Dr Andrew Turley

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Broken Hearts Acute Heart Failure
Dr Andrew Turley Cardiology Consultant South Tees
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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• Serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

4
Overview Acute Heart Failure

• Complex syndrome caused by impaired cardiac
  function
• 2 types
• left ventricular systolic dysfunction (LVSD)
• Heart failure with preserved ejection fraction
  (HFPEF/HFNEF/Diastolic dys.)
• Commonest cause(s)
• IHD, Hypertension, alcohol, cytotoxics
• 3040 of patients die within a year of diagnosis
• Around 900,000 people in the UK
• Expected to rise in the future

• The cardiac dysfunction may be related to
• Ischaemia
• Arrhythmias
• Valvular dysfunction
• Pericardial disease
• Increased filling pressures
• Elevated systemic resistance.

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Drugs
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Diagnosis

• ECG
• CXR
• ABG
• Laboratory Tests
• A small elevation in cardiac troponin may be seen
  in patients with AHF without ACS.
• Echo

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Diagnosis Cardiac Biomarkers

• In patients with symptoms and signs of heart
  failure
• Measure serum natriuretic peptides
• Refer to have echocardiography and specialist
  assessment within 2 weeks if
• Previous MI
• BNP gt 400 pg/ml or
• NTproBNP gt 2000 pg/ml
• If BNP lt 100 pg/ml or NTproBNP lt 400 pg/ml, heart
  failure is unlikely in an untreated patient

• Natriuretic peptides
• Negative predictive value
• There is no consensus regarding BNP or NT-proBNP
  reference values in AHF.
• Important prognostic information.

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Cardiac Biomarkers

• Troponin/BNP/CRP

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New Classification of MI-Type 2?
Secondary to spasm, embolism, anaemia,
arrhythmia, BP changes
Troponinitis
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Natriuretic Peptides Origin and Stimulus of
Release
Relaxation of smooth muscle cells Vasodilatation
of veins and arteries GFR ?, Na reabsorption
inhibited ? diuresis SNS and RAS activity reduced
ANP Atrial Natriuretic Peptide BNP B-type
Natriuretic Peptide CNP C-type Natriuretic
Peptide
Adapted from Burnett JC, J Hypertens
200017(Suppl 1)S37-S43
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The natriuretic peptides Biochemistry of
NT-proBNP
proBNP
NT-proBNP
BNP
COOH
t½ 70-120 min
t½ 20 min
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Clinical Potential of BNP/NT-proBNP

• Extensively studied
• A blood test for heart failure
• Diagnosis-Raised in LVSD/AF/LVH/VHD/ACS
• Screening for asymptomatic LVSD
• Risk stratification Prognosis in established HF
• Therapy monitoring
• Treatment of HF

Normal BNP makes LVSD very unlikely NEGATIVE
PREDICTIVE VALUE
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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

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Acute Cardiogenic Pulmonary Oedema

• Common
• 15-20,000 hospital admissions per annum in UK
• Deadly
• 15-20 in-hospital mortality
• Costly
• 6.5 million hospital days per annum in USA

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Initial Treatment

• The evidence in favour of morphine use for AHF is
  limited.
• Multiple agents are used to manage AHF, but there
  is a paucity of clinical trials data and their
  use is largely empiric.
• Most agents improve haemodynamics but no agent
  has been shown to reduce mortality.

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Non-invasive Ventilation In Acute Cardiogenic
Pulmonary Oedema
When the household vacuum cleaner is employed,
the machine should be run for some minutes first
of all to get rid of dust
Poulton EP, Oxon DM Left-sided heart failure
with pulmonary oedema Its treatment with the
"pulmonary plus pressure machine." Lancet
(1936)231981-983.
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Physiological Improvement with CPAP in Patients
with ACPO
Kelly et al. Eur Heart J 2002231379-1386
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Mortality Benefit of CPAP/NIPPV in Patients with
ACPO
Mortality reduced from 22 to 11 RR 0.53 (95
CI 0.35-0.81) (Individual Group Sizes small)
However, in 3CPO, a large RCT........
Masip et al. JAMA 20052943124-3130
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Trial summary
3CPO

• Background

• Intervention

• Aims
• Clinical effectiveness of non-invasive
  ventilation
• Comparative effectiveness of CPAP and NIPPV
• Safety of non-invasive ventilation
• Hypothesis
• Non-invasive ventilation reduces mortality

• Randomised (111)
• Standard oxygen therapy (by facial mask)
• CPAP (5 cmH2O up titrated to a maximum of 15
  cmH2O)
• NIPPV (8/4 cmH2O up titrated to a maximum of
  20/10 cmH2O)
• Inhaled oxygen of 60
• Attending physicians were encouraged to use
  vasodilator (nitrate) and diuretic therapy
• Opiate therapy was administered at the discretion
  of the treating physician

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Outcome Any NIV v StandardMortality
3CPO
Active Trial 1069 patients 350 per arm Baseline
Characteristics matched Baseline Medications
matched Baseline Interventions matched (nitrate,
diuretic, opiate, oxygen)
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3CPO
Outcome Hospital stay
No significant differences (Pgt0.05)
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CONCLUSIONS
3CPO

• In patients with acute cardiogenic pulmonary
  oedema non-invasive ventilation (1069 patients)
• UK study, RCT

Produces more rapid resolution of metabolic
abnormalities and respiratory distress Has no
major effect on 7-day or 30-day mortality Is
beneficial irrespective of the mode (CPAP or
NIPPV) of delivery
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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

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Inotropes

• Inotropic agents should only be administered in
  patients with low SBP or a low measured cardiac
  index in the presence of signs of hypoperfusion
  or congestion.

• Dobutamine
• Positive inotropic agent acting through
  stimulation ß1-receptors to produce
  dose-dependent positive inotropic and
  chronotropic effects.
• The infusion rate may be progressively modified
  according to symptoms, diuretic response.
• The elimination of the drug is rapid after
  cessation of infusion.
• Care should be exercised in weaning patients from
  dobutamine infusion.

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Treatment related to BP
Respiratory support, Furosemide (infusion) IV
Dobutamine plus low dose IV GTN IABP
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Other treatment options

• Vasopressin antagonists
• Unproven
• Levosimendan is a calcium sensitiser that
  improves cardiac contractility
• Exerts significant vasodilatation mediated
  through ATP-sensitive potassium channels

• Levosimendan infusion increases cardiac output
  and stroke volume and reduces pulmonary wedge
  pressure, systemic vascular resistance, and
  pulmonary vascular resistance.
• Vasopressors (norepinephrine) are not recommended
  as first-line agents

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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

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Vasodilators

• Vasodilators relieve pulmonary congestion usually
  without compromising stroke volume or increasing
  myocardial oxygen demand in acute HF.
• Often combined with diuretic inotrope
• Nitrates Predominantly venodilator effect.

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Nesiritide

• Intravenous
• Recombinant form of human B-type natriuretic
  peptide,
• Venous and arterial vasodilator with a combined
  modest diuretic and natriuretic effect.
• Approved by FDA in 2001
• Reduce PCWP (_at_ 3 hrs!)

• Non-invasive BP measurements are usually
  adequate.
• Combination with other i.v. vasodilators is not
  recommended.
• 2005
• 2 meta-analysis? Renal safety

Nesiritide is not available in most European
countries.
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Ascend HF AHA 14th Nov 2010

• 7141 patients
• 11
• Placebo vs Nesiritide

Safe No mortality benefit Minimal symptomatic
improvement
Acute Study of Clinical Effectiveness of
Nesiritide in Decompensated Heart Failure Trial
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Overview Acute Heart Failure

• New ESC guidelines
• Diagnosis
• serum natriuretic peptides
• Non-invasive ventilation
• Inotropes
• Nesiritide
• Cardiac Devices

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What is the rhythm?
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Causes of death in heart failure
NYHA II
I No Limitation II SOB on severe exertion III SOB
on mild exertion IV House bound (SOB at rest)
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(No Transcript)
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Pre-implant counsellingHow do you want to die?

• Heart failure death

• Sudden death

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Device X Rays

• ICD Lead

• BiV LV Lead position

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ICD Myths

• Myths
• ICDs prevent syncope
• Contacts can be electrocuted by ICD discharge
• Not safe to use mobile phone, mircowave,
  playstation etc.
• Will stop you dying from VF
• Diathermy kills patients devices
• PPM may inhibit (pulse oximetry)
• ICD will detect as VF (reprogram)

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Consequences of tachycardia therapy

• VT Storm

• Inappropriate shocks

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End of life issues NECVN
Ventricular arrhythmias and/or poor LV function ?
is an ICD indicated ? Temporarily disabled with a
ring magnet
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The Future?
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The Reality
Intrathoracic Impedance Concept
Drier lungs means the intrathoracic impedance is
higher
Wetter lungs means the intrathoracic impedance is
lower
LessFluid
MoreFluid
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Summary

• Normal BNP makes LVSD very unlikely
• NEGATIVE PREDICTIVE VALUE
• Non invasive ventilation
• Produces more rapid resolution of metabolic
  abnormalities and respiratory distress
• Has no major effect on 7-day or 30-day mortality
• Is beneficial irrespective of the mode
  (CPAP/NIPPV)
• Respiratory support, Furosemide (infusion), IV
  Dobutamine plus low dose IV GTN, ( IABP)
• Nesiritide
• Safe, No mortality benefit, Minimal symptomatic
  improvement
• ICD Temporarily disabled with a ring magnet
• End of life issues NECVN