Current Approaches to Monitoring and Management
of Heart Failure Clyde W. Yancy, MD
Professor of Internal Medicine/CardiologyMedical Director Heart Failure/Heart Transplantation
UT Southwestern Medical Center at DallasDallas, Texas
2
HF, heart failure; LOS, length of stay. Jong P et al. Arch Intern Med. 2002;162:1689-1694.
0
25
50
75
100
20%
50%
30days
6mo
Hospital Readmissions
0
25
50
75
100
12%
50%
30days
12mo
Mortality
33%
5yr
Median hospital LOS: 6 days Annual mortality rate-NYHA Class III HF-12% [COPERNICUS data]NYHA Class II HF-7% [SCD-HeFT data]
Outcomes in Hospitalized Patients With HF
Contemporary Monitoring and Management of Heart Failure
Is there a surrogate marker for decompensation?
4
SBP > 140 mm Hg 1 50%SBP 90 - 140 mm Hg 1 48%SBP < 90 mm Hg 1 2%
Mean heart rate (bpm) 2 90
PCWP (mm Hg) 2 25 - 30
Cardiac index 2 usually preserved
Congestion, Not Low Cardiac Output: Main Finding in Hospitalized Patients
SBP, systolic blood pressure; PCWP, pulmonary capillary wedge pressure.1 Fonarow GC. Rev Cardiovasc Med. 2003;4 (Suppl. 7):S21-S30.2 The VMAC Investigators. JAMA. 2002;287:1531-1540.
5
Change in Weight During HospitalizationAll Enrolled Discharges (n=150,745) October 2001 to December 2004
8% 7%
13%
24%
32%
11%
3% 2%
0
5
10
15
20
25
30
35
En
rolle
d D
isch
arg
es
(%)
20% of ADHF patients discharged with weight
gain or no change in weight
Evidence of Incomplete Relief From Congestion
Note: For the chart, n represents the number of patients who have both baseline and discharge weight, and the percentage is calculated based on the total patients in the corresponding population. Patients without baseline or discharge weight are omitted from the histogram calculations.ADHF, acute decompensated heart failure.
6
Clinical Status at Time of DischargeAll Enrolled Discharges (n=150,745) October 2001 to December 2004
No Mention11%
Asymptomatic44%
No change <1%Not applicable 4%Worse <1%
Improved(but still
symptomatic)40%
Evidence of Incomplete Relief From Congestion
7
DispositionAll Enrolled Discharges (n=150,745) October 2001 to December 2004
Home 62%
Hospice/Long-term Care15%
Home with Additional Care 14%
Deceased 4%Inter-hospital transfer 3%Other/unknown 2%Outpatient care <1%
8
Overall Na<136 BUN>29 Severe Congestion*
6.3
14.5
11.4
7.8
42.2
3.5
0%
10%
20%
N = 319 69 250 140 179 204 115 (21.6%) (78.4%) (44%) (56%) (64%) (36%)
*Edema, dyspnea, and JVD at baseline.JVD, jugular venous distension.Na, sodium, BUN, blood urea nitrogen.Gheorghiade M et al. JAMA. 2004;291:1963-1971.
Na136 BUN29 No Severe Congestion*
Congestion after Initial In-Hospital Therapy Is Associated With Higher 60-day Mortality
60-Day All-cause Mortality
9Lucas C et al. Am Heart J. 2000;140:840
Criteria for congestion: Orthopnea, JVD, wt. gain ≥ 2 lb. in a week, need to increase diuretic dose, leg edema (0-5)
100
80
60
40
20
0
0 6 12 18 24
Months after reassess
Su
rviv
al (
%)
P < 0.001
No congestion (N=80)
1-2 congestion (N=40)
3-5 congestion (N=26)
Reassess at 4-6 weeks
Post-discharge Freedom of Congestion is Associated with Better Prognosis
10
JVD & S3* Predict Hospitalization/Death
*Difficult to assess clinically. JVP, Jugular venous pressure.Drazner MH et al. N Engl J Med. 2001;345:574-581.
Eve
nt
free
su
rviv
al
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 250 500 750 1000 1250 1500
Days
No S3
S3p<0.001
Eve
nt
free
su
rviv
al
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
00 250 500 750 1000 1250 1500
Days
No JVP
JVPp<0.001
Endpoint Elevated JVP S3 Elevated JVP and S3
All-cause mortality 1.15 (0.95 – 1.38) 1.15 (0.99 – 1.33) 1.17 (1.02 – 1.35)
HF hospitalization 1.32 (1.08 – 1.62) 1.42 (1.21 – 1.66) 1.43 (1.23 – 1.66)
11
2005 ACC/AHA Guidelines for the Monitoring and Management of
Chronic Heart Failure
Recommendations for the Initial Clinical Assessment of Patients Presenting with HF:– Class I: Hx & PE, routine labs incuding serum Cr,
BUN; 12-lead ECG; CXR; ECHO; ? L heart catheterization
– if angina
– Class IIa: ? Cath; ? VO2 max; BNP measurement
– Class IIb: non-invasive imaging
– Class III: biospy, measurement of neurohormones
HF, heart failure; Hx, history; PE, physical exam; Cr, creatinine; BUN, blood urea nitrogen; ECG, electrocardiogram; ECHO, echocardiogram; VO2, oxygen uptake; BNP, B-type natriuretic peptide.Circulation. 2005;112:1825-1852.
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2005 ACC/AHA Guidelines for the Monitoring and Management of
Chronic Heart Failure
Recommendations for Serial Clinical Assessment of Patients Presenting with HF– Class I: functional class; “volume status & weight”
– Class IIa: ? serial measurement of LVEF and remodeling
– Class IIb: ? Serial BNP measurement
HF, heart failure; LVEF, left ventricular ejection fraction; BNP, B-type natriuretic peptide.Circulation. 2005;112:1825-1852.
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Recommendations for Self-Management
2000 mg sodium diet
Daily weights
Exercise, sexual activity, energy conservation
Medication compliance
Symptom management
Smoking cessation
Limited ETOH consumption
ETOH, alcohol.
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Home Daily Weights
The vascular bed can hold 10 pounds of fluid before it starts to seep out into the tissues
2 pounds = 1 quart of water extra in the circulation (use patient’s water pitcher as a visual aide)
Usual recommendation:– Report a 2- to 3-pound weight gain
overnight or a 5-pound gain in 1 week
15
Goldberg LR, et al. Am Heart J. 2003;146(4):705-712.
Results of RCT Using Home Monitor
280 patients from 16 US centers– 138 received home monitors, 162 standard care
Similar baseline characteristics– Medications, LVEF, 6MWT, creatinine, QOL– 98.5% compliance
No difference between groups in:– Time to death or first hospitalization– Time to first ED visit or total ED visits– Total hospitalizations or CV hospitalizations
Difference in mortality rates– 18.6% control vs 8.0% in ALERE group (p<0.003)– Survival rates began to separate at 30 days
RCT, randomized controlled trial; LVEF, left ventricular ejection fraction; 6MWT, 6-minute walk test; QOL, quality of life; ED, emergency department; CV, cardiovascular.
Biomarker Monitoring and Management of Heart Failure
17
Potential Uses for Plasma BNP Test
Rule out false positives for HF
Measure severity of LV compromise
Quantify functional class
Estimate prognosis and predict future cardiac events
Evaluate efficacy of HF therapy
BNP, B-type natriuretic peptide; HF, heart failure; LV, left ventricular.Maisel AS et al. N Engl J Med. 2002;347:161-167.
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BN
P C
on
cen
trat
ion
(p
g/m
L)
186 ± 22
791 ± 165
2013 ± 266
HF Severity
Mild(n = 27)
Moderate(n = 34)
Severe(n = 36)
0
500
1000
1500
2000
2500
BNP, B-type natriuretic peptide; HF, heart failure.Dao Q, et al. J Am Coll Cardiol. 2001;37:379-385.
BNP Concentration and Degree of HF Severity
19
CHF, congestive heart failure, ECG, electrocardiogram; BNP, B-type natriuretic peptide; Adapted from Maisel A. Rev Cardiovasc Med. 2002;3(suppl 4):S10–S17.
Patient with dyspnea or other CHF signs/symptoms
History/physicalexam/ECG/chest x-ray
Diagnostic for CHF
Acute/chronicCHF
management(echocardiography, if not
done previously)
Nondiagnostic
PositiveBNP blood test
Negative
Evaluate for non-CHF etiologies(echocardiography usually not indicated)
Heart Failure Diagnostic Algorithm
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Death or Rehospitalization Rates According to Discharge
B-type Natriuretic Peptide (BNP)
Logeart D, et al. J Am Coll Cardiol. 2004;43(4):635-641.
Follow-up (Days)
Dea
th o
r R
ead
mis
sio
n (
%)
100
75
50
25
0
0 30 60 90 120 150 180
Predischarge BNP >700 ng/Ln=41, events=38
Predischarge BNP 350-700 ng/Ln=50, events=30
Predischarge BNP <350 ng/Ln=111, events=18
P<0.0001
15.2
5.1
1
P<0.0001
Hazard Ratios of 2nd and 3rd vs 1st
BNP Range
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Combination of B-type Natriuretic Peptide (BNP) and Troponin-I (TnI) Levels in
Patients With Heart Failure
RR, relative risk.Tnl-, Tnl <0.0 ng.mL; Tnl+, Tnl ≥0.04 ng/mL; BNP-, BNP <485 pg/mL; BNP+, BNP >485 pg/mL.
P trend=0.004 RR=12.3
RR=4.7
RR=2.1
RR=1.0
n=34 n=17 n=22 n=23
Mo
rtal
ity
(%)
50
45
40
35
30
25
20
15
10
5
0BNP- Tnl- BNP- Tnl+ BNP+ Tnl- BNP+ Tnl+
22
1Loke I, et al. Eur J Heart Fail. 2003;5:599-606. 2Wiviott SD, et al. Clin Chim Acta. 2004;346:119-128. 3Suzuki S, et al. Circulation. 2004;110:1387-1391.4Schwam E. Acad Emerg Med. 2004;11:686-691.
Other Causes of Elevated BNP Levels
Age1
Female gender1
ACS2
MI3
Renal failure4
Right-sided HF4
– Cor pulmonale: 200–500 pg/mL
– Primary pulmonary HTN: 300–500 pg/mL
– Acute pulmonary embolism:150–500 pg/mL
MI, myocardial infarction; HF, heart failure; HTN, hypertension.
Thoracic Bioimpedance Monitoring and Management
of Heart Failure
24
Current Transmitted Through Chest
Current Seeks Path of Least Resistance: Blood-Filled Aorta
ICG Measures Baseline Impedance (Resistance) to Current
With Each Heartbeat, Blood Volume and Velocity in the Aorta Change
ICG Measures Corresponding Change in Impedance
ICG Uses the Baseline and Changes in Impedance to Measure and Calculate Hemodynamic Parameters
Impedance Cardiography (ICG) Method
25
Aortic Blood Flow Changes Impedance
Aorta Impedance Waveform (inverse)
Pressure Volume Impedance
26
ICG Parameters
Measured parameters
– Thoracic fluid content (TFC)
– Acceleration index (ACI)
– Velocity index (VI)
– Pre-ejection period (PEP)
– LV ejection time (LVET)
– Heart rate (HR)
Calculated parameters – Stroke volume/index
(SV/SI)– Cardiac output/index
(CO/CI)– Systemic vascular
resistance/index (SVR/SVRI)
– Systolic time ratio (STR)– Left cardiac work/index
(LCW/LCWI)
ICG, impedance cardiography.
Invasive Hemodynamic Monitoring and Management
of Heart Failure
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PCWP, pulmonary capillary wedge pressure, CI, cardiac index; SVR, systemic vascular resistance.Adapted from Fonarow GC. Rev Cardiovasc Med. 2001;2(suppl 2):S7
Congestion at Rest
LowPerfusion
at Rest
YesNoWarm & Dry
PCWP normal CI normal
(compensated)RARE
Cold & WetPCWP elevated
CI decreasedMOST PATIENTS
Cold & DryPCWP low/normal
CI decreasedRARE
Normal SVR High SVR
No
Yes
Warm & WetPCWP elevated
CI normal FAIRLY COMMON
Patient Selection and Treatment
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Goals for HF-Tailored Therapy
Hemodynamic
– SBP 80 mm Hg
– PCWP <15 mm Hg
– RAP <8 mm Hg
– SVR <1200 dyne•s•cm-5
Clinical
– SBP 80 mm Hg
– No orthopnea
– No peripheral edema
– No hepatomegaly/ascites
– JVP <8 cm
– Warm extremities
SBP, systolic blood pressure; PCWP, pulmonary capillary wedge pressure, RAP, right atrial pressure; SVR, systemic vascular resistance; JVP, jugular venous pressure.
30
The Swan-Ganz Catheter Invasive hemodynamic monitoring
ICU stay
Patient supine and inactive
Not practical for ambulatory monitoring of HF patients
ICU, intensive care unit; HF, heart failure.
31
Impact of Therapy Guided by Pulmonary Artery Catheterization During
the Course of Hospitalization*
Hemodynamic Measurement Baseline Final†
Right atrial pressure, mm Hg 14 (10) 10 (7)
Pulmonary capillary wedge pressure, mm Hg 25 (9) 17 (7)
Cardiac index, L/min/m2 1.9 (0.6) 2.5 (0.7)
Cardiac output, L/min 3.8 (1.2) 4.8 (2.1)
Systemic vascular resistance, dynes x sec/cm5
1500 (800) 1100 (500)
*Data are expressed as mean (SD).†P<0.001 for all variables. The final hemodynamics are those measured just before removal of the pulmonary artery catheter, which occurred at a median of 1.9 days after insertion.The ESCAPE Investigators and ESCAPE Study Coordinators*, JAMA. 2005;294:1625-1633.
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Primary Outcomes: Mortality and Hospitalizations
MeasurePAC
Group
Clinical Assessment
Group
Endpoint Estimate (95% CI)* 2
P Value
Days alive out of hospital, mean LVADs/transplants coded dead
133 135 Hazard ratio,1.00 (0.82-1.21)
0.00 .99
LVAD/transplants coded well 141 143 Hazard ratio,0.99 (0.92-1.21)
0.00 .95
Mortality (dead at 180 d), No. 43 38 Odds ratio,1.26 (0.78-2.03)
0.86 .35
Total days initial hospitalization, mean
8.7 8.3 Hazard ratio,1.04 (0.86-1.27)
0.18 .67
PAC-related deaths, No. 0 0 NA NA NA
Early deaths (in-hospital plus 30 d), No.
10 11 Odds ratio,0.97 (0.38-2.22)
0.04 .97
*Values less tan 1 favor PAC.CI, confidence interval; LVAD, left ventricular assist device; NA, not applicable; PAC, pulmonary artery catheter.The ESCAPE Investigators and ESCAPE Study Coordinators*. JAMA. 2005;294:1625-1633.
Predictive Variables in the Monitoring and Management
of Heart Failure
34
ADHERE® CART: Predictors of Mortality
SYS BP 115n=24,933
SYS BP 115n=24,933
SYS BP 115n=7,150
SYS BP 115n=7,150
6.41%n=5,1026.41%
n=5,10215.28%N=2,04815.28%N=2,048
21.94%n=620
21.94%n=620
12.42%n=1,42512.42%n=1,425
5.49%n=4,0995.49%
n=4,0992.14%
n=20,8342.14%
n=20,834
BUN 43N=33,324
BUN 43N=33,324
Greater thanLess than
2.68%n=25,122
2.68%n=25,122
8.98%n=7,2028.98%
n=7,202
Cr 2.752,045
Cr 2.752,045
Highest to lowest risk cohortOR 12.9 (95% CI 10.4-15.9)
BUN, blood urea nitrogen; SYS BP, systolic blood pressure; Cr, creatinine; OR, odds ratio.Fonarow GC, et al. JAMA. 2005;293:572-580.
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* Still investigational.
Interventions to Relieve Congestion
Sodium restriction
Fluid restriction
Loop diuretics
Thiazide diuretics
Metolazone
Vasopressin antagonists*
Ultrafiltration/dialysis*
36
Remaining Questions
What are the best methods of monitoring chronic ambulatory heart failure?
How is congestion best identified and/or anticipated in chronic HF?
Is it possible to interrupt episodes of impending decompensation prior to hospitalization?
What is the cost-efficacy of intensive monitoring?
37
Contemporary Monitoring and Management of Heart Failure
SUMMARY
Congestion predicts poor outcomes in heart failure
Clinical signs/symptoms, biomarkers, thoracic bioimpedance, and invasive hemodynamics have shortcomings
No strategy for effective monitoring other than clinical assessment is currently recommended in national guidelines
