UC California, USA SF 18.May, 2015/ 22.June, 2015 Presenter - PDF document

5/22/2015 Advances in Heart Failure: The “New” Guidelines John R. Teerlink, M.D., FACC, FAHA, FESC, FRCP(UK) Director, Heart Failure Program Director, Echocardiography San Francisco Veterans Affairs Medical Center; Professor of Clinical Medicine, University of California San Francisco UC California, USA SF 18.May, 2015/ 22.June, 2015 Presenter Disclosure Information: UCSF Advances in Internal Medicine 2015 • Financial Disclosure – J.R. Teerlink has received research grants and/or consulting fees from Amgen, Cytokinetics, Janssen, Medtronic, Novartis, St. Jude, Takeda, and Trevena. • Unlabeled/unapproved uses disclosure – I will be discussing investigational therapies that are not approved by the FDA. UC SF 1

5/22/2015 Mr. “HCE” (Here Comes Everybody): Question #1 • Intake sheet reports: 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, and obesity According to the ACC/AHA 2013 Heart Failure Guidelines, does Mr. HCE have heart failure? A. Yes B. No C. Maybe; Need more information Advances in Heart Failure • Definition, Nomenclature, Epidemiology • Evaluation and Diagnosis • Treatment of Stages of Heart Failure • Co-morbidities • Future directions 2

5/22/2015 Advances in Heart Failure • Definition, Nomenclature, Epidemiology Heart Failure • HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. • No single diagnostic test for HF; a clinical diagnosis based on careful history and physical examination, supplemented by diagnostic studies. • May result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels or from certain metabolic abnormalities, but most patients with HF have symptoms due to impaired left ventricular (LV) myocardial function. • Heart failure (not Congestive Heart Failure) 3

5/22/2015 Heart Failure with Reduced/Preserved Ejection Fraction (HFrEF and HFpEF) Yancy CW, et al. J Am Coll Cardiol 2013;62:e147 – 239. Heart Failure: Here Comes Everybody • Lifetime risk of developing HF is 20% for Americans 40 years of age • >650,000 new HF cases diagnosed annually • Approximately 5.1 million persons in the US have clinically manifest HF • Blacks have the highest risk for HF and a greater 5-year mortality rate than whites • Absolute mortality rates for HF remain approximately 50% within 5 years of diagnosis • Cost of heart failure in 2012: $71-$127 billion (Voigt J, et al. Clin Cardiol 2014 37, 5, 312 – 321.) 4

5/22/2015 2013 ACC/AHA Heart Failure Guidelines Advances in Heart Failure • Definition, Nomenclature, Epidemiology • Evaluation and Diagnosis 5

5/22/2015 Diagnosis of Heart Failure • Symptoms • Physical Exam – Dyspnea (Exertional, – Edema (Legs, Abd, PND, Orthopnea) Sacral) – Cough – Rales, Effusion – Fatigue – JVP, HJR/AJR – Abd discomfort – Weight (bloating, anorexia) – Cool extremities – Sleep disturbances – MR murmur – S3 (S4) – Blood/ pulse pressure – Pulsus alternans “First, strike for the jugular and let the rest go” - Oliver Wendell Holmes, Jr. 6

5/22/2015 Potential Limitations to BNP in the Evaluation of Heart Failure Teerlink JR. Acute Heart Failure . Braunwald’s Heart Disease. 2008 Practical Diagnostics in the Evaluation of Heart Failure • History – Etiology: CAD, HTN, Familial, Toxins (EtOH, drugs, chemo, alternative rx, etc.) – Symptoms, exercise tolerance (specific personal markers) • Physical exam: Diagnosis and Monitoring • Labs include Chem-7, HgbA1c, Ca, Mg, CBC, ferritin/TIBC, TSH, U/A, Lipid profile, LFT • CXR, ECG • Echocardiogram: probably single most useful; RVG/MUGA useful at some centers • Cardiac catheterization: right and left heart • Other: HIV, sleep disordered breathing, disease specific tests, BNP/ NT-pro-BNP (diagnosis/ risk stratification/?Guide therapy) 7

5/22/2015 Advances in Heart Failure • Definition, Nomenclature, Epidemiology • Evaluation and Diagnosis • Treatment of Stages of Heart Failure Stages of Heart Failure 8

5/22/2015 Prognostic Significance of the Stages of Heart Failure Ammar KA, et al. Circulation 2007;115:1563-1570. ACCF/AHA Stages Compared to NYHA Functional Class Yancy CW, et al. J Am Coll Cardiol 2013;62:e147 – 239. 9

5/22/2015 Stages of Heart Failure “ When you ’ re a Hammer, Everything looks like a Nail! ” 10

5/22/2015 Mr. “HCE” (Here Comes Everybody) Question #1: Discussion • 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, and obesity • Does Mr. HCE have heart failure? A. Yes B. No C. Maybe; Need more information Risk Factor Modification in HF • Weight loss • Smoking cessation • Hypertension therapies • Diabetes management • Lipid control • Sleep apnea • Exercise 11

5/22/2015 Lifetime Risk of Heart Failure According to Number of Healthy Lifestyle Factors Djousse L, et al. JAMA 2009;302:394-400. • Physicians Health Study cohort (20,900 men) • Six modifiable risk factors: Maintained Body weight - No Smoking - Exercise - Less Alcohol intake - Eats breakfast cereals - Eats fruits and vegetables - Essential Topics in Patient Education Dickstein K, et al. Eur Heart J 2008; 29:2388-442. 12

5/22/2015 Mr. “HCE” (Here Comes Everybody) • Intake sheet reports: 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, and obesity • ECG: NSR @88bpm, LAE, LVH, possible inferior MI Stages of Heart Failure 13

5/22/2015 Mr. “HCE” (Here Comes Everybody) • 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, and obesity • ECG: NSR @88bpm, LAE, LVH, possible inferior MI • Reports early satiety, abdominal discomfort, mildly increasing abdominal girth, 5 kg weight gain • HR 90 bpm, BP 134/76, RR 14, O2 sat 98% Lungs: clear to A&P CV: JVP~10 cm, -A(H)JR; S1,S2 +S4, no S3, Abd: mild RUQ tenderness, abd distension; ?ascites Extrem: No peripheral edema Stages of Heart Failure 14

5/22/2015 Mr. “HCE” (Here Comes Everybody) • 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, and obesity • ECG: NSR @88bpm, LAE, LVH, possible inferior MI • Reports early satiety, abdominal discomfort, mildly increasing abdominal girth, 5 kg weight gain • HR 90 bpm, BP 134/76, RR 14, O2 sat 98% Lungs: clear to A&P CV: JVP~10 cm, -A(H)JR; S1,S2 +S4, no S3, Abd: mild RUQ tenderness, abd distension; ?ascites Extrem: No peripheral edema • Labs: Na 135, K 3.9, BUN 30, Cr 1.6 • Echo: moderate LAE, mild LVH, mild LVE, EF 30%, global hypokinesis Mr. “HCE”: Question #2 • 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, obesity • ECG: NSR @88bpm, LAE, LVH, possible inferior MI • Reports early satiety, abd discomfort, mildly increasing abd girth, 5 kg weight gain • HR 90 bpm, BP 134/76, RR 14, O2 sat 98%; Lungs: clear to A&P CV: JVP~10 cm, -A(H)JR; S1,S2 +S4, no S3, Murmur; Abd: mild RUQ tenderness, abd distension, ?ascites; Extrem: No peripheral edema • Labs: Na 135, K 3.9, BUN 30, Cr 1.6 • Echo: moderate LAE, mild LVH, mild LVE, EF 30%, global hypokinesis The optimal initial therapy for this patient is: A. Furosemide 20 mg po qd B. Lisinopril 10 mg po qd C. Furosemide 20 mg po bid and Lisinopril 2.5 mg po qd D. Metoprolol tartrate 25 mg po bid 15

5/22/2015 Mr. “HCE”: Question #2 Discussion • 76 yo man with h/o diabetes mellitus (oral agents), hypertension, COPD, obesity • ECG: NSR @88bpm, LAE, LVH, possible inferior MI • Reports early satiety, abd discomfort, mildly increasing abd girth, 5 kg weight gain • HR 90 bpm, BP 134/76, RR 14, O2 sat 98%; Lungs: clear to A&P CV: JVP~10 cm, -A(H)JR; S1,S2 +S4, no S3, Murmur; Abd: mild RUQ tenderness, abd distension, ?ascites; Extrem: No peripheral edema • Labs: Na 135, K 3.9, BUN 30, Cr 1.6 • Echo: moderate LAE, mild LVH, mild LVE, EF 30%, global hypokinesis The optimal initial therapy for this patient is: A. Furosemide 20 mg po qd B. Lisinopril 10 mg po qd C. Furosemide 20 mg po bid and Lisinopril 2.5 mg po qd D. Metoprolol tartrate 25 mg po bid Stages of Heart Failure 16

5/22/2015 2013 ACC/ AHA Heart Failure Guidelines Yancy CW, et al. J Am Coll Cardiol 2013;62:e147 – 239. Use of Diuretics in Heart Failure Patients • Self- titration: need “dry” weight on patient’s scale – Daily weights (routine; daily log with symptoms, etc.) – If weight increased by >3-5 lbs, take double diuretic – If patient requires supplemental potassium, also double – If worsening at any time or no improvement after 2-3 days, call • Some patients can be maintained on thiazides (i.e. HCTZ) • Many patients will require loop diuretics; furosemide has short duration of action, should be dosed b.i.d. (AM and mid- afternoon/ early evening) • Many patients may not require diuretics when ACE inhibitor, beta blocker, aldosterone antagonist, etc. are optimized; reassess diuretic requirements after time on stable regimen 17

5/22/2015 Diuretics in Chronic Heart Failure Cósin J, et al. Eur J Heart Fail 2002;4:507-13. TORIC Study • Open-label, non-randomized, post-marketing study Incidence of Mortality (%) • 1377 patients; NYHA II-III • 778 pts torsemide (10 mg/d) • 527 pts furosemide (40 mg/d) • 72 pts other diuretics • 12 month follow-up 2013 ACC/ AHA Heart Failure Guidelines Yancy CW, et al. J Am Coll Cardiol 2013;62:e147 – 239. 18