amos slides - updated for posting - acponline.org · vitals: bp 128/65, p 72 pe: no jvd, minimal le...

Heart Failure Review and Update Through CasesHeart Failure Review and Update Through Cases

Ankie Amos, MD, FACCAlaska Heart Institute

April 2017

Ankie Amos, MD, FACCAlaska Heart Institute

April 2017

Why Care about Heart Failure?Why Care about Heart Failure?

83% of CHF patient are taken care of solely by primary care physicians.

Common Problem: 5 million have HF in the USA 550,000 are diagnosed with HF each year.

Mortality and Morbidity: 4 million hospitalizations per year 60% 5-year Mortality

Costly! > $32 billion spent on HF in the USA in

2011.

83% of CHF patient are taken care of solely by primary care physicians.

Common Problem: 5 million have HF in the USA 550,000 are diagnosed with HF each year.

Mortality and Morbidity: 4 million hospitalizations per year 60% 5-year Mortality

Costly! > $32 billion spent on HF in the USA in

2011.

Heart Failure Hospitalizations Remain Common

Heart Failure Hospitalizations Remain Common

Mozaffarian D et al. Circulation. 2015;131:e29-e322.

Coronary Heart Disease Heart Failure

Heart Failure DefinitionHeart Failure Definition

Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or ejectblood.

Dyspnea, edema, fatigue

Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or ejectblood.

Dyspnea, edema, fatigue

The Changing Epidemiology of HFThe Changing Epidemiology of HF

Steinberg et al. Circulation. 2012; 126(1):65–75Oktay et al. Curr Heart Fail Rep. 2013 Dec;10(4):401-10

Heart Failure: The Tip of the Iceberg?Heart Failure: The Tip of the Iceberg?

Heart Failure StagingHeart Failure Staging

At risk for HF-------------------> Heart FailureAt risk for HF-------------------> Heart Failure

Stage AAt High risk for HF

But without structuralHeart disease orSymptoms of HF.

Stage BStructural heart

Disease but withoutSigns or symptoms.

Stage CStructural heart disease

With prior or currentSymptoms.

Stage DRefractory HF

Requiring specialized Interventions.

Patients with:-HTN-CAD-DM-Obesity-Metabolic Syndrome

Patients with:-Previous MI-LV remodeling-LVH-Low EF-Valvular disease

Patients with:-Structural Heart Ds-SOB/Fatigue-Reduced ExerciseTolerance

Patients with:-Rest Symptoms-On maximal medTherapy-Recurrent hosp.

Structural Hrt Ds Symptoms Refractory Rest Sx

Define your Heart Failure Patient!Define your Heart Failure Patient!

Heart Failure

L Heart Failure

R Heart Failure

HFpEFEF>50%

AdvancedChronic Stable

Acute Failure

New Onset

HFrEFEF <40%

Define Your Heart Failure PatientNYHA Class

Define Your Heart Failure PatientNYHA Class

I: NO symptoms

II: Symptoms with moderate activity

III: Symptoms with minimal activities of daily living

IV: Symptoms at rest

I: NO symptoms

II: Symptoms with moderate activity

III: Symptoms with minimal activities of daily living

IV: Symptoms at rest

Case of Mr ACase of Mr A

Mr. A is a 56yo male who comes in for HF follow up. No Sx or complaints. EF 25%, Class II HF (has had CHF dx for 8

years) Vitals: BP 128/65, P 72 PE: No JVD, minimal LE edema at feet

only, NO crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg

BID, Lasix 10mg a day

What Quad is this patient in?


years) Vitals: BP 128/65, P 72 PE: No JVD, minimal LE edema at feet

only, NO crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg


What Quad is this patient in?

The Quad of HF:A paradigm to Guide Treatment


Perfusion

VOLUME •BNP elevated

•Crackles in lung (dyspnea)•LE edema•Ascites•Increased weight•JVD

•Cr increased•AMS•Dyspnea•Elevated bilirubin/lfts-Abd pain•Hypotension•Feel cold in feet

HemodynamicsHemodynamics

Perfusion: CI: Digoxin, Inotropes SVR: Ace-I, ARBS, Nitrates/Hydralazine

Volume: PCW (Lung fluid): Diuretics only work if RA

pressure high! RA (peripheral fluid)=JVD:

Diuretics/ultrafiltration

Normal #’s: PCW 12, RA 5-10, CI >2, CO >4, SVR 900-1000.

Interrogate Device!! Many have Volume estimations or Echo.

Perfusion: CI: Digoxin, Inotropes SVR: Ace-I, ARBS, Nitrates/Hydralazine

Volume: PCW (Lung fluid): Diuretics only work if RA

pressure high! RA (peripheral fluid)=JVD:

Diuretics/ultrafiltration

Normal #’s: PCW 12, RA 5-10, CI >2, CO >4, SVR 900-1000.

Interrogate Device!! Many have Volume estimations or Echo.

Hemodynamics in the QuadHemodynamics in the Quad

Perfusion

VOLUME

•RA/CVP: Normal•PCW: Normal•CI/CO: Low•SVR: High

•RA/CVP: 5-10•PCW: 10-15•CI/CO: >2, >4•SVR: 1000

•RA/CVP: High•PCW: High•CI/CO: ok•SVR: ok

The Quad of HF: TreatmentsThe Quad of HF: Treatments

Perfusion

VOLUME

•Diuretics•HF Cocktail

HF “Cocktail”•Ace-I/ARB•Beta – blocker•Spironolactone•Hydralazine/Nitrates•Digoxin

•Afterload Reduction•Nitrates/hydralazine•Ace-I/ARB

•Inotropes•Dobutamine•Milrinone

•Same as these quads

Case of Mr ACase of Mr A


years) Vitals: BP 128/65, P 72 PE: No JVD, No LE edema, NO crackles.

Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg


Would you change anything?


years) Vitals: BP 128/65, P 72 PE: No JVD, No LE edema, NO crackles.

Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg


Would you change anything?

Target Doses: Important!Target Doses: Important!

Goal SBP: As low as they can tolerate!Goal HR 50’s

Goal SBP: As low as they can tolerate!Goal HR 50’s

What therapy changes would you recommend?What therapy changes would you recommend?

1. Add digoxin 0.25mg a day

2. Increase Coreg to 50mg BID

3. Add spironolactone 25mg a day

4. Switch Lisinopril to Entresto

5. No changes recommended

1. Add digoxin 0.25mg a day

2. Increase Coreg to 50mg BID

3. Add spironolactone 25mg a day

4. Switch Lisinopril to Entresto

5. No changes recommended

Chronic Heart Failure : ENTRESTOChronic Heart Failure : ENTRESTO

Entresto now a class I recommendation for NYHA Class 2/3 on maximized ace/arb and BB

Entresto now a class I recommendation for NYHA Class 2/3 on maximized ace/arb and BB

Who were the Patients?Who were the Patients?

<10% were in the USA

5% were African American

Mostly Class II-III HF with “sturdy BP”

<10% were in the USA

5% were African American

Mostly Class II-III HF with “sturdy BP”

Results of ParadigmResults of Paradigm

Stopped Early due to dramatic benefit

20% reduction of Mortality

Significant differences in 30 days.

More decreased death than all other HF trials combined and more patients than all other trials combined.

To prevent one death, need to treat 32 patients.

Stopped Early due to dramatic benefit

20% reduction of Mortality

Significant differences in 30 days.

More decreased death than all other HF trials combined and more patients than all other trials combined.

To prevent one death, need to treat 32 patients.

10%

20%

30%

40%

ACEinhibitorARB

0%

Sacubitril/valsartan

% D

ecre

ase

in M

orta

lity 15%

16%

Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial.Effect of ARB vs placebo CHARM-Alternative and CHARM-Added,Effect of LCZ696 vs ACE inhibitor derived from PARADIGM-HF trial.

Sacubitril/valsartan doubles the survival benefit of current renin-angiotensin inhibitors

Sacubitril/valsartan doubles the survival benefit of current renin-angiotensin inhibitors

Neprilysin inhibition

Practical Entresto TidbitsPractical Entresto Tidbits

Not in Liver Failure

Contraindicated with Ace-I (36hr washout) Consider switching to ARB for 36 hrs

If following serial BNP’s, they will rise. Better to follow NT-BNP or pro-bnp

Not in Liver Failure

Contraindicated with Ace-I (36hr washout) Consider switching to ARB for 36 hrs

If following serial BNP’s, they will rise. Better to follow NT-BNP or pro-bnp

Switching to EntrestoSwitching to Entresto

Mortality Reduction of Evidence Based ManagementMortality Reduction of Evidence Based Management

ACE Inhibitors/ARB 17-36%

ARB/Neprilysin (Entresto) 16-20%

β-blockers 20-35%

Hydralazine/nitrates 30%

Aldactone 25-30%

Inotropic Drugs 36-50% increase

ACE Inhibitors/ARB 17-36%

ARB/Neprilysin (Entresto) 16-20%

β-blockers 20-35%

Hydralazine/nitrates 30%

Aldactone 25-30%

Inotropic Drugs 36-50% increase

Mentz, Felker, Mann. Heart Failure, a Companion to Braunwald’s Heart Disease. 2014

New Developments in HF Therapy: 1999 EditionNew Developments in HF Therapy: 1999 Edition

The Body’s adaption to the disease becomes as important than the initial insult itself

The Body’s adaption to the disease becomes as important than the initial insult itself

Adapted from Packer M. Prog Cardiovasc Dis. 1998;39(suppl I):39–52.

CNS sympathetic outflow

1-receptors

Cardiac sympathetic activity

2-receptors

1-receptors Activation

of RAS

VasoconstrictionSodium retention

Myocyte hypertrophy, dilation,ischemia, arrhythmias, death

Disease progression

Neurohormonal Hypothesis:SNS Activation Leads Directly to Impaired Cardiac Fnx

Sympathetic activity tokidneys + blood vessels

Lasix

RemodelingRemodeling

1 week 3 months

EDV 137 mL ESV 80 mLEF 41%

EDV 189 mL ESV 146 mLEF 23%

Apical 4 Chamber View

Chamber Enlargement

Answer of Mr A CaseAnswer of Mr A Case


years) Vitals: BP 128/65, P 72 PE: No JVD, 1+ LE edema at feet only, NO

crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg


Switch Lisinopril to Entresto!


years) Vitals: BP 128/65, P 72 PE: No JVD, 1+ LE edema at feet only, NO

crackles. Ext warm Meds: Coreg 25mg BID, Lisinopril 20mg


Switch Lisinopril to Entresto!

Case Mr. ABCCase Mr. ABC

65yo with a PMH of an ICM with a stable EF of 30%, NYHA class II HF, CKD (Cr 1.8) presenting for routine follow up. Meds: Coreg 50mg BID, Entresto

97/103mg BID, Spironolactone 25mg QD, Lasix 20mg QD

Vitals: HR 95, BP 128/78 PE: Euvolemic

Do these vitals make sense?

65yo with a PMH of an ICM with a stable EF of 30%, NYHA class II HF, CKD (Cr 1.8) presenting for routine follow up. Meds: Coreg 50mg BID, Entresto


Vitals: HR 95, BP 128/78 PE: Euvolemic

Do these vitals make sense?

Case Mr. ABC: Compliance?Case Mr. ABC: Compliance?

CHF Medication non-adhearance is common After a hospital DC, 80% are still on their Ace-I

at 1 mo, only 60% at 1 year. 1 year after initiation of CHF meds, 10% are

still on the full regimen at the end of 1 year Moname M et al; Arch Int Med 1994; 154: 433-437. Vanderwal et al. Int J Cardiol 2008; 125: 203-208

Think about remembering 6-10 meds 3 times a day plus a regimen fluid/salt restriction (possibly also low sugar?). Takes high IQ, organization, Literacy Consider neurocognitive testing, mini-mental

status testing.

CHF Medication non-adhearance is common After a hospital DC, 80% are still on their Ace-I

at 1 mo, only 60% at 1 year. 1 year after initiation of CHF meds, 10% are

still on the full regimen at the end of 1 year Moname M et al; Arch Int Med 1994; 154: 433-437. Vanderwal et al. Int J Cardiol 2008; 125: 203-208

Think about remembering 6-10 meds 3 times a day plus a regimen fluid/salt restriction (possibly also low sugar?). Takes high IQ, organization, Literacy Consider neurocognitive testing, mini-mental

status testing.

Super Bowl Sunday:Mean Heart Failure Admissions During Holidays

Super Bowl Sunday:Mean Heart Failure Admissions During HolidaysHoliday 4 Immediate

post-holiday Days

The month – 4 immediate post

holiday days

Holiday itself

Independence Day 5.6 5 3.8

Thanksgiving 5.7 5.6 4.2

Christmas 6.5 5.5 3.6

New Year’s 6.5 6.3 5.1

Superbowl Sunday 7 6.2 5.5

Shah, et al. HFSA poster 2014. Study of 12,727 CHF admits in Philadelphia.

Case Mr. ABCCase Mr. ABC

Assuming compliance, what med can be added to lower CV death and hospitalization? Meds: Coreg 50mg BID, Entresto


Vitals: HR 95, BP 128/78

Assuming compliance, what med can be added to lower CV death and hospitalization? Meds: Coreg 50mg BID, Entresto


Vitals: HR 95, BP 128/78

SHIFT Trial: Corlanor/IvabradineSHIFT Trial: Corlanor/Ivabradine >6500 patients with Class II-IV CHF and EF

<35%.

Corlanor/ivabradine adjusted to achieve a HR 50-60

Approved for Chronic, stable HF with HR >70 maximized on a BB.

18% decrease in CV death/hospitalization

(Criticism: not all patients on target BB therapy)

2016 HF Guidelines: Class IIarecommendation

>6500 patients with Class II-IV CHF and EF <35%.

Corlanor/ivabradine adjusted to achieve a HR 50-60

Approved for Chronic, stable HF with HR >70 maximized on a BB.

18% decrease in CV death/hospitalization

(Criticism: not all patients on target BB therapy)

2016 HF Guidelines: Class IIarecommendation

Heart Rate as a Risk Factor in HFHeart Rate as a Risk Factor in HF

Bohm, M et al Lancet 2010

Ivabradine/Corlanor:Selectively blocks the Hyperpolarization-activated

cyclic nucleotide-gated Channel. (HCN)

Ivabradine/Corlanor:Selectively blocks the Hyperpolarization-activated

cyclic nucleotide-gated Channel. (HCN)

Corlanor Reduced the RR of hospitalization for worsening HF by 26%

Corlanor Reduced the RR of hospitalization for worsening HF by 26%

Case Mr. ZCase Mr. Z

59yo with an ICM who has been in the hospital 9 times over a year for heart failure – he presents with SOB. Last cath 2 mo ago – Prior stents in LAD and RCA

patent. LCX non-dominant. Echo: 6 mo ago: EF 30% (down from 45% 1 yr

ago) Meds: Coreg CR 20, Lisinopril 10 BID, Lasix 80

qd, Kcl 40 qd Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA.

JVD 8cm, Lungs – decreased BS at bases, CV –tachy, RR, pmi displaced, SEM at LLSB 3/6, Ext –cool,trace edema

Labs: Na 128, K 5, Cr 1.9 (baseline 0.9), Hct 29,

59yo with an ICM who has been in the hospital 9 times over a year for heart failure – he presents with SOB. Last cath 2 mo ago – Prior stents in LAD and RCA

patent. LCX non-dominant. Echo: 6 mo ago: EF 30% (down from 45% 1 yr

ago) Meds: Coreg CR 20, Lisinopril 10 BID, Lasix 80

qd, Kcl 40 qd Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA.

JVD 8cm, Lungs – decreased BS at bases, CV –tachy, RR, pmi displaced, SEM at LLSB 3/6, Ext –cool,trace edema

Labs: Na 128, K 5, Cr 1.9 (baseline 0.9), Hct 29,

Case Mr Z:Case Mr Z:

What would you do first? 1) Increase lisinopril by 2.5mg a day 2) Re-echo 3) Cath or stress MRI 4) Give Lasix 80mg IV in clinic

What Quad is the patient in?

What would you do first? 1) Increase lisinopril by 2.5mg a day 2) Re-echo 3) Cath or stress MRI 4) Give Lasix 80mg IV in clinic

What Quad is the patient in?

The Quad of HF: Patient Physical ExamThe Quad of HF: Patient Physical Exam

Lasix would not help symptoms, may worsen.

Increasing lisinopril with a high K and Cr and low BP would probably worsen things.

Lasix would not help symptoms, may worsen.

Increasing lisinopril with a high K and Cr and low BP would probably worsen things.

Perfusion

VOLUME

•Cold hands/feet•Confusion, fatigue•Abdominal pain•Labs: Elevated Bili, LFt’s, Cr

Definition of Heart Failure: StagingDefinition of Heart Failure: Staging

At risk for HF-------------------> Heart FailureAt risk for HF-------------------> Heart Failure

Stage AAt High risk for HF

But without structuralHeart disease orSymptoms of HF.

Stage BStructural heart

Disease but withoutSigns or symptoms.

Stage CStructural heart disease

With prior or currentSymptoms.

Stage DRefractory HF

Requiring specialized Interventions.

Patients with:-HTN-CAD-DM-Obesity-Metabolic Syndrome

Patients with:-Previous MI-LV remodeling-LVH-Low EF-Valvular disease

Patients with:-Structural Heart Ds-SOB/Fatigue-Reduced ExerciseTolerance

Patients with:-Rest Symptoms-On maximal medTherapy-Recurrent hosp.

Structural Hrt Ds Symptoms Refractory Rest Sx

Clinical Events and Findings Useful for Identifying Patients With Advanced HFClinical Events and Findings Useful for Identifying Patients With Advanced HF

Repeated (≥2) hospitalizations or ED visits for HF in the past yearProgressive deterioration in renal function (e.g., rise in BUN and creatinine)Weight loss without other cause (e.g., cardiac cachexia)Intolerance to ACE inhibitors due to hypotension and/or worsening renal functionIntolerance to beta blockers due to worsening HF or hypotensionFrequent systolic blood pressure <90 mm HgPersistent dyspnea with dressing or bathing requiring restInability to walk 1 block on the level ground due to dyspnea or fatigueRecent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapyProgressive decline in serum sodium, usually to <133 mEq/LFrequent ICD shocks

Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.

Highest Risk IndicatorsHighest Risk Indicators

Drug Intolerance

Lasix > 1.5mg/kg/day

BUN > 40

Drug Intolerance

Lasix > 1.5mg/kg/day

BUN > 40

Adapted from Russell SD, et al.

64% 1-year Mortality

Recognize Stage D Heart Failure: Options

Recognize Stage D Heart Failure: Options

Options:1. Hospice2. Home Inotropes3. Mechanical support4. Transplant

Options:1. Hospice2. Home Inotropes3. Mechanical support4. Transplant

Mechanical Circulatory SupportMechanical Circulatory Support

DT Trial CAP: BackgroundDT Trial CAP: Background

1 Slaughter MS, Rogers JG, Milano CA et al: Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009 Dec 3;361(23):2241-51.

2 Fang JC: Rise of Machines – Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure N Engl J Med. 2009 Dec 3;361(23):2282-84.Source: Park SJ, AHA 2010

HeartMate III TrialHeartMate III Trial

Worldwide HeartMate II Clinical ExperienceWorldwide HeartMate II Clinical ExperienceMore than 20,000+ patients worldwide have now been implanted with the HeartMate II®LVAS.

Over 6,000 patients on ongoing support

Patients supported ≥ 1 year: 1,634

Patients supported ≥ 2 years: 963


8 Years is the longest

As of April 2016

*Based on clinical trial and device tracking data

More than 20,000+ patients worldwide have now been implanted with the HeartMate II®LVAS.

Over 6,000 patients on ongoing support

Patients supported ≥ 1 year: 1,634



8 Years is the longest

As of April 2016

*Based on clinical trial and device tracking data

HeartmatePatients

HeartmatePatients

HeartMate II VADHeartMate II VAD

JarvickJarvick

Mastoid Bone Exit or Abdominal Mastoid Bone Exit or Abdominal

Heartware DeviceHeartware Device

Centrifugal pump Centrifugal pump

HeartMate III TrialHeartMate III Trial

Smaller

Pulse Technology -Lower GI bleeding?

Magnetically levitated centrifugal pump

Smaller

Pulse Technology -Lower GI bleeding?

Magnetically levitated centrifugal pump

Case Mrs. DNCase Mrs. DN

33yo dx 3 mo ago with a PPCM EF 10% and recent h/o meth use who presents to the ER with abd pain. Cardiology consulted pre-op choly. Vitals: BP 90/66, P 110 Exam: +JVD, +crackles, no LE edema,

abd bloating per report, warm ext Labs: WBC nl, Hct 33, Cr 1.9, Bilirubin 2 Abd ultrasound unremarkable except for

ascites

Dx?

33yo dx 3 mo ago with a PPCM EF 10% and recent h/o meth use who presents to the ER with abd pain. Cardiology consulted pre-op choly. Vitals: BP 90/66, P 110 Exam: +JVD, +crackles, no LE edema,

abd bloating per report, warm ext Labs: WBC nl, Hct 33, Cr 1.9, Bilirubin 2 Abd ultrasound unremarkable except for

ascites

Dx?

Case Ms. DNCase Ms. DN

What is best first step? Clear for Choly Dobutamine Digoxin Hydralazine/nitrates

What is best first step? Clear for Choly Dobutamine Digoxin Hydralazine/nitrates



Perfusion

VOLUME •BNP elevated

•Crackles in lung (dyspnea)•LE edema•Ascites•Increased weight•JVD

•Cr increased•AMS•Dyspnea•Elevated bilirubin/lfts-Abd pain•Hypotension•Feel cold in feet

Hemodynamics in the QuadHemodynamics in the Quad

Perfusion

VOLUME

•RA/CVP: Normal•PCW: Normal•CI/CO: Low•SVR: High

•RA/CVP: 5-10•PCW: 10-15•CI/CO: >2, >4•SVR: 1000

•RA/CVP: High•PCW: High•CI/CO: ok•SVR: ok

The Quad of HF: TreatmentsThe Quad of HF: Treatments

Perfusion

VOLUME

•Diuretics•HF Cocktail

HF “Cocktail”•Ace-I/ARB•Beta – blocker•Spironolactone•Hydralazine/Nitrates•Digoxin

•Afterload Reduction•Nitrates/hydralazine•Ace-I/ARB

•Inotropes•Dobutamine•Milrinone

•Same as these quads

Case Ms DN: RHC on patientCase Ms DN: RHC on patient

RHC: CI 1.3, RA 5, PCW 30, SVR 2010 RHC: CI 1.3, RA 5, PCW 30, SVR 2010

Case Ms DN: Answer?Case Ms DN: Answer?

What is best first step? Dobutamine Digoxin Cholyctectomy Hydralazine/nitrates Nipride

What is best first step? Dobutamine Digoxin Cholyctectomy Hydralazine/nitrates Nipride

HFSA GuidelinesHFSA Guidelines

When adjunctive therapy is needed in patients with ADHF, administration of vasodilators should be considered instead of intravenous inotropes (milrinone or dobutamine). (Strength of Evidence 5 C)

When adjunctive therapy is needed in patients with ADHF, administration of vasodilators should be considered instead of intravenous inotropes (milrinone or dobutamine). (Strength of Evidence 5 C)

HFSA Guidelines for our patientHFSA Guidelines for our patient

12.20 Intravenous inotropes (milrinone or dobutamine) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by LV dilation, reduced LVEF, and diminished peripheral perfusion or end-organ dysfunction (low output syndrome), particularly if these patients have marginal systolic blood pressure (! 90 mm Hg), have symptomatic hypotension despite adequate filling pressure, or are unresponsive to, or intolerant of, intravenous vasodilators. (Strength of Evidence 5 C)

12.20 Intravenous inotropes (milrinone or dobutamine) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by LV dilation, reduced LVEF, and diminished peripheral perfusion or end-organ dysfunction (low output syndrome), particularly if these patients have marginal systolic blood pressure (! 90 mm Hg), have symptomatic hypotension despite adequate filling pressure, or are unresponsive to, or intolerant of, intravenous vasodilators. (Strength of Evidence 5 C)

Journal of Cardiac Failure Vol. 16 No. 6 2010

The Failing Heart is more Afterload sensitive than the normal LV

The Failing Heart is more Afterload sensitive than the normal LV

Vasodilators Increase

Stroke Volume BP stays the

same

Vasodilators Increase

Stroke Volume BP stays the

same

Acute Heart Failure and Vasodilators:Do not hold meds if SBP >90!!

Acute Heart Failure and Vasodilators:Do not hold meds if SBP >90!!

By afterload reducing with vasodilators (hydralazine, nitrates, ace-I)

Stroke volume

Blood pressure

By afterload reducing with vasodilators (hydralazine, nitrates, ace-I)

Stroke volume

Blood pressure

What we did: Patient Cold and wetWhat we did: Patient Cold and wet

Afterload reduction (Target SVR) with hydralazine/isosorbide/captopril

Lasix gtt at 5mg/hr

Bp stayed the same/then increased. HR decreased.

Bilirubin normalized, Cr normalized

Afterload reduction (Target SVR) with hydralazine/isosorbide/captopril

Lasix gtt at 5mg/hr

Bp stayed the same/then increased. HR decreased.

Bilirubin normalized, Cr normalized

Case Mr. SWCase Mr. SW

Mr. SW is a 63yo with a PMH of morbid obesity (BMI 50), Sleep apnea, and COPD who presents with SOB and edema. Over 3 mo he has gained 65lbs Vitals: BP 98/62, P 90, O2sat 89% on RA PE: JVD >20cm, CV: irr irr, mildly tachy,

Lungs – mild crackles, abd – ascites, Ext –anasarca – can pit up to mid chest. Feet are warm.

Labs: Cr 2, K 4, Hct 50

What kind of heart failure do you suspect?

Mr. SW is a 63yo with a PMH of morbid obesity (BMI 50), Sleep apnea, and COPD who presents with SOB and edema. Over 3 mo he has gained 65lbs Vitals: BP 98/62, P 90, O2sat 89% on RA PE: JVD >20cm, CV: irr irr, mildly tachy,

Lungs – mild crackles, abd – ascites, Ext –anasarca – can pit up to mid chest. Feet are warm.

Labs: Cr 2, K 4, Hct 50

What kind of heart failure do you suspect?

Case Mr SW: What kind of HF do you suspect?Case Mr SW: What kind of HF do you suspect?

1) Systolic left heart failure

2) Diastolic left heart failure

3) Right heart failure

4) This is not heart failure

1) Systolic left heart failure

2) Diastolic left heart failure

3) Right heart failure

4) This is not heart failure

Pickwickian:Classic RV

Failure

Pickwickian:Classic RV

Failure

Afib

Hypotension

Renal failure

Anasarca

Afib

Hypotension

Renal failure

Anasarca

Case Mr. SW: What treatments would you suggest?Case Mr. SW: What treatments would you suggest?

1) Digoxin or inotropes?

2) Nesiritide

3) Lasix gtt or fluids?

5) Torsemide

6) Spironolactone

7) Isosorbide OR sildenafil

1) Digoxin or inotropes?

2) Nesiritide

3) Lasix gtt or fluids?

5) Torsemide

6) Spironolactone

7) Isosorbide OR sildenafil

What is the most common cause of Right Heart Failure?

What is the most common cause of Right Heart Failure?

Left heart failure Left heart failure

Case Mr SW: Right Heart FailureThe cause is usually pulmonary.Case Mr SW: Right Heart FailureThe cause is usually pulmonary.

Pulmonary HTN work up: PFT V/Q scan for chronic PE’s LE U/s to rule out DVT Non-contrasted Chest CT Sleep study RHC with nitric oxide Echo with bubble

Pulmonary HTN work up: PFT V/Q scan for chronic PE’s LE U/s to rule out DVT Non-contrasted Chest CT Sleep study RHC with nitric oxide Echo with bubble

Case Mr. SWCase Mr. SW

Isolated RV failure TV issue? Carcinoid RV issue? Cardiac MRI

• ARVD

• Can consider RVAD

Isolated RV failure TV issue? Carcinoid RV issue? Cardiac MRI

• ARVD

• Can consider RVAD

RV Failure Treatment Strategies: No DataRV Failure Treatment Strategies: No Data

Reduce RV Afterload

Reduce RV Pressure

Increase RV contractility

Reduce RV Afterload

Reduce RV Pressure

Increase RV contractility

RV failure Treatment Strategies: No DataRV failure Treatment Strategies: No Data

Reduce RV afterload O2 for hypoxia/CPAP Treat underlying causes for pulmonary

hypertension Sildenafil Isosorbide

Reduce RV Pressure Diuretics: Lasix gtt, high dose spiro Ultrafiltration *Careful as they are preload dependent

Reduce RV afterload O2 for hypoxia/CPAP Treat underlying causes for pulmonary

hypertension Sildenafil Isosorbide

Reduce RV Pressure Diuretics: Lasix gtt, high dose spiro Ultrafiltration *Careful as they are preload dependent

RV failure Treatment Strategies: No Data

RV failure Treatment Strategies: No Data

Increase RV contractility Digoxin Milrinone, dobutamine, NE, Dopamine

?Raise BP to help kidneys? Midodrine?

Increase RV contractility Digoxin Milrinone, dobutamine, NE, Dopamine

?Raise BP to help kidneys? Midodrine?

SummarySummary

New mortality reducing treatments in HF Entresto Corlanor

Recognize Stage D heart failure to refer for viable options to increase quality and quantity of life.

Afterload reduce the failing heart to improve perfusion.

RV failure: afterload reduce, reduce RV pressure, RV inotropy.

New mortality reducing treatments in HF Entresto Corlanor

Recognize Stage D heart failure to refer for viable options to increase quality and quantity of life.

Afterload reduce the failing heart to improve perfusion.

RV failure: afterload reduce, reduce RV pressure, RV inotropy.

amos slides - updated for posting - acponline.org · vitals: bp 128/65, p 72 pe: no jvd, minimal le...

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