Update in heart failure

management
Dr Brian Gordon
Consultant Cardiologist
 What not to expect
• Defining/diagnosing heart failure

• Trial evidence base for heart failure

• Acute heart failure

• HF-PEF

• Advanced heart failure options

 The
evidence

The real Heart failure The

world management individual

The
guidelines
 9.6%

In-hospital 6.4% 29.6% ~45%

mortality rate

HOSPITAL
30-day 1-year 5-year
mortality* mortality mortality

30 1 5
days year year
Hospitalisation Discharge

* in the 36721 patients who survive to discharge

 An individual case in the real
world- it starts in 2004
• Male, age 46

• Anterolateral STEMI- thrombolysis, no revasc

• ECG- anterior q waves

• Echo- significant LV dysfunction

• Asymptomatic, BP104/70, HR 100 (SR)

 What should he be on for his
asymptomatic LV dysfunction post MI?

1. ACE inhibitor

2. ACE inhibitor and Bblocker

3. ACE inhibitor, Bblocker and aldosterone blocker

Guidelines in the real world- constantly changing
• NICE chronic heart failure guide 2010

• NICE chronic heart failure standards 2011

• ESC acute and chronic heart failure guideline 2012

• ACC/AHA heart failure guideline 2013

• NICE acute heart failure guide 2014

• NICE acute heart failure standards 2015

• ESC acute and chronic heart failure guideline 2016

• ACC/AHA heart failure update 2017

• (NICE chronic heart failure update expected 2018)

 What should he be on for his
asymptomatic LV dysfunction post MI?

1. ACE inhibitor

2. ACE inhibitor and Bblocker ✔

3. ACE inhibitor, Bblocker and aldosterone blocker

 Fast forward to 2012
• Referred to heart failure clinic with NYHA class 2
symptoms (dyspnoea on 2 flights stairs), no
angina

• Heart rate 108/min, ankle oedema

• Echo- EF 20%, EDD6.4cm

• ECG- AF, QRS 120msec

• Previous intolerance to carvedilol

7
“We should avoid all reducing
measures; we must endeavour
to improve the condition of the
blood and, by stimulants and
tonics, increase the power of
the weakened muscular fibres. I
allude to the beneficial action
of mercury in relieving many of
the symptoms and removing the
consequences of this disease”
William Stokes 1853

13
 What should he now have for his
symptomatic LV impairment?
1. ACE inhibitor and aldosterone blocker

2. ACE inhibitor, Bblocker and aldosterone blocker

3. ACE inhibitor, Bblocker, aldosterone blocker and

ICD

4. ACE inhibitor, Bblocker, aldosterone blocker and

CRTD
Pathology

• Initial insult
• Biological system activation
• Electromechanical uncoupling
• Metabolic inefficiency
• Molecular abnormalities
• Structural remodelling
Devices in heart failure
Devices: biventricular pacing
Devices: implantable cardioverter defibrillator
DRUG Mortality RRR Hospital NNT Comment
(%) RRR (%)
CONSENSUS 1987
ACEi 16-27 26 7-22 over 41m (d)
SOLVD 1991
CIBIS-2 1999
Bblocker 34 28-36 14-23 over 12m (d) COPERNICUS 2001
MERIT-HF 1999
30 35 9 over 2 years (d) RALES 1999
MRA
24 42 33 over 21m (d) EMPHASIS-HF 2011
Ivabradine - 26 24 over 23 m (c) SHIFT 2010

ARB - 23 14 over 34m (h) CHARM-ALT 2003

Hydralizine/
43 33 25 over 10m A-HEFT 2004
ISDN
24-36 52 6 over 29m (c) CARE HF 2005
CRT 25 32 14 over 40m (c) RAFT 2010
- 41 12 over 28m (c) MADIT CRT 2009

ICD 23 - 14 over 45m (d) SCD-HEFT 2005

Sacubitril/Valsart PARADIGM 2014

16* 21* 21 over 27m (c)
an *compared to enalapril
21
Guidelines

2016
 NICE CRT/ICD guidance 2014*

* in conjunction with medical therapy from 2010 guidance

 What should he now have for his
symptomatic LV impairment?

1. ACE inhibitor and aldosterone blocker

2. ACE inhibitor, Bblocker and aldosterone blocker

3. ACE inhibitor, Bblocker, aldosterone blocker and ICD ✔

4. ACE inhibitor, Bblocker, aldosterone blocker and CRTD

 2013-2015
• Symptoms variable NYHA 2-3; can do 9 holes
golf, continues to work, general deconditioning

• Acute heart failure admission

• Fluctuating eGFR 38-50

• Ramipril 5, bisoprolol 7.5, eplerenone 25

• QRS now 146msec

• BP 95/58 - 109/71
 What now?
1. Persist with current regime- titrate as able

2. Sacubitril/Valsartan

3. Upgrade ICD to CRTD

4. Heart failure nurse and cardiac rehab

5. Refer for transplant assessment

A practical note- underuse and under dosing is a problem
 NICE CRT/ICD guidance 2014*

* in conjunction with medical therapy from 2010 guidance

Acute heart failure 2015
Chronic heart failure update 2016
 What now?
1. Persist with current regime- titrate as able ✔

2. Entresto ?

3. Upgrade ICD to CRTD ?

4. Heart failure nurse and cardiac rehab ✔

5. Refer for transplant assessment

 2016
• NYHA 3, 100m exercise tolerance, stopped playing golf,
reduced hours at work

• Low mood

• 1 further acute heart failure admission

• Ramipril 5, bisoprolol 5, eplerenone 25 alternate days

• BP101/70, HR71/min AF

• QRS 163 msec

 What now?
1. Sacubitril/Valsartan

2. Upgrade CRTD

3. Antidepressant

4. 1, 2 and 3

5. Refer for transplant assessment

37
ARR 4.7%
 NICE CRT/ICD guidance 2014*

* in conjunction with medical therapy from 2010 guidance

Management of comorbidity is very important

• Anaemia • Angina
• Cachexia • Hypertension
• Depression • COPD
• Arrhythmia • Diabetes
• Gout • Obesity
• Iron deficiency • Erectile dysfunction
• Renal dysfunction • Silent ischaemia
• Sleep disturbance • Perioperative
• Pregnancy • Drugs
• Infection • Non compliance
 What now?
1. Sacubitril/Valsartan

2. Upgrade CRTD

3. Antidepressant

4. 1,2 and 3 ✔

5. Refer for transplant assessment

 2017
• Now age 59, NYHA 3, NTProBNP >3000

• Ramipril 5, bisoprolol 7.5, bumetanide 2 +1alt days,

metolazone 2.5 once/week

• Admitted Feb with decompensated heart failure, acute kidney

and liver injury- ICU for temporary inotrope support

• Admitted March with aborted OOH cardiac arrest- ICD shows

VT with rate below programmed VF zone, wife gives CPR

• Medications all halted due to hypotension and organ failure

ESC HF guideline 2008
 What now?

1. Reprogram ICD and refer for transplant

assessment

2. Switch off ICD and refer for palliative care

1. Diagnosis and initiation of therapy
2. Response to therapy and stability
3. Period of decompensation
4. Refractory heart failure
5. End of life JACC 2009;54:386-396
Clinical indicators that should prompt transplant referral
consideration
 What now?

1. Reprogram ICD and refer for transplant

assessment ✔

2. Switch off ICD and refer for palliative care

Guidelines

2016
 Summary
• Heart failure is a major health concern in terms of NHS resource and
patient outcome

• The key disease modifying drug treatments are ACE inhibitor, B-

blocker and Mineralocorticoid inhibitor

• Device therapy should be used when appropriate

• Specialist nurse input, cardiac rehab, comorbidity management and

regular follow up are all key interventions

• Guidelines and standards are helpful in terms of achieving best and

equitable care

• All physicians should be confident to initiate appropriate treatment and

know the local pathway for titration of drugs, selection for device
therapy, continuing review and referral for advanced treatments