55 year old man with breathlessness on mild exertion'

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• 55 year old man with breathlessness on mild
  exertion.
• No cough, fever, chest pain, palpitations. No
  exertional chest discomfort
• Otherwise healthy.
• Type 2 diabetes, diet controlled
• 10 pack year cigarette smoking
• Hypertension, well controlled on perindopril 10mg
• BP 135/90. Resps 26. Afebrile. Sats 95 room air.
• Normal heart sounds.
• Lungs normal.
• JVP not seen.
• Rest of exam normal.

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What tests?
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• Normal FBE
• Normal EUC LFTs
• Normal TSH
• HBAIC 6.9
• Troponin not raised
• FEV1 2.9 l, FVC 3.5 l

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BNP 400
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Rapid Measurement of B-Type Natriuretic Peptide
in the Emergency Diagnosis of Heart Failure

• B-type natriuretic peptide is released from the
  ventricles of the heart in response to
  hemodynamic stress, and blood levels of B-type
  natriuretic peptide may be useful in the
  diagnosis of heart failure
• In this study, a rapid, bedside immunoassay for
  B-type natriuretic peptide was used to make or
  exclude the diagnosis of heart failure in
  patients with acute dyspnea from various causes
• The assay was found to have good sensitivity and
  excellent specificity in the diagnosis of heart
  failure
• Measurement of B-type natriuretic peptide levels
  is not a stand-alone test for heart failure
• It will be of most value when used in conjunction
  with clinical observations, especially when the
  cause of acute dyspnea is unclear
• The finding of a low level of B-type natriuretic
  peptide (less than 50 pg per milliliter) is good
  evidence of the absence of heart failure

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Box Plots Showing Median Levels of B-Type
Natriuretic Peptide Measured in the Emergency
Department in Three Groups of Patients
Maisel, A. et al. N Engl J Med 2002347161-167
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Box Plots Showing Median Levels of B-Type
Natriuretic Peptide among Patients in Each of the
Four New York Heart Association Classifications
Maisel, A. et al. N Engl J Med 2002347161-167
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Multiple Logistic-Regression Analysis of Factors
Used for Differentiating between Patients with
and Those without Congestive Heart Failure
Maisel, A. et al. N Engl J Med 2002347161-167
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Spot quiz
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• Assessment of left ventricular function

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Definition?

• heart failure is a complex clinical syndrome
  that can result from any structural or functional
  cardiac disorder that impairs the ability of the
  ventricle to fill with or eject blood
• Cardinal manifestations
• Dyspnea and fatigue which may limit exercise
  tolerance
• Fluid retention which may lead to pulmonary
  congestion and peripheral oedema
• Heart failure is preferred to congestive heart
  failure

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what are the recommended blood tests for initial
diagnosis?

• Class 1
• FBE
• UA
• EUC Ca Mg PO4
• Fasting BSL
• Lipids
• LFTs
• TSH
• Class 2a
• Iron studies
• HIV
• Amyloid
• Rheumatologic disease
• BNP in urgent care setting where diagnosis is
  uncertain

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Spot quiz.
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Long-Term Trends in the Incidence of and Survival
with Heart Failure

• Congestive heart failure has an extremely poor
  prognosis
• This investigation from the Framingham Heart
  Study tracked trends over a 50-year period in the
  incidence of heart failure and in survival after
  its onset
• During this period, the incidence of heart
  failure declined among women but not among men,
  whereas survival improved among both men and
  women
• Despite substantial improvement during the study
  period, overall survival rates among patients
  with heart failure remained below 50 percent at
  five years, pointing to the urgent need for
  better means of preventing this serious health
  problem

N Engl J Med Volume 347181397-1402 October 31,
2002
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Temporal Trends in the Age-Adjusted Incidence of
Heart Failure
Levy, D. et al. N Engl J Med 20023471397-1402
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Temporal Trends in Age-Adjusted Survival after
the Onset of Heart Failure among Men (Panel A)
and Women (Panel B)
Levy, D. et al. N Engl J Med 20023471397-1402
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Stages of Heart Failure and Treatment Options for
Systolic Heart Failure. NEJM Volume
3482007-2018 May 15, 2003 Number 20 Mariell
Jessup, M.D., and Susan Brozena, M.D.
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AF and Heart Failure Study Overview

• In this clinical trial involving patients with
  atrial fibrillation and congestive heart failure,
  rhythm control (to maintain sinus rhythm) and
  rate control (to control the ventricular rate in
  atrial fibrillation) were compared
• The two strategies were nearly identical with
  respect to all clinical outcomes
• Thus, the simpler approach, rate control, should
  be considered the treatment of choice in such
  patients

Roy D et al. N Engl J Med 20083582667-2677
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Baseline Characteristics of the Patients
Roy D et al. N Engl J Med 20083582667-2677
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Medical Therapy at 12 Months
Roy D et al. N Engl J Med 20083582667-2677
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Kaplan-Meier Estimates of Death from
Cardiovascular Causes (Primary Outcome)
Roy D et al. N Engl J Med 20083582667-2677
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Kaplan-Meier Estimates of Secondary Outcomes
Roy D et al. N Engl J Med 20083582667-2677
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Effect of Carvedilol on Survival in Severe
Chronic Heart FailureNEJM Volume 3441651-1658
May 31, 2001 Number 22Milton Packer, M.D.,et al

• 2289 patients
• heart failure at rest or on minimal exertion
• clinically euvolemic
• ejection fraction of less than 25 percent
• In a double-blind fashion
• 1133 patients to placebo
• 1156 patients to carvedilol
• for a mean period of 10.4 months
• standard therapy for heart failure was continued

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Kaplan-Meier Analysis of Time to Death in the
Placebo Group and the Carvedilol Group
Packer M et al. N Engl J Med 20013441651-1658
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What is the magnitude of benefit of AICD

• EF lt31, previous infarct
• Over 20 months
• Absolute mortality benefit 5.6
• 31 relative risk reduction
• 15 ? 10
• 20 risk of inappropriate shock
• Reserved for patients with greater than 1 year
  life expectancy
• Should not have class 4 symptoms

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Spot quiz
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Cardiac Resynchronization in Chronic Heart
FailureN Engl J Med Volume 346241845-1853 June
13, 2002

• About a third of patients with chronic heart
  failure have an intraventricular conduction
  delay, which may lead to dyssynchrony of cardiac
  contraction and further clinical impairment
• The patients in this clinical trial were randomly
  assigned to a group receiving resynchronization
  therapy with an atrial-biventricular pacemaker or
  to a control group
• As compared with the control group, the
  resynchronization group had improved functional
  capacity, quality of life, and ejection fraction
  over a six-month period
• Resynchronization therapy has considerable
  promise in patients with heart failure, but there
  are limitations
• It is applicable to only about a third of
  patients, and it requires the insertion of a
  complex pacing device that may be associated with
  a variety of technical problems and complications
• This technique should be reserved for experienced
  centers

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Change in the Distance Walked in Six Minutes and
the Quality-of-Life Score
Abraham, W. et al. N Engl J Med 20023461845-1853
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Kaplan-Meier Estimates of the Time to Death or
Hospitalization for Worsening Heart Failure in
the Control and Resynchronization Groups
Abraham, W. et al. N Engl J Med 20023461845-1853
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• Dont forget sprionolactone in class 3 and 4
  heart failure

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• 55 year old female with palpitations.
• Skipped and extra beats for 3 months
• No chest pain, shortness of breath
• No syncope, presyncope
• Past history of HT
• Currently on atenolol 50 mg daily and candesartan
  8mg daily.
• Pulse irregular 90bpm BP 125/90 Resps 18 Afebrile
  Sats 97
• Heart sounds normal. Chest clear.
• Rest of examination normal.

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What tests?
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• FBE normal
• TSH normal
• BNP, Troponin Normal
• EUC LFTs Normal
• Fasting BSL 4.8

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Question 1

• Additional diagnostic workup

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Question 2

• Warfarin or Aspirin

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Guidelines for Antithrombotic Therapy in Atrial
Fibrillation
Page R. N Engl J Med 20043512408-2416
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Management Strategies Recommendations CHADS2
Risk Criteria Score Prior stroke or TIA 2 Age
gt75 years 1 Hypertension 1 Diabetes mellitus
1 Heart failure 1 Patients Adjusted Stroke
Rate (N1733) (/year) (95 CI) CHADS2
Score 120 1.9 (1.2-3.0) 0 463 2.8 (2.0-3.8)
1 523 4.0 (3.1-5.1) 2 337 5.9 (4.6-7.3)
3 220 8.5 (6.3-11.1) 4 65 12.5 (8.2-17.5)
5 5 18.2 (10.5-27.4) 6
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Question 3

• Rate control or rhythm control

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Pharmacologic Agents to Control Heart Rate and
Rhythm
Page R. N Engl J Med 20043512408-2416
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A Comparison of Rate Control and Rhythm Control
in Patients with Atrial FibrillationN Engl J Med
Volume 347231825-1833 December 5, 2002

• There are two approaches to the treatment of
  atrial fibrillation rate control, allowing
  atrial fibrillation to persist, and rhythm
  control, with cardioversion and antiarrhythmic
  drugs
• This North American study found that, contrary to
  prevailing practice, rhythm control offered no
  survival advantage and was associated with higher
  rates of adverse drug effects than rate control
• Atrial fibrillation is associated with
  substantial morbidity and mortality
• As compared with rhythm control, rate control has
  advantages that have previously been
  underappreciated

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Cumulative Mortality from Any Cause in the
Rhythm-Control Group and the Rate-Control Group
The Atrial Fibrillation Follow-up Investigation
of Rhythm Management (AFFIRM) Investigators, . N
Engl J Med 20023471825-1833
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Base-Line Characteristics of the Patients
The Atrial Fibrillation Follow-up Investigation
of Rhythm Management (AFFIRM) Investigators, . N
Engl J Med 20023471825-1833
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Drugs Used in the Rate-Control Group and the
Rhythm-Control Group
The Atrial Fibrillation Follow-up Investigation
of Rhythm Management (AFFIRM) Investigators, . N
Engl J Med 20023471825-1833
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Adverse Events
The Atrial Fibrillation Follow-up Investigation
of Rhythm Management (AFFIRM) Investigators, . N
Engl J Med 20023471825-1833
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Spot quiz.
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• 60 year old female
• Mother AMI age 70
• Glucose intolerance
• Obese
• Candesartan for HT
• BP at home average 125 systolic
• Osteoathritis
• 2 episodes of prolonged chest pain, last one 5
  days ago.
• Dull retrosternal lasted 15 minutes
• Examination normal

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• Cholesterol 6.5, LDL 3.5
• BSL 6.4
• HBAIC 6.4
• Normal FBE EUC LFTs
• Troponin not raised

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• Stress test showed equivocal ST depression with
  non limiting chest pain at 5 minutes on Bruce
  Protocol.

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EST in determining prognosis

• Asymptomatic population
• EST is positive in 5 10 of middle age men
• If abnormal, risk is 9 times higher
• Over 5 years only 25 have cardiac event,
  commonly angina
• Symptomatic patients
• If exercise tolerance gt10 mets prognosis is
  excellent regardless the severity of coronary
  angiography
• Provides an estimate of the functional
  significancd of CAD
• If Bruce lt 1 AND gt1mm ST depression - mortality
  5/year (12 of those undergoing EST)
• If Bruce gt 3 AND no ST depression mortality
  lt1/yr over next four years (35 of those
  undergoing EST)

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Duke treadmill score

• Duke Treadmill Score Calculation
• (Time in minutes on Bruce protocol)
• (eg 1 if exercises for 1 minute, 12 if exercise
  for 12 minutes)
• then subtract
• (5 x amount of ST depression (in mm))
• (eg if 1 mm of ST depression subtract 5, if 2 mm
  of ST depression subtract 10)
• then subtract
• (0 if no angina on test, 4 if non-limiting
  angina, 8 if limiting angina)
• Total score
• Score Risk Group Annual Mortality
• IF treadmill score is gt5 THEN annual mortality
  is LOW (0.25/yr)
• IF treadmill score is 10 to 4 THEN annual
  mortality is INTERMEDIATE (1.25/year)
• IF treadmill score is lt-11 THEN annual mortality
  is HIGH (5.25/yr)

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• Coronary angiography showed 50 LAD stenosis.
• Left ventricular function normal.
• Recommended for medical management.

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HOPE study study populationEffects of an
Angiotensin-Converting-Enzyme Inhibitor,
Ramipril, on Cardiovascular Events in High-Risk
PatientsNEJM Volume 342(3)     20 January 2000 

• gt 55 years old
• history of
• coronary artery disease
• stroke
• peripheral vascular disease
• diabetes ( at least 1 other cardiovascular risk
  factor)
• hypertension
• elevated total chol., LDL chol.
• cigarette smoking
• Microalbuminuria

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Composite Outcome of Myocardial Infarction,
Stroke, or Death from Cardiovascular Causes
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Spot quiz
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CARE inclusion criteriaThe Effect of
Pravastatin on Coronary Events after Myocardial
Infarction in Patients with Average Cholesterol
LevelsNEJM 335(14)             3 October 1996 

• Inclusion criteria
• total cholesterol lt 6.2 mmol/l
• and
• LDL cholesterol 3.0 to 4.5 mmol/l
• AMI 3 and 20 months before randomization
• 21 to 75 years of age
• Fasting triglyceride levels lt 4.0 mmol/l
• BSL lt 12.2 mmol/l
• EF gt 25 (no symptomatic CCF)

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Effect of Beta-Blockade on Mortality among
High-Risk and Low-Risk Patients after Myocardial
Infarction NEJM 339(8)    20 August 1998

• Several large trials show long-term
  administration of beta blockers to patients after
  myocardial infarction improves survival
• physicians prescribe for lt 35
• cardiologists prescribe for lt 50,
• especially in..
• older age
• impaired left ventricular function
• transient heart failure
• patients on diuretic drugs.

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Spot Quiz
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