Optimal Heart Failure Management Daniel D Borgeson, MD, FACC, FASE Assistant Professor of Medicine Mayo Clinic College of Medicine Mayo Clinic, Rochester, MN Borgeson.daniel@mayo.edu Mayo Clinic Rochester MN November 4th, 2011 Disclosures: None Heart Failure Management LV Systolic Dysfunction Heart failure With normal Left Ventricular Ejection Fraction Tricuspid Regurgitation COPD Sleep Apnea Right Heart Faiure Mitral Regurgitation Cardio-Renal Syndrome Coronary Artery Disease Diabetes Degenerative Joint Disease Dementia Atrial Fibrillation [...]... What about Heart failure with Normal Ejection Fraction Perindopril in Elderly People with Chronic Heart Failure (PEP-CHF 40 HR 0.92 95% CI 0.70-1.21 P=0.545 30 Placebo Heart failure Hospitalization or death 20 (%) Perindopril 10 0 0 1 Pt at risk (no.) 424 374 426 356 Cleland et al European Heart Journal 27:2238 2 3 184 186 70 69 Years CP1265575-2 Perindopril In Elderly with Chronic Heart Failure (PEP-CHF)... at the right dose, for the right reason Heart Failure Management Details Medications that Demonstrated Survival Benefit ACE Inhibitors • Genally thought to be a class effect, first line therapy • Improves survival • Improves LV ejection fraction • Improves symptoms • Renal protective in diabetics • Decrease MI in patients with CAD SOLVD Trial: Congestive Heart Failure 0.3 Event rate Risk reduction=37%... digoxin; follow-up 6 months; placebo (n=84), carvedilol (n=261) *Multicenter Oral Carvedilol Heart Failure Assessment †Mortality was not a planned endpoint in this study Adapted from Bristow et al Circulation 1996;94:2807-2816 ‡P.05 §P=.07 vs placebo vs placebo Use of Carvedilol Added to ACE Inhibitors in Heart Failure • Optimize volume status • Start at the lowest possible dose • 3.125 mg bid • Increase... hazard ratio 0.85, P=0.010 10 0 0.0 0.5 1.0 No at risk Candesartan Placebo Lancet 362, 2003 1,276 1,272 1,176 1,136 1.5 2.0 Years 1,063 1,013 2.5 3.0 3.5 948 906 457 422 CP1154535-25 How about ARB’s in Heart Failure with Normal Left Ventricular Ejection Fraction CHARM Preserved: Cardiovascular Death or ReHospitalization Proportion with CV death or hospital admission for CHF (%) 50 Hazard ratio 0.89 (95%...Individualization of Therapy • Importance of Co-morbidities • Atrial fibrillation (tachycardia) • Hypertension • Ongoing Ischemia • Diabetes • DJD (NSAID use) • Renal failure • Sleep apnea Survival Benefit Pharmacological Therapy YES ACE Inhibitor YES YES Beta Blocker YES YES Aldosterone Inhibitor YES ???? Diuretic YES No Digoxin LBBB CRT . Disclosures: None Heart Failure Management LV Systolic Dysfunction Heart failure With normal Left Ventricular Ejection Fraction Tricuspid Regurgitation COPD Sleep Apnea Right Heart Faiure. Optimal Heart Failure Management Daniel D Borgeson, MD, FACC, FASE Assistant Professor of Medicine Mayo. this be an Atypical Presentation of Coronary artery Disease? Medical Management of Heart Failure Principles of Medical Management • Only Three Types of Medications • Medications that improve