Trial


Heart Failure: Address Following 4 points in Assessment of Heart Failure 

Type 
  • HFrEF / HFpEF / HFpEF, borderline / HFpEF, improved; 
  • Ischemic vs Non-Ischemic
  • Lowest EF …Last EF
Volume Status
  • Compensated / Decompensated 
  • Acute / Acute on Chronic / Chronic 
    • Classification of Acute Decompensation
Functional Status (NYHA I/II/III/IV) 
Worsening 2/2 – ACS/Uncontrolled HTN / Noncompliant to Salt or Med (with reasons for non-compliant) – Rx
 
Treatment:
  • Goal of Acute HF management: No benefit seen on long term survival 
  • Diuretics (2-3 X their home dose, initially IV)
  •  
     
  • ACEI or BB (if already on it, and reasonably good BP) or Aldo ants (see reference)
  • No need to put in Foley cath in floor; daily in/out and weight MUST
 
Goal of Chronic HF management: GDMT (Guideline directed medical therapy)
  • Relieving Congestion
    •  
  • Slowing progression
    • BB
      • Carvedilol Dose_response trial (MOCHA) 1996 Circulation
      • Reverse remodeling is time dependent. 
      • Not much diff between Met S vs Carvedilol. Carv CR is not to be used. 
    • ACEI
    • Aldosterone Antagonist
      • Eplerenone (EMPHASIS-HF; NYHA 2) 
        • EF < 30 or 31-35 with wide QRS
        • Effective at high risk subgroups
          • >75
          • DM
          • eGFR <60
          • SBP <123 
        • Follow them on Day 3, Day 7. Close monitoring of volume status is needed. 
      • Spironolactone in HEpEF (TOPCAT) NEJM 2013
        • More Hyperkalemia, more AKI 
        •  
           
    • BiDil
    • Iva... (SHIFT Trial)
    •  
  • Primary prevention of SCD after MI 
    • Late Post-MI Trials
      • MADIT (1996)
        • Prior MI 
        • NSVT on monitoring
        • LVEF (≤35 percent)
        • Inducible sustained monomorphic VT during electrophysiology study (EPS) that was also inducible after administration of intravenous procainamide
      • MUSTT (1999)
        • Prior MI (4 days post MI to 3 yrs prior)
        • Asymptomatic NSVT  (at least 4 days post MI )
        • EF < 40 
        • Inducible Sustained VT during EPS in a patient with NSVT
        • No history of Sustained VT or V tach (Secondary prevention) 
      • MADIT2 (2002)
        • Prior MI (>30 days of MI or > 3 months of CABG
        • EF <30
      • CABG Patch Trial (1997 NEJM)
        • Severe CAD requiring surgical revascularization
        • LVEF <36 percent
        • Abnormal signal-averaged electrocardiogram
        • No history of sustained ventricular tachyarrhythmia or syncope
      • SCD HeFT (2005 NEJM) 
        • > 40 days post MI 
        • NYHA II-III, 
        • EF < 35
        • CHF present for at least 3 mth prior to randomization with optimal medical management 
      • Bottom line
      • SCE HeFT criteria (No need to fulfill other electrical criteria of MADIT-I due to its absence in SCD HeFT and still had benefit) 
      • MUSTT Trial Data still valid due to EF < 40 % as inclusion criteria 
        • Vs. SCD HeFT: less severe patients but high risk on further Elecrophysiological Study
      • MADIT - II still valid as it was for EF < 30 % and NYHA Class I patients 
        • Vs. SCD HeFT: Less symptoms but higher risk by EF
    • Early POST-MI 
      • DYNAMIT
      • IRIS 
  • Non-MI
    • Dilated Cardiomyopathy
      • CAT
      • AMIOVIRT
      • DEFINITE
CRT / ICD 
  • Who benefits with CRT? 
    • Symptomatic patients: NYHA III - IV 
      • Who are symptomatic patients?
        • Typically Low EF : < 35 %
        • Who have ventricular desynchronization: QRS > 150; QRS > 120 could also be considered as desynchronized ventricle 
  • Typically these patients also qualify for ICD criteria's 
HFpEF
  • TOPCAT (spirinolactone)
  • Control BP
  • Releif of volume overload
  • Coronoary revascularization (IIc)
 
Prevention of HF
  • Post-MI: ACEI or ARB, BB, Statin
  • BNP vs NT-proBNP
    • Normal BNP: around 30
  • BNP Causes of elevation
    • Cardiac Cause
    • Non-cardiac cause: Advancing age, Anemia, Renal Failure, Hypoxia, Toxic-Metabolic insults, Endocrinopathies, Critical Illness, Bacterial Sepsis, Severe burns, Cahectic Syndromes
  • 2013 Guideline has included BNP as a tool to include and exclude diagnosis. It also helps in prognosis.
    • >30 % fall prior to discharge is associated with good prognosis
    • > 30 % rise in outpatient set up in concern for worsening HF 
  • Refe: 
    • Yancy et al, Circ 2013, 
    • Moe et al Can J Cardio 2015
  • Newer biomarker
    • Galectin-3 (IIb) : released by activated macrophages
    • ST-2 (IIb) : soluble ligands of IL-33 which counteracts cardioprotective effects 
    • Does not get affected by age, body habitus, renal function
    • BNP itself may be a marker of preclinical HF diseases 
Non-pharmacoligical 
  • OSA evaluation and CPAP use
  • Exercise
  • Salt restriction
 
Reference:      

2013 ACCF/AHA Guideline for the Management of Heart Failure: DEFINITIONS of HFpEF and HFrEF

 
Heart Failure References
 
Other case based readings on Heart Failure:
 
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desh bandhu Nepal,
Feb 6, 2016, 9:40 PM
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