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Evidence Based Review CHF

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1-hour resident-level presentation on CHF 2005

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Evidence Based Review CHF

  1. 1. An Evidence-Based Review: Congestive Heart Failure Mike Mendoza, MD, MPH Chief Resident Department of Family and Community Medicine
  2. 2. Overview <ul><li>Pathophysiology </li></ul><ul><li>Diagnosis of CHF </li></ul><ul><li>ACC / AHA Reclassification of CHF </li></ul><ul><li>Pharmacologic Treatments </li></ul><ul><li>Diastolic Heart Failure </li></ul>
  3. 3. The Syndrome of Heart Failure
  4. 4. It’s Not Just About Diuresis and Digoxin Anymore, Toto! <ul><li>Long-term reduction of circulating volume and improvement of cardiac function alone do not prevent progression of disease. </li></ul><ul><li>Treatment focused only on diuresis and inotropy is insufficient. </li></ul>
  5. 5. The “Neurohumoral” Effect <ul><li>Plays a role in compensatory mechanisms resulting from the initial cardiac insult. </li></ul><ul><ul><li>Sympathetic Nervous System </li></ul></ul><ul><ul><li>Renin-Angiotensin System </li></ul></ul><ul><li>Successful treatment of heart failure must account for these neurohumoral processes. </li></ul>
  6. 6. Sympathetic Nervous System <ul><li>Adaptive mechanism if you are being consumed by a dinosaur. </li></ul><ul><li>Counterproductive in heart failure. </li></ul><ul><ul><li>Sodium (i.e., volume) retention </li></ul></ul><ul><ul><li>Increased peripheral resistance through vasoconstriction </li></ul></ul><ul><ul><li>Increased release and decreased reuptake of NE </li></ul></ul>
  7. 7. Circulating Evil Humours <ul><li>In a series of patients with stable CHF treated with digoxin but NOT diuretics, ACE-Is or beta-blockers… </li></ul>
  8. 8. Increases in NE are Bad <ul><li>Increases in circulating norepinephrine confer worse prognosis. </li></ul><ul><li>ValHeFT Study </li></ul>
  9. 9. Renin-Angiotensin-Aldosterone
  10. 10. The Role of Remodeling <ul><li>Ventricular remodeling results in decline of overall pump function of the heart </li></ul><ul><li>Trials aimed at reducing remodeling showed a return normal ventricular size and shape. </li></ul>
  11. 11. Remodeling <ul><li>The SOLVD study demonstrated that enalapril significantly improved clinical course of patients with LVSD. </li></ul><ul><li>The SOLVD-Echo Substudy sought to determine the basis for this improvement. </li></ul><ul><li>A subset of the original patients in the treatment and placebo groups underwent TTE. </li></ul>
  12. 12. Clinical Diagnosis of CHF <ul><li>Can be difficult based on history and exam alone. </li></ul><ul><li>Cross-sectional study of 259 patients thought to have CHF by conventional clinical criteria underwent TTE. </li></ul><ul><li>Clinical findings then correlated to presence of LVSD (LVEF < 25%) on echo. </li></ul><ul><li>Only 16% of patients suspected to have CHF had LVSD on echo. </li></ul><ul><li>Addition of electrocardiogram (ECG) assists in making diagnosis. </li></ul>
  13. 13. Clinical Diagnosis of CHF 89% Displaced Apex + Hx of MI - 0.03 + 4.2 + 6.0 + 8.5 + 16.5 + 24.0 Likelihood Ratio Absence of DOE Hx of MI Hx of DM2 64% JVD 75% Displaced Cardiac Apex 77% S3 gallop PPV Exam Finding
  14. 14. New York Heart Association Symptoms at rest. Class 4 Marked limitation of activity; comfortable only at rest. Class 3 Slight, mild limitation of activities; comfortable with rest or with mild exertion. Class 2 No limitation of activities; asymptomatic from ordinary activities. Class 1
  15. 15. ACC/AHA Classification of CHF Refractory symptoms requiring special intervention Stage D Structural heart disease, previous or currently symptomatic Stage C Structural heart disease, asymptomatic Stage B At high risk for the development of heart failure but have no apparent structural abnormality of the heart Stage A
  16. 16. Why the Reclassification? <ul><li>NYHA classification </li></ul><ul><ul><li>A functional classification only; you could be reclassified based on your response to medication </li></ul></ul><ul><ul><li>No emphasis on risk factors and modification </li></ul></ul><ul><li>ACC/AHA classification </li></ul><ul><ul><li>Underscores progressive nature of CHF </li></ul></ul><ul><ul><li>Emphasizes identification of risk factors and risk factor modification </li></ul></ul><ul><ul><li>Link Stage of CHF to Treatment Recommendations </li></ul></ul>
  17. 17. ACC/AHA Treatment Recommendations
  18. 18. STAGE A <ul><li>Treating hypertension reduces the prevalence of LVH and CHF. </li></ul><ul><li>A retrospective cohort study of 10,333 participants in the Framingham study, aged 45 to 74 years old, conducted from 1950-1989 </li></ul><ul><ul><li>Age-adjusted prevalence of SBP > 160 or DBP > 100 declined from </li></ul></ul><ul><ul><ul><li>18.5% to 9.2% in men and </li></ul></ul></ul><ul><ul><ul><li>28.0% to 7.7% among women </li></ul></ul></ul><ul><ul><li>Age-adjusted prevalence of LVH (on ECG) declined from </li></ul></ul><ul><ul><ul><li>4.5 percent to 2.5% among men and </li></ul></ul></ul><ul><ul><ul><li>3.6% to 1.1% among women </li></ul></ul></ul><ul><li>Over this period, incidence of heart failure has decreased 30 to 50% </li></ul>
  19. 19. Anti-Hypertensive Therapy <ul><li>Goal diastolic BP in patients with DM2 < 80. </li></ul><ul><li>Treatment with ACE-inhibitor even in absence of symptoms reduces rates of death, MI and stroke. </li></ul><ul><ul><li>Type 2 Diabetics especially at risk. </li></ul></ul><ul><ul><li>UKPDS: an RCT of 1148 patients randomized to tight or less tight BP control </li></ul></ul><ul><ul><li>Significant reduction in the risk of death related to diabetes, diabetic nephropathy, diabetic retinopathy. </li></ul></ul><ul><ul><li>ACE-I or beta-blocker equally effective for these endpoints. </li></ul></ul><ul><li>Prevent remodeling. </li></ul>
  20. 20. STAGE B <ul><li>Structural heart disease is present, but asymptomatic </li></ul><ul><li>Continue to address risk factors </li></ul><ul><ul><li>Moderate sodium restriction </li></ul></ul><ul><ul><li>Weight monitoring </li></ul></ul><ul><ul><li>Moderation of EtOH, avoidance of NSAIDs </li></ul></ul><ul><li>ACE-inhibitors or ARBs in all patients; beta-blockers in selected patients </li></ul>
  21. 21. ACE Inhibitors <ul><li>Decrease the conversion of angiotensin I to angiotensin II, thus minimizing the physiologic effects of angiotensin II on the heart, vasculature, and renal blood flow. </li></ul><ul><li>A meta-analysis of all RCTs of ACE-inhibitors showed a statistically significant reduction in total mortality (OR, 0.77) and in combined endpoint of mortality or hospitalization (OR, 0.65). </li></ul><ul><ul><li>Similar effects for all ACE-Is studied. </li></ul></ul><ul><ul><li>Patients with the lowest EF had the greatest benefit, usually in the first 3 months of treatment. </li></ul></ul><ul><li>CONSENSUS trial showed that one-year mortality reduced from 52% to 36% for NYHA Class IV patients. </li></ul>
  22. 22. Beta Blockers <ul><li>Blunt the sympathetic nervous system, slow HR, decrease blood pressure. Also thought to have a direct effect on reversing remodeling. </li></ul><ul><li>Reported reduction in mortality is 34 to 65% with NNT 14 to 26. </li></ul><ul><li>Most widely studied: metoprolol, carvedilol, and bisoprolol. </li></ul><ul><li>Most patients enrolled in these studies had NYHA Class II or worse CHF. </li></ul>
  23. 23. Beta Blockers (cont’d) <ul><li>Metoprolol </li></ul><ul><ul><li>MERIT-HF </li></ul></ul><ul><ul><li>3991 patients with NYHA Class II – IV CHF and EF < 40% randomized to metoprolol or placebo, with target metoprolol dose of 200mg daily. </li></ul></ul><ul><ul><li>Study stopped early after one year when all-cause mortality was lower in the metoprolol group vs. placebo group. </li></ul></ul><ul><ul><li>Overall reduction in mortality (RR 0.66). </li></ul></ul>
  24. 24. Beta Blockers (cont’d) <ul><li>Carvedilol </li></ul><ul><ul><li>COPERNICUS Trial </li></ul></ul><ul><ul><li>A study of 2289 patients with severe HF, EF < 25%, randomized to carvedilol or placebo in addition to usual care. </li></ul></ul><ul><ul><li>35% decrease in the risk of death in carvedilol group </li></ul></ul><ul><ul><li>24% decrease in the combined risk of death or hospitalization </li></ul></ul>
  25. 25. Angiotensin Receptor Blockers <ul><li>ARBs also interfere with the renin-angiogensin-aldosterone system </li></ul><ul><li>A Cochrane meta-analysis of 17 RCTs comparing ARBs to ACE-Is in patients with NYHA Class II – IV CHF </li></ul><ul><ul><li>ARBs and ACE-Is are equivalent for all-cause mortality </li></ul></ul><ul><ul><li>Small reduction in rate of hospitalization for the combination of ARB + ACE over ACE alone (OR, 0.74) </li></ul></ul><ul><ul><li>A good option for people who cannot tolerate ACE-Is </li></ul></ul>
  26. 26. Angiotensin Receptor Blockers
  27. 27. STAGE C <ul><li>Symptomatic from structural heart disease. </li></ul><ul><li>ACE-Is and beta-blockers in all patients </li></ul><ul><li>Consider digoxin, diuretics and revascularization. </li></ul>
  28. 28. Digoxin <ul><li>Digitalis Investigation Group (“DIG”) </li></ul><ul><ul><li>Overall survival is not improved with digoxin. </li></ul></ul><ul><ul><li>Rate of hospitalization is improved, particularly those with EF < 25%, dilated cardiomyopathy, and NYHA III or IV. </li></ul></ul><ul><ul><li>Improves exercise tolerance and decreases symptoms. </li></ul></ul><ul><li>Cochrane review of 20 RCTs in 2004 agreed with the above. </li></ul>
  29. 29. Spironolactone <ul><li>A potassium-sparing diuretic that antagonizes aldosterone at the DCT and causes water excretion and potassium retention. </li></ul><ul><li>RALES Trial </li></ul><ul><ul><li>1663 NYHA Class IV patients already on ACE-I and loop diuretic. 70% of patients also on digoxin. Only 10% taking beta-blockers. </li></ul></ul><ul><ul><li>Randomized to addition of placebo or spironolactone 25 titrated upward. </li></ul></ul><ul><ul><li>30% reduction in death in treatment group. NNT=9. </li></ul></ul>
  30. 30. Diuretics <ul><li>Loop diuretics (e.g., furosemide) relieve symptoms but do not slow progression of underlying disease. </li></ul><ul><li>Loop diuretics preferable to thiazides. </li></ul>
  31. 31. Diastolic Heart Failure <ul><li>Refers to an abnormality of diastolic distensibility, filling or relaxing of the LV. </li></ul><ul><li>One-third of all patients with CHF. </li></ul><ul><li>Etiologies: hypertrophic, scarring from ischemic disease, infiltrative diseases </li></ul><ul><li>Diagnosis requires Echo with EF > 40% and no evidence of acute valvular disease or pericarditis. </li></ul>
  32. 32. Diastolic Heart Failure
  33. 33. Management of Diastolic HF <ul><li>Initial Management </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Rate control </li></ul></ul><ul><li>Long-term Management </li></ul><ul><ul><li>RCTs of any one agent are generally lacking. </li></ul></ul><ul><ul><li>In one RCT of NYHA II, III or IV comparing candesartan (ARB) to placebo, treatment was associated with fewer hospitalizations, and a non-significant trend toward reducing death. </li></ul></ul>