Heart Failure
A to D
Garrie J. Haas, M.D.
Heart Failure and Cardiac Transplant Program
Division of Cardiovascular Medicine
The Ohio State University
Heart Failure Epidemiology
5.8 million persons in U.S. have HF
> 550,000 diagnoses each year
15 million office visits
Annual number of hospitalizations
> 1 million with primary HF diagnosis
> 3 million primary or secondary diagnosis
Re-hospitalization rates post discharge
25% at one month
50% at 6 months
Estimated direct / indirect cost of HF in U.S.
AHA Heart Disease and Stroke Statistics 2010
Heart Failure Incidence
Similar trends over past several
years
Increased in Men, Blacks, Elderly,
CAD, HTN
Highest in Black Males, lowest in
White Females
Heart Failure:
Prevalence by Stage and Class
Death
CHF
Patients
5MM USNYHA
Class 1
1.75 MM
NYHA
Class 2
1.75MM
NYHA
Class 3
1.25MMNYHA
Class 4
.25MM
Based upon US prevalence of 5MM
Remodeling Progression / Worsening of Cardiac Function
AHA/ACC STAGE CSTAGE B
STAGE D
Stage B - ALVD
One half the mortality rate of those
with symptoms
Risk of death 5-8 x higher than
normal age-matched population.
The transition from Stage B to Stage C heart failure is
associated with in increase in the risk of death by a
factor of 5 **
Ammar et al. Circulation 2007.
Established and Possible Risk
Factors for Heart Failure
Over 100 Risks
identified
Varying degrees of
‘independent’
association
Clinically relevant
VS. Esoteric
Schocken D. Circulation 2008; 117: 2544
Key Messages
From JNC-7
Estimated that 28%
unaware of HTN
39% of those aware are
not on medication
65% treated are not
Controlled
42 million in U.S. with
uncontrolled HTN
Diuretic
Digoxin
Diuretic
Digoxin
ACEI
Diuretic
Digoxin
ACEI
Diuretic
Digoxin
ACEI
-blocker
Diuretic
Digoxin
ACEI
-blocker
Diuretic
Digoxin
ACEI
-blocker
ARB
SOLVD-T (1991)
RRR 21%
CIBIS-2 (1999)
RRR 33%
CHARM-Added (2003)
(-blocker subgroup)
RRR 30%
Improving Survival in CHF
One-Year Mortality
0
5
10
15
20
Perc
en
t (
%)
Hospitalization: The Predominant Contributor to
HF Costs 38.1 billion (5.4% of healthcare)
60.6%
Inpatient care
38.6%
Outpatient care
(3.4 visits/year
/patient)
0.7%
Transplants
$270 million
(O’Connell JB et al. J Heart Lung Transplant. 1994;13:S107-S112)
23.1
billion
14.7
billion
Mortality Rates After First Hospitalization for HF
Jong et al. Arch Intern Med. 2002;162:1689-1694.
Age- and Sex-Stratified Case-Fatality Rates 30 Days and 1 Year
After First Hospitalization for HF
Men Women
Mortality, % Mortality, %
Age Group, y No. of Patients 30-Day 1-Year No. of Patients 30-Day 1-Year
20-49
50-64
65-74
≥75
All Ages
655
3048
5923
9310
18,936
4.6
5.5
8.6
15.6
11.4
15.0
20.5
28.8
43.1
34.0
375
1892
4412
13,087
19,766
4.3
5.4
6.8
14.7
11.8
10.9
19.5
23.0
37.9
32.3
Hospitalization for Heart Failure: Symptoms at Rest or
Minimal Exertion
At Rest or with Minimal
Activity
Orthopnea/PND/cough
Resting or immediate
dyspnea
Anorexia, abd. symptoms
Edema
Fatigue
Trouble concentrating
Elevated Filling Pressures Low CO
Left
Due to above symptoms
Due to above symptoms
Right
±
±
90 % in
ADHERE
35% in
ADHERE
66 % in
ADHERE
Courtesy of Dr. Lynne W. Stevenson
Over 90% of All Hospitalizations for
Acutely Decompensated Heart Failure Are
Due to Fluid Overload1
The Majority of These Patients Have
Failed Treatment With Oral Diuretics2
1. Aronson. ACC. 2000.
2. Adams et al. Am Heart J. 2005;149:209-216.
Most Common Intravenous Medications
0
10
20
30
40
50
60
70
80
90
100
Patients
(%
)
IV Diuretic Dobutamine Dopamine Milrinone Nesiritide Nitroglycerin Nitroprusside
IV Vasoactive Meds
88%
6% 6%10%
3% 1%
10%
ADHERE® Registry. Benchmark Report. 2004.
All Enrolled Discharges (n=105,388) October 2001–January 2004
Inadequate Diuresis During ADHF Treatment
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.
ADHERE® Database
All Enrolled Discharges in Over 12 Months (01.01.2003–12.31.2003)
Who Were Discharged Home (including home with additional and/or outpatient care)
The Nationn=26,757, 68%
Change in Weight From Admission to Discharge
7% 6%
13%
24%
30%
15%
3% 2%
0
10
20
30
40
50
Enro
lled D
ischarg
es (
%)
(<-20) (-20 to -15) (-15 to -10) (-10 to -5) (-5 to 0) (0 to 5) (5 to 10) (>10)
Change in Weight (lb)
Increased Morbidity
and Mortality
Diuretic Therapy
Impaired Renal
Function Decreased Renal
Perfusion
Development
of Diuretic and
Natriuretic
Resistance Diminished
Blood Flow
Neurohormonal
Activation
The Cardiorenal Syndrome of HF
ADHERE® CART: Predictors of Mortality
SYS BP 115n=24,933
SYS BP 115n=7150
6.41%
n=5102
15.28%
N=2048
21.94%
n=62012.42%
n=1425
5.49%
n=4099
2.14%
n=20,834
BUN 43N=33,324
Greater thanLess than
2.68%
n=25,122
8.98%
n=7202
Cr 2.752045
Highest to Lowest Risk Cohort
OR 12.9 (95% CI 10.4–15.9)
Fonarow GC et al. JAMA. 2005;293:572-580.
Jaske B. J Card Fail. 2003;9:227-231.
Ultrafiltration for Acute Heart Failure
Removal of excess volume
mechanically
A simplified peripheral ultrafiltration
system including a miniaturized
disposable circuit developed for
patients with volume-overload states
Evaluated in multiple observational
studies and a recently reported
multicenter trial (UNLOAD)
Urine vs UF Electrolytes After Intravenous Diuretics or
Ultrafiltration
Sodium Potassium Magnesium
0
20
40
60
80
100
120
140IVD
UF
P =.000025
P =.000017
P =.017
mg
/dL
Ali et al. J Card Fail. 2006;12(6 suppl):114.
Secondary End Point Net Fluid Loss at 48 H
P =.001
M = 3.3, CI + 0.29 L
(N=82)
M = 4.6, CI + 0.29 L
(N=81)
Net F
luid
Loss (
liters
)
Ultrafiltration Arm Standard Care Arm
5.5
5
4.5
4
3.5
3
2.5
2
Costanzo MR et al. J Am Coll Cardiol. 2007;49:675-683.
Sodium removed644 mEq
198 mEq
Freedom From Rehospitalization for HF
100 -
80 -
60 -
40 -
20 -
-
10 20 30 40 50 60 70 80 90
Days
Pe
rce
nta
ge
of P
atie
nts
Fre
e F
rom
Re
ho
sp
ita
liza
tio
n
No. Patients at Risk
Ultrafiltration Arm 88 85 80 77 75 72 70 66 64 45
Standard Care Arm 86 83 77 74 66 63 59 58 52 41
P=.037
Ultrafiltration Arm (16 Events)
Standard Care Arm (28 Events)
0
Costanzo MR et al. J Am Coll Cardiol. 2007;49:675-683.
Acute HF – Pre-Discharge Phase
Goals at discharge
Improve signs and symptoms
Appropriate management of precipitants
Euvolemia with transition to oral diuretics
Implementation of HF guidelines
Transition to chronic HF therapy
Post discharge planning and education
Weight monitoring
Diet
Telephone and clinic follow-up
Medications
When to call for symptoms
Gheorghiade and Pang. JACC 2009.
Haas GJ, Young JB. Texbook of CV Medicine
2009 ACC/AHA Updated Guidelines
ICD therapy is recommended for primary
prevention of sudden cardiac death to reduce
total mortality in patients with nonischemic
dilated cardiomyopathy or ischemic heart
disease at least 40 days post-myocardial
infarction, have an LVEF less than or equal to
35%, with NYHA functional class II or III
symptoms while receiving chronic optimal
medical therapy, and who have reasonable
expectation of survival with a good functional
status for more than 1 year.
Patients With Reduced Left Ventricular
Ejection Fraction
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Primary Prevention: Implantable Cardioverter-Defibrillator
Does patient have Class IV symptom (most patients hospitalized with HF)?
Does patient have risk profile for heart failure death during next year?
Is prognosis for more than one year survival with good overall
Function status limited by non-cardiac conditions?
Is patient within 40 days of myocardial infarction?
Are there reversible factors for which treatment may improve LVEF?
If all answers “No” : Discuss risk and benefit of ICD in outpatient setting
No ICD now,Re-evaluatefor stabilityand riskafter 1 month
Selecting Patients with Heart Failure for Discussion About ICD as Primary
Prevention of Sudden Death
Stevenson and Desai. J Cardiac Failure 2006
Yes
Yes
High risk HF profile
NoICD
YesNoICD
No ICD now,Re-evaluateafter 3-6 mosof optimalmedical Rx
Yes
Yes
Factors to Consider, e.g.High creat/BUN
HypotensionACEI/ARB intolerance
Low serum sodiumVery high serum BNP
Multiple HF hosps
Less than 3-6 months optimal med RxProlonged tachycardiaExcess alcohol consumptionMedications that can exacerbate HF
ICD Information for Patients
If we put an ICD in 100 patients with heart disease like
yours, over the next 5 years we would expect:
30 patient will die anyway
7-8 patients will be saved
by the ICD
Stevenson and Desai. J Cardiac Failure 2006
10-20 would have a shock
they don’t need
5-15 would have other
complications
The rest of patients will not
experience their devices at
all
Some patients will request to have the device
inactivated to allow natural death.
Cardiac Resynchronization Therapy
1/3 of patients with low LVEF and class III-IV
symptoms manifest QRS > 120 msec.
The ECG representation of abnormal cardiac
conduction has been used to identify patients with
dyssynchronous LV contraction.
While this is imperfect, no other consensus definition
of cardiac dyssynchrony currently exists.
Cardiac Resynchronization Therapy Guidelines
For patients with LVEF ≤ 35%, QRS ≥ 120 ms, NYHA Functional
Class III or ambulatory Class IV, on optimal recommended medical
therapy, and
in sinus rhythm ………… CRT is Recommended
with AF …………………. CRT is Reasonable
with frequent dependence on
ventricular pacing ….. CRT is Reasonable
I IIa IIb III
A
I IIa IIb III
B
I IIa IIb III
CACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac
Rhythm Abnormalities. J Am Coll Cardiol, 2008; 51:2085-2105.
Future Directions in CRT
Expanding the indication to less severe heart failure (asymptomatic LVD and mild HF)
Expanding the indication to narrow QRS patients with ECHO dysynchrony
Expanding the indication to less severe LVD (e.g., LVEF 36% to 50%)
Changing the definition of ventricular dysynchrony (QRS duration ECHO)
Further leveraging CRT devices for monitoring clinical status
Future Directions in CRT
Expanding the indication to less severe heart failure (asymptomatic LVD and mild HF)
Expanding the indication to narrow QRS patients with ECHO dysynchrony
Expanding the indication to less severe LVD (e.g., LVEF 36% to 50%)
Changing the definition of ventricular dysynchrony (QRS duration ECHO)
Further leveraging CRT devices for monitoring clinical status
Moss AJ. NEJM 2009
Moss AJ. NEJM 2009
MADIT-CRT: Results
Impedance Decreases with Increasing Lung
Wetness
Heart Failure Exacerbation
Pulmonary Congestion
Decrease in Intrathoracic Impedance
Physician Programmable Threshold
OptiVol Fluid Index
Daily Impedance
Reference Impedance
40 80 120 160 2000
20
60
100
Days
Flu
id I
ndex
(Wd
ays)
0 40 80 120 160 200
70
80
90
Days
Imp
edance (W
)
Physician Programmable Threshold
OptiVol Fluid Index
Daily Impedance
Reference Impedance
40 80 120 160 2000
20
60
100
Days
Flu
id I
ndex
(Wd
ays)
0 40 80 120 160 200
70
80
90
Days
Imp
edance (W
)Algorithm Developed to Track Fluid
Accumulation
Medtronic data on file
Another Approach to Heart Failure Management
LASIX®
(Furosemide)
40 mg
1 white tablet
Recheck in 12h
LASIX®
40
LARA
HeartPOD™SystemPatient Advisory Module (PAM)
LARA
Modified PDA
Powers through clothing
Atmospheric reference
Stores telemetry
Alerts patient to monitor
‘DynamicRX®’ instructs
Meds
Activity
Clinician contact
based on LAP values and
physician’s prescription
SAVACOR, INC
Advanced HF (StageD)
Progressive symptoms
Resting tachycardia / low BP
Progressive LV remodelling
Intolerance of evidence-based medications
Hyponatremia
Worsening renal function
Diuretic resistance
Increased QRS duration
Anemia
Increased arrhythmia
Refer for advanced HF
Med,Surg, Device treatment
options
Inotrope dep. ??
Yes NoAssess with*CPX, RHC
*NYHA
•HFSS,
•SHFM
*Evaluate forTransplant
*MCS
*Clinical Trial
*Hospice
Evaluation of Advanced HF (Stage D)
Realistic Expectations following Transplant
Referral
1174 Transplant referrals
558 treated medically
418 (36%) listed for transplant
168 received other surgery
Of those Listed …
217 (18% of those referred originally) transplanted
77 de-listed (27 improved, 32 non-tsplt surgery)
74 died
50 waiting
Mahon NG et al. J Card Fail 2004; 10: 273
Factors involved in determining appropriateness of
Transplant or VAD Implantation ( Stage D HF )
Wilson SR, et al. Circulation. 2009; 119: 2225-2232
Hepatic
Function
Neurologic
Function
Multiorgan
Failure
Age
Body Size
Malignancy
Psychological and
Psychiatric Conditions
Arrhythmias
Inotropic
Support
Valvular
Disease
Right Ventricular
Function
Ischemic Heart
DiseaseInfectious
Disease
Nutritional
Status
Renal
Function
Pulmonary
FunctionIntracardiac
Shunt
Non-Cardiovascular
Considerations
Cardiovascular
Considerations
Left Ventricular Assist Device
Heartmate II (long-term) Heartware (long-term)
*investigational
Ventrassist (long-term)
*investigational
Centrimag (short-term)
Slaughter M, et al. NEJM 2009
Continuous Flow LVAD (HM II) vs.
Pulsatile LVAD (HM XVE)
1. The CONSENSUS Trial Study Group. N Engl J Med. 1987;316:1429-1435.
2. Packer M et al. N Engl J Med. 1996;334:1349-1355.
3. Pitt B et al. N Engl J Med. 1999;341:709-717.
4. Moss A et al. N Engl J Med. 1996;335:1933-1940.
5. Abraham WT et al. N Engl J Med. 2002;346:1845-1853.
Therapies Demonstrated to Reduce Mortality in
Heart Failure
ACE Inhibitors / ARB’s (Stage A-D)
Beta Blockers (Metoprolol, Carvedilol) (Stage A-D)
Aldosterone Antagonists (Stage C)
Hydralazine / Nitrates (AA) (Stage C,D)
Transplant / LVAD (Stage D)
ICD
LVEF < 35, Class II or III (Stage C)
Cardiac Resynchronization +/- ICD
LVEF <35, QRS >120 ms, Class III or IV (Stage C)