • Treatments improve survival and reduce morbidity substantially. A Focused Update on New Pharmacological Therapy for Heart Failure • 4 5 classes of medications improve survival CIRCULATION, 2016 • 2 3 classes of medications improve symptoms 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment JACC, 2018

Question 1: Which of the following Why is Heart Failure Challenging to Manage? establishes a HF diagnosis? • Patients are very complicated and often frail 35% 35% EF < 35% on echo • CHF travels with many other comorbidities: a. 28% BNP > 300 on blood test b. − CAD, hypertension, diabetes, CKD S3 on exam c. • Polypharmacy All of the above d. • Diastolic heart failure becoming more common None of the above e. 2% 0% o t m e e h s v v e a c o o e t x b b d e n a a o n o e e o o l h h % b 3 t t 5 n S f f 3 o o o < l e 0 A l F 0 n o E 3 N > P N B Heart Failure is a Clinical Diagnosis Diastolic vs. Systolic Heart Failure • Based on the Ejection Fraction • Essential Symptoms: dyspnea, fatigue, orthopnea − <40%, 40-50%, >50% • Signs: rales , edema, JVD, S3 • Diastolic HF (>50%): • Physical exam : does not distinguish systolic vs. − Official term is “Heart Failure with Preserved diastolic Ejection Fraction” • Helpful features include: − Abbreviated as HFpEF • Systolic HF (<40%): − Chest X-Ray : pulmonary congestion − Official term is “Heart Failure with Reduced − Elevated BNP or Nt-proBNP Ejection Fraction” − Echo showing diastolic or systolic dysfunction − Abbreviated as HFrEF “Intermediate” – 40-50% (excluded from RCTs)

AHA (2009) Classification of Heart NYHA Functional Classes Failure Classes assume a prior diagnosis of heart failure Risk factors for heart failure- no clear A. signs/symptoms No limitation on ordinary physical activity I. Not HF Asymptomatic LV disease- LVH, diastolic B. Slight limitation – ordinary physical activity II. dysfunction, valve disease, low EF III. Marked limitation- < ordinary physical activity C. Symptomatic heart failure- dyspnea at rest or IV. Symptoms or discomfort at rest exertion, fluid retention Combines stages 1-3 D. Advanced heart failure - inotrope requirement, consideration for assist device or transplant Problems with these classes: • Patients vary across stages, going up and down • Can only progress down the classes • All class 4 at time of hospitalization • Emphasizes prevention over staging Outline Strategies that apply to all CHF Patients Initial ECHO • • Diagnosis and Staging Repeat only if major changes • • Diastolic Heart Failure Salt restriction • Daily weight monitoring • • Systolic Heart Failure Medications Exercise • • Devices and End-Stage Heart Failure Diuretics for symptoms • Avoid NSAIDS • Monitor: • − Volume status − Electrolytes, renal function

Question 2: Which of the following improve What is Diastolic Heart Failure? survival in diastolic heart failure? 30% 30% • “Stiff heart syndrome”- heart cannot relax in diastole ACE-I a. to allow the left ventricle to fill ARB’s b. 24% • Causes increased pressure in the left atrium, and Beta blockers c. pulmonary edema Ca-channel blockers d. • Defined by EF, yet actual stroke volume may be same All of the above e. as Systolic HF 7% None of the above f. 5% 3% • Same signs and symptoms as systolic HF • Relative prevalence of diastolic HF vs. systolic HF s I s s e e - ’ r r v E B e e v o o C R k k c b b A A c increases with age, and higher in women o o a a l l e b b e h h l a e t t t n f f e o o B n a l e h l A n c o - a N C ACC/AHA Guidelines for DHF Treatment Diastolic HF: Good and Bad News • BP control (SBP < 130) Good news: • Rate/rhythm control in AF • More favorable prognosis than SHF • Diuretics for pulmonary congestion • Simpler regimen, as diuretics cornerstone of therapy • Revascularization and other treatment for coronary Bad news: ischemia • Often progresses to SHF • No therapies improve DHF survival

ACE Inhibitors Outline • Improve symptoms and reduce hospitalizations • Diagnosis and Staging • Decrease mortality risk for all heart failure stages • Diastolic Heart Failure • Class effect- all ACE inhibitors • Systolic Heart Failure Medications • Aim for target dose – 40mg has better outcomes than • Devices and End-Stage Heart Failure 5mg (ATLAS trial) Kidney Function and ACE Inhibitors Meta-Analysis of ACE Trials in Heart Failure • 30 RCTs- ACE-I vs. placebo • Clinical trials show benefit if estimated GFR > 30 • Mortality • No evidence for lower GFR levels − 0.77 (0.67-0.88) • Expect the creatinine to rise at least 30% • Death or hospitalization for heart failure − 0.65 (0.57-0.74) • Even creatinine doubling is OK- typically returns near baseline • Specific ACE-I’s with benefits in RCT’s: • Worry about K increase (keep < 5.5); balance the K − Benzapril -Enalapril -Ramipril with diuretic dose. − Captopril -Lisinopril • Continue ACE-Is as eGFR declines unless cannot control K. Shlipak MG, Ann Intern Med 2003

ARBs in Systolic Heart Failure Question 3: What is an “ARNI”? Novel heart failure agent that slows • Generally equivalent to ACE inhibitors A. down the SA node to allow greater • Use for patients with cough on ACE inhibitors ventricular filling 73% New class of heart failure drugs that B. • Combination of ACE and ARB? prevents arrhythmias so patients will not require an ICD − Decreases hospitalization risk; increases adverse effect A combination of an Angiotensin risk (increased K) C. Receptor Blocker with a medication that − No survival difference blocks neprilysin 14% 6% 4% 4% A novel beta-blocker that has the ability D. − Generally, not recommended, as safety probably lower to increase ejection fraction in actual practice e . . . . . . . . v . . . . o t r g a n u n h b e l All of the above i A t a E. g a a f n r e e h e t a k r t r a f c u o o f l e l o i h n b a l f f o - A l o i a t t t r a e a s s n b e a i h l b l c m e l v e w o o Yusuf S. et al. Lancet 2003 v e n o c N A A N PARADIGM-HF Trial: Angiotensin- PARADIGM-HF Trial Receptor blocker/Neprilysin • N=8,442 Inhibitor (ARNI) vs. Enalapril • Class 2-4 HF symptoms • EF< 40% • The new drug: − LCZ696 − Valsartan/Sacubritril − Entresto − 2015 FDA approval • Sacubritril- blocks Neprilysin  • ↓ vasoconstriction, ↓ Na retention, ↓ remodeling • Prior ARNI- Omipatrilat (caused ↓ BP, angioedema, and cognitive dysfunction)

PARADIGM-HF Trial PARADIGM-HF Trial Baseline Characteristics of Patients • Inclusion Criteria: Mean Age 64 − EF< 40% % Female 22% − BNP > 150 Race − Prior ACE/ARBs White 66% • Exclusion Criteria: Black 5% Asian 18% − SBP< 95 Other 11% − eGFR< 30 Mean BP 122/72 − K> 5.2 Mean Creatinine 1.12 − ACE/ARB angioedema % eGFR<60 36% Class 2 70% Class 3 24% PARADIGM-HF Trial PARADIGM-HF Trial Baseline Characteristics of Patients (continued) Enrollment in 3 Phases 1.) Enalopril 10mg 2x/day: 2 weeks (N= 10,513) Medications -10% drop out (5.6%- adverse effects) ACE/ARB 100% 2.) ARNI: 4 weeks (N=9,419) BB 93% -100 mg and 200 mg Diuretics 80% -10% drop out (5.8%- adverse effect) Aldo-Antagonist 55% Digitalis 30% 3.) RCT: Enalopril (10 mg 2x/day) vs. ARNI (200 mg 2x/day) (N=8,442) Devices ICD 15% -trial stopped early CRT 7% -median follow-up 27 months