docMaryam AlQaseer Consultant Cardiologist King Fahad Specialist
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Maryam AlQaseer Consultant Cardiologist King Fahad Specialist
Maryam AlQaseer Consultant Cardiologist King Fahad Specialist Hospital in Dammam Sub-investigator in SHIFT, REVERESE, ATMOSPHERE, REPORT-HF 2 brief case histories Outline of management of HFrEF management.. What do the guidelines say.. Recent evidence and therapeutic options.. Pharmacotherapy Devices Surgical interventions Glimpse into the future outlook of heart failure 53 year old gentleman with no previous medical illnesses gets admitted via ER with a history of progressively worsening sob for 4 weeks, orthopnoea and PND. He denied any chest pain Very good baseline effort tolerance, works as a grave digger. Examination was positive for sinus tachycardia of 110bpm. BP128/71mmHg, SpO2 93% on room air and RR24bpm. Elevated JVP 8cm H2O S1, S2, S3, no murmurs. Bibasal crepitations Minimal pitting pedal oedema at the level of ankles. ECG: Sinus tachycardia with LBBB Troponin was mildly elevated, BNP 1050, Normal RFT, CBC, Iron profile and TSH. ECHO CAG normal coronaries. Started on anti-failure therapy and sent home after education Regular f/u at the HFU managed to take him up to bisoprolol 10mg, spironolactone 25mg od, perindopril 10mg od, lasix 40mg od, and warfarin as per INR. 3 months after OMT brought him back for an echo, LV function remains same and LV thrombus disappeared. CRT-D implanted, and brought him back in 6 weeks after implant. Device check was good and BiV pacing about 97% of the time. An echo was done, EF~50%. Patient is back to working 70-80 hour weeks 29 year old gentleman, smoker, history of myocarditis which improved 3 years ago lost to follow up and stopped medications. Comes back with a history of recent URTI and was in florid pulmonary oedema. SBP~80-90mmHg. Required NIPPV. Bloods BNP of 3450, Troponin mildly elevated, Normal RFT, CBC, Iron, TSH, Non specific ECG changes CAG: Normal coronaries Bisoprolol 10mg od, spironolactone25mg od, valsartan 80 mg BD, lasix 40mg BD, and warfarin as per INR. 3 months after OMT still severe LV dysfunction. Narrow QRS. ICD rejected. Recurrent admissions with heart failure 4x/year, needed inotropes once. Right heart cath, elevated PAP. INTERMACS class 6-7 Awaiting heart transplant. Studies working towards the upcoming ESC HF guidelines in 2016 ESC HF Guidelines 2012 1987CONSENS US 1991SOLVED • • • • 3 components: ACE-i/ARB--------- -ARN-i BB MRA 1991- V HEFTII 1996CARVEDI LOL HEART FAILURE GROUP 1997- DIG TRIAL 1999RALES 2001-VALHEFT 2001COPERNI CUS 2011EMPHASI S HF 2014PARADIG M-HF It’s not only about the addition of drugs but rather achieving the target doses of therapy Courtesy of ESC slides 2015 1. CHRONIC STABLE HF 2. CLASS II-III 3. WITHOUT SIGNIFICANT HYPOTENSION 4. WITHOUT SIGNIFICANT RENAL IMPAIRMENT ARN-i Courtesy of ESC slides 2015 Iron therapy IRONMAN TRIAL.. Results awaited.. 2004COMPANION 2005- CARE HF 2005- SCD HeFT 2009- MADIT CRT 2010- RAFT 2013- ECHO CRT 2014- MADIT CRT TAKE HOME MSG, Consider CRT if: • • • • Severe LV systolic dysfunction, EF < 35% despite OMT NYHA II or more LBBB Or alternatively, non LBBB preferably >150 msec TWO CAVEATS.. • • If Class IV, expected to live for a year with a good functional status. If Afib, ensure adequate BiV pacing, or else will need concomitant AVN ablation TAKE HOME MESSAGE: • Severe LV systolic dysfunction, EF < 35% despite OMT • NYHA II or more • Narrow QRS CAVEAT.. The patient needs to know that this will NOT improve their symptoms but rather improve their sudden cardiac death(SCD)risk.. The patients at highest risk of SCD are those in Class II INTERMACS Evidence of Heart Tx Evidence of MCS Establishing a Heart Failure Unit Education to the patient Education to the staff Checklists CPGs Clinical pathways Minimize variation Start early from admission Prevention is Key.. Target those at risk before they get HF.. Stage A HF.. ARN-i ATMOSPHERE Where do we draw line between HFpEF vs HFrEF PRADA Courtesy of ESC slides 2015 CABG ICD vs CRT OMT Sinus rhythm NYHA II or more Resting HR > 70bpm Target HR ~ 50-60 bpm
