Juan M. Aranda, Jr., MD, FACC, FHFSAProfessor of Medicine
Director of Heart Failure and Cardiac TransplantationUniversity of Florida College of Medicine
Heart Failure Guidelines For your Daily Practice
Heart Failure in Latin America
• Latin American countries experiencing a large-scale epidemic of heart failure risk factors
• Patients admitted to public hospitals (younger, more illiterate, noncompliance before admission, less BB, ACE inhibitor use, ↑ length of stay, ↑ mortality) compared to private hospitals
(Lack of Access) jj
• Heart failure with preserved ejection fraction (HFpEF) accounts for 20 to 45% of hospitalized patients with decompensated HF
• No substantial financial support for development of clinical trials specific for Latin American countries
J Am Coll Cardiol 2013; 62:949-58 and Am J Cardiol 2011; 108:1289-96.
The Reality of Heart Failure in Latin America
Bocchi, EA, et al. J Am Coll Cardiol 2013; 62:949-958.
Characteristics of Patients with HFpEF and Patients with HFrEF
+ = occasionally associated with++ = often associated with+++ = usually associated with0 = not associated with
Jessup M and Brozena S,N Engl J Med 2003;348:2007-2018.
Ponikowski P. Eur Heart J. 2016;37:2129-200
CR
ITER
IA
1Symptoms ±
SignsSymptoms ±
SignsSymptoms ±
Signs
2 LVEF < 40% LVEF 40-49% LVEF ≥ 50%
3 ---
• BNP ↑• At least one additional
criterion:1. Relevant structural heart
disease (LVH/LAE)2. Diastolic dysfunction
Pathophysiology of HFpEF
Borlaug B. Circ J. 2014;78:20-32
Kaplan-Meier Plots of Two Components of the Primary Outcome: Time to Confirmed Death of Cardiovascular Causes
and Time to the First Confirmed Hospitalization for Heart Failure (TOPCAT)
Pitt B, et al. New Engl J Med 2014; 370:1838-1892.
Placebo
TOPCAT: Exploratory Post-hoc AnalysisPlacebo vs Spironolactone by Geographic Region
HR = 0.82 (0.69-0.98)
HR = 1.10 (0.79-1.51)
Interaction P = 0.122
US, Canada, Argentina, Brazil
Russia, Rep GeorgiaPlacebo
Spironolactone
Spironolactione
Pfeffer MA et al. Circulation. 2015;131:34-42.
de Denus S, et al. N Engl J Med 2017; 376:1690-1692.
Recommendations for Stage C HFpEF
Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.
ARBs, Nitrates, Phosphodiesterase-5, and NutritionalSupplements in Patients with HFpEF
Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.
If you had to have heart failure, would you rather have:
Systolic Heart Failure?
Heart Failure with Preserved EF
OR
Clinical Course of Systolic Heart Failure
JACC HF 2013, 1-20. Circulation 2012, 125:1928-1952
Latin America: 1 million HF hospitalization, LOS 4 to 10 days
Classification of Patients Presenting with Acutely Decompensated Heart Failure
Yancy CW, et al. Circulation 2013; 128:1810-1852.
Inpatient mortality from ADHERE Registry Based on admission BUN, creatinine and BP
Analysis of patients in the National Acute Decompensated Heart Failure National Registry (ADHERE)BUN=blood urea nitrogen, Cr=serum creatinine, SBP-systolic blood pressureFonarow GC et al. J Cardiac Fail 2003;9(suppl 1):S79.
≥
≥
BUN 43(n=32220)
≥
≥
8.35%(n=67640)
SBP 115(n=6697)
15.30%(n-1863)
5.63%(n-4834)
Cr 2.75(n-1862)
13.23%(n-1270)
19.76%(n-592)
2.88%(n=24469)
SBP 115(n=2,702)
5.67%(n=3882)
2.31%(n=20820)
<
<
<
Initial Management of a Patient with Acute Heart Failure
Pinikowski P, et al. Eur J Heart Fail 2016; 18:891-975.
Factors Triggering Acute Heart Failure
Ponikowski P, et al. Eur Heart J 2016; 37:2129-2200.
Recommendations for Therapies in the Hospitalized HF Patient
Yancy CW, et al. Circulation 2013; 128:1810-1852.
Typical 6-Day HF Journey
Day 1Day 2 Day 5
Day 6
Admission Most of day in
ER Diuretic
regimen not established until evening
Diuresis begins
Patient feels better Wants to go
home
Discharge Patient
converted to PO meds Feels better Still volume
overloaded
Pulmonary and systemic congestion
Background: Congestion and Symptoms in Heart Failure
Abnormal LV function
Increased filling pressures
SYMPTOMS
(Most discharged HF patients)
Heart Failure Admission
*
The abnormal systolic and/or diastolic function lead to increased left ventricular diastolic pressure (LVDP) and impaired volume regulation. These may be further aggravated by progressive activation of neurohormonal systems (such as Sympathetic Nervous System (SNS), Renin-Angiotensin-Aldosterone System (RAAS), and vasopressin (VPA)).
The increased blood volume and increased LVDP, often aggravated by mitral regurgitation (MR), will translate into backward failure and increased PCWP. The increased PCWP lead to increased pulmonary artery (PA) pressure, increased right ventricular (RV) and atrial (RA) pressures, tricuspid regurgitation (TR) and, finally, development of the systemic signs and symptoms of congestion (jugular venous distension (JVD), hepatomegaly, leg edema).
Alternatively, depending on several factors, such as the hydrostatic pressure of the pulmonary capillaries, the plasma oncotic pressure, the permeability and integrity of the alveolar-capillary membrane, as well on the lymphatic drainage of the lungs, the increased PCWP will lead to redistribution of the excess fluid in the pulmonary vascular bed, interstitial edema, and alveolar edema. The fluid redistribution may be evident on the chest x-ray (CXR) as redistribution of pulmonary vessels, hilar engorgement and, sometimes, pulmonary edema.
All this processes, together with abnormalities in lung function and respiratory muscle dysfunction, contribute to the development of dyspnea in heart failure patients. Increased right ventricular (RV) and atrial (RA) pressures follow, leading to tricuspid regurgitation(TR) and, finally, development of the systemic signs and symptoms of congestion (jugular venous distension, hepatomegaly, leg edema).
The iceberg represents the build-up of congestion, and its tip represents its clinical manifestations. Unfortunately, these manifestations (symptoms and signs) are present late even though the PCWP has been elevated for several days or weeks; moreover even when present, they are often difficult to assess.
High CVP ≅ Elevated Creatinine
Proposed Pathophysiology of Renal Venous Hypertension (Backward flow)
Ross EA. J Cardiac Failure 2012;18:930-938.
Diuretics to increasesodium loss and decreasevenous pressures
Concept of Plasma Refill Rate in ADHF
Redefining the Therapeutic Objective in Decompensated Heart Failure: Hemoconcentration as a Surrogate for Plasma Refill Rate Boyle and Sbotka J Card Failure May 2006
↓ Intravascular volume↓ Hydrostatic pressure declinesInterstitial pressure + serum
oncotic pressure exceeds luminal hydrostatic pressure
↓Fluid is
reabsorbed
Recommendations for Hospital Discharge
Yancy CW, et al. Circulation 2013; 128:1810-1852.
Components of Early Post-Discharge Follow-Up
Gheorghiade, et al. J Am Col Cardiol 2013;391-403.
2017 ACC/AHA/HFSA Focused Update Biomarkers: Recommendationsfor Prognosis
Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.
Selected Potential Causes of Elevated Natriuretic Peptide Levels
Yancey CW, et al. J Am Coll Cardiol 2017; 70:776-803.
Changes in BNP Levels and Pulmonary Artery Wedge Pressure During 1st 24 Hours of Treatment
Kazanegra, et al. J Cardiac Fail;2001:7:21-9.
Anemia Recommendations
Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.
Sleep Disordered Breathing
Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.
Clinical Course of systolic Heart Failure
JACC HF 2013, 1-20. Circulation 2012, 125:1928-1952
Latin America: 1 million HF hospitalization, LOS 4 to 10 days
Treatment of HFrEF Stage C and D
Yancey CW, et al. J Am Coll Cardiol 2017; 70:776-803.
CRT Responders (EF 150 msec, LBBB sinus, NYHA 2, 3, 4
• QRS >150 msec, non LBBB, sinus, NYHA 3, 4, OR• QRS 120 to 149, LBBB, NHYA 2, 3, 4, OR• RV Pacing >40%
• QRS >150 msec, no LBBB, sinus, NYHA 2, OR• QRS 120 to 149, no LBBB, sinus, NYHA 3,
Ambulatory Class V
• QRS
Stevenson et al. Journal of Cardiac Failure, August 2006.
Prognostic Importance of Defibrillator Shocks in Patients with Heart Failure (SCD-HeFT)
Poole JE, et al. N Engl J Med 2008;359:1009-17.
6.2 Nonischemic Cardiomyopathy
Al-Khatib SM, et al. Circulation 2017; epub ahead of print.
All-Cause Mortality After Each Subsequent Hospitalization for HF
Setoguchi S, et al. Am Heart J 2007;154:260-266.
Dunlay, S. M. et al. J Am Coll Cardiol 2009;54:1695-1702
Multivariable Predictors of Hospitalization After HF Diagnosis
28% reduction in HF hospitalizations
20% reduction in CV death, HF hospitalizations
26% reduction in HF hospitalizations
Meta-Analysis of Remote Patient Monitoring
Klersy, et al. JACC 2009;1683-94.
Adamson PB et al. J Am Coll Cardiol. 2003; 41: 565
Congestion Precedes Hospitalization
Clinical Course of Systolic Heart Failure
JACC HF 2013, 1-20. Circulation 2012, 125:1928-1952
Latin America: 1 million HF hospitalization, LOS 4 to 10 days
2017 ACC Expert Consensus Decision PathwayReferral to Advanced Heart Failure Specialist
I NEED HELPI IV inotropesN NYHA IIIB/IV or ↑BNPE End organ dysfunctionE EF 1E Edema despite escalating diureticL Low BP, high HRP Prognostic medication – downtitration of GDMT
Yancey, et al. J Am Coll Cardiol 2017; 71:201-230.
Successful 2018 Treatment of Congestive Heart Failure = Complex Multidisciplinary Management Strategy
CHFPatient
HFEducation
DietCardiac
Rehabilitation
Compliance
Home Telemonitoring
Systems Cardiac Devices
AICDCRT
MedicationsARNI
ivabradineRAAS blockersBeta blocker
Diureticsaldosterone
blockerDigoxin
Heart FailureClinics
Less ER visits,Less hospitalizations, Better quality of life
Treatment Algorithm for GDMT Including Novel Therapies
Yancey CW, et al. J Am Coll Cardiol 2018; 71:201-230.
ACE/ARB and BB with Diuretic as Needed
HFrEF
Slide Number 1Slide Number 2Heart Failure in Latin AmericaThe Reality of Heart Failure in Latin AmericaSlide Number 5Characteristics of Patients with HFpEF and Patients with HFrEFSlide Number 7Slide Number 8Kaplan-Meier Plots of Two Components of the Primary Outcome: Time to Confirmed Death of Cardiovascular Causes and Time to the First Confirmed Hospitalization for Heart Failure (TOPCAT)Slide Number 10Slide Number 11Slide Number 12Slide Number 13If you had to have heart failure, would you rather have:Clinical Course of Systolic Heart FailureClassification of Patients Presenting with Acutely Decompensated Heart FailureSlide Number 17Initial Management of a Patient with Acute Heart FailureFactors Triggering Acute Heart FailureRecommendations for Therapies in the Hospitalized HF PatientTypical 6-Day HF JourneySlide Number 22High CVP Elevated CreatinineProposed Pathophysiology of Renal Venous Hypertension (Backward flow)Slide Number 25Recommendations for Hospital DischargeComponents of Early Post-Discharge Follow-UpSlide Number 28Selected Potential Causes of Elevated Natriuretic Peptide LevelsChanges in BNP Levels and Pulmonary Artery Wedge Pressure During 1st 24 Hours of TreatmentSlide Number 31Slide Number 32Clinical Course of systolic Heart FailureTreatment of HFrEF Stage C and DCRT Responders (EF
