Acute Decompensated Heart Failure and the Use of Vasodilator Therapy in Canada

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Acute Decompensated Heart Failure and the Use of
Vasodilator Therapy in
Canada
Case-based Study DIAGNOSIS TREATMENT OPTIONS
All trademark rights used under license.
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Session Objectives

• By the end of this session, participants will be
  able to
• Understand how to diagnose acute decompensated
  heart failure (ADHF)
• Identify current treatment goals and options

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Challenges in CHF Management in Multi-system
Disease

• Recognition of heart failure
• Co-morbidities or complications?
• Barriers to appropriate heart failure therapy
• Goals of therapy

Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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Case Study 1 Mr. B

• Presentation
• 65 year-old male smoker
• gt10 years history of hypertension, COPD and
  previous MI
• Chronic cough, minimally productive
• Presents to ER reporting acute onset of shortness
  of breath that awakened him from sleep
• Physical exam
• BP 160/100 mm Hg
• HR 96 beats/min regular
• Normal heart sounds
• RR 30 breaths/min
• Room air O2 sat 92

Fictitious patient profile. May not be
representative of all patients with ADHF.

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Case Study Mr. B

• Jugular Venous Pressure (JVP) 6 cm
• Rales, S3 and S4 heart sounds
• Lab values
• Troponin negative
• Serum creatinine 132.6 µmol/L
• Lipid levels HDL lt45 mg/dL LDL 189 mg/dL TG
  212 mg/dL
• Na 1.1 mmol/L K 4.7 mmol/L
• Blood urea nitrogen 13.56 mmol/L
• No peripheral edema x-ray suggests acute
  pulmonary edema

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CXR Shows Cardiomegaly Without Evidence of Venous
Congestion

• Q1. What diagnosis would you give this patient?
• COPD
• End-stage emphysema
• Reactive airway disease
• ADHF

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Q 2 Which of the Historical Features is Most
Suggestive of CHF as a Cause of his Dyspnea?

• Remote MI
• Cough
• Nocturnal cough
• PND
• Smoking
• He does not have heart failure

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Q 3 Which Physical Exam Feature Best Supports a
Diagnosis of CHF?

• High JVP
• Presence of AF
• S3
• Holosystolic murmur
• Quiet heart sounds
• He does not have heart failure

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Positive Likelihood Ratios for
Heart Failure (in ER)

• Past history CHF 5.8
• PND 2.6
• S3 11
• CXR venous congestion 12
• EKG AF 3.8

Wang CS et al. JAMA 20052941944-56.
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Negative Likelihood Ratios for
Heart Failure (in ER)

• No rales (crackles) 0.51
• No past CHF 0.45
• No SOBOE 0.48
• CXR without cardiomegaly 0.33
• EKG normal 0.64

Wang CS et al. JAMA 20052941944-56.
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Clinical Presentation of AHF
Data from ADHERE database (Acute Decompensated
Heart Failure National Registry in the US)

• Dyspnea in 89 of patients at presentation
• Rales in 68
• Peripheral edema in 66
• SBP lt90 mm Hg in lt3

Adams KF et al ADHERE Scientific Advisory
Committee and Investigators. Am Heart J
2005149209-16.
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Signs of Heart Failure

• Elevated neck veins (jugular venous pressure)
• Positive abdominojugular reflux
• Rales or evidence of pleural effusion
• S3
• Ascites
• Lower extremity edema

Arnold JMO et al. Can J Cardiol 200622(1)23-45.
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Difficulties in Diagnosing Heart Failure

• Can be a wide range of presentations
• Many of the symptoms of heart failure overlap
  with other disease states such as COPD, obesity,
  nephrotic syndrome, drug- induced edema,
  cirrhosis and sleep apnea
• How to effectively and efficiently differentiate
  between these entities?

Arnold JMO et al. Can J Cardiol 200622(1)23-45.
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Bedside Cardiovascular Examination in Patient
with CHF

• Did careful physical exam on heart failure
  patients about to undergo a right heart
  catheterization
• 52 patients, mostly NYHA III, average EF 18

Butman SM et al. J Am Coll Cardiol
199322(4)968-74.
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Bedside Cardiovascular Examination in Patient
with CHF

• If rales were present, all had a wedge pressure
  gt18, very specific
• However, only 9 of 37 with a wedge pressure gt18
  had rales, very insensitive
• Soclear lung fields tell you very little about
  the fluid status in heart failure

Butman SM et al. J Am Coll Cardiol
199322(4)968-74.
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Bedside Cardiovascular Examination in Patient
with CHF

• Only 3 of 15 with a low PCWP had a high JVP or
  positive abdominojugular reflux test, spec of 80
  
• 30 of 37 with a high wedge had either a high JVP
  or positive abdominojugular reflux test,
  sensitivity of 81
• So a careful examination of the neck veins is the
  best physical exam technique for determining the
  fluid status in heart failure

Butman SM et al. J Am Coll Cardiol
199322(4)968-74.
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How Good are Existing Tools for Diagnosing Heart
Failure?
In ED, clinical misdiagnosis occurs in 25-50 of
patients presenting with decompensating
HF (Agency for Health Care and Research 1994)
Dao Q et al. J Am Coll Cardiol 200137379-85.
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Therapeutic Goals for ADHF
1. Fonarow GC. Rev Cardiovasc Med
20023(4)S18-S27. 2. Stier CT Jr et al. Cardiol
Rev 20021097-107.

3. Masai T et al. Ann
Thorac Surg 200273549-55. 4. VMAC. JAMA
20022871531-40.
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ADHF Clinical Presentation in US

• HF with SBP gt140 mm Hg (50)
• HF with SBP 90 140 mm Hg (47)
• HF with SBP lt90 mm Hg (3)
• Cardiogenic shock (lt1)
• Pulmonary edema(lt3)
• CXR in 90 Radiographic pulmonary
  congestion in 76
• Isolated right-sided HF (?)
• ACS with HF
• 30 of ACS have HF, 10 of AHFS have ACS

Fonarow GC et al. Rev Cardiovasc Med 20034(Suppl
7)21.
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Clinical Assessment and Outcomes of Patient with
Severe CHF
Nohria A et al. J Am Coll Cardiol
2003411797-1804.
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What are the Guidelines and Recommendations for
Treating Patients with ADHF?
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Current Guidelines for ADHF
1. HFSA J Card Fail 200612(1)e86-103. 2.
Nieminen MS et al. Eur Heart J 2005. 3. Arnold
JMO et al. Can J Cardiol 200622(1)23-45. 4.
Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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Treatment Algorithm for Acute HF
Arnold JMO et al. Can J Cardiol 200622(1)23-45.
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Mr. B is Admitted to the Ward and Diuretics are
Administered
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Mr. Bs Diuretic Treatment Was Increased. How
Did He Respond?

• Remains dyspneic minimal relief of symptoms
• Moderate increase in SCr
• Mr. B is, therefore, still wet
• BP remains elevated

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Day 1 15 to 30 Minutes AfterInitiation of
Vasodilator Therapy

• Patient characteristics indicate Mr. B is an
  appropriate candidate for nesiritide
• BP decreases by 20
• Symptom relief Mr. B appears more comfortable,
  breathes better, less volume overload
• He went on to recover and was ultimately
  discharged on day 5 to follow up with family MD
  and with HF clinic

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Day 2

• Mr. B is asymptomatic at rest
• No S3, no rales
• JVP 3 cm
• Diuretic dose is changed to oral form
• Chronic meds are optimized
• Mr. B is assessed to be euvolemic IV nesiritide
  discontinued

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Case Study 2 Old and SOB

• 85 year old female with SOBOE for 3 months
• Flu 12/03 (cough, SOB, fever, mild leg edema LgtR)
• Dx viral pneumonia in ER antibiotics
• CXR in ER ? nodule with subsequent CT 03/04 fine
  interstitial pattern
• 3 days ago ER with progressive dyspnea NYD (seen
  and discharged with antibiotic and puffer)
• Return to ER complaining of dyspnea

Fictitious patient profile. May not be
representative of all patients with ADHF.
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Case 2 Old SOB

• PMH
• Longstanding depression/ anxiety disorder
• ? MI 1973 (never hospitalized)
• Medication
• Elavil and Clonazepam

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Examination (off service resident)

• BP162/96 mm Hg
• HR102 beats/min T36.2 C RR26 breaths/min
• Mild respiratory distress
• JVP not sure
• Chest a few creps
• Normal heart sounds
• Mild asymmetric edema RgtL

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Q4 Does Old SOB Have CHF?

• Definitely yes
• Possibly
• Probably not
• Definitely not

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Elderly Clinical Features CHF

• Delirium
• Falls
• Functional decline
• Sleep disturbance
• Nocturia/incontinence
• Dyspnea uncommon if sedentary

• Ankle edema
• Other causes
• Sacral edema
• Pulmonary findings non-specific

Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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Investigations

• O2 sat 90 on RA
• WBC 12 left shift, HB 110 NCNC
• Cr 140 µmol/L
• CK and Tn I normal
• D-dimer positive

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EKG
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Further Investigations

• pH 7.50
• pCO2 28
• pO2 82
• Bicarb. 22
• Saturation 3 litres
• Leg dopplers negative
• Spirometry poor effort

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Q5 What is the Next Most Appropriate
Investigation?

• Await response to clinical treatment (lasix, O2,
  antibiotics, heparin, steroids)?
• Obtain more history?
• Spiral CT to R/O PE?
• Echocardiogram?
• BNP?

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Diagnosis of HF

• Best clinician diagnosis is about 801
• Average time in ER before diuretic is 3 hours
• Most common drugs in ER Salbutamol, antibiotics,
  furosemide
• Worsening renal function in hospital is
  associated with poor prognosis2
• So we wish to avoid inappropriate diuretic while
  maximizing use when indicated
• Better diagnostic methods needed2
• BNP, NT- pro-BNP
• IMPROVE- CHF CANADA Study3

1. Maisel A. Rev Card Med 20023(Suppl 4)S10-7.
2. Arnold et al. Can J Cardiol 200622(1)23-45.
3. Moe GW et al. Circulation 20071153103-10.
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B-Type Natriuretic Peptide (BNP)

• 32-amino acid peptide secreted primarily from the
  ventricles of the heart
• Released in response to stretch and increased
  volume in the ventricles
• BNP levels correlate with
• Left ventricular end-diastolic pressure and
  volume
• New York Heart Association (NYHA) functional
  classification
• Extent of reversible ischemia
• Rapid, point-of-care assay for BNP now available
  to facilitate diagnosis of CHF and use as a
  prognostic marker

Moe GW. Heart Fail Monitor 20054(4)116-22.
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Processing of the Human BNP Gene
Hino J et al. Biochem Biophys Res Comm
1990167693-700.
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Physiology of BNP
1. Marcus LS, et al. Circulation
1996943184-89. 2. Zellner C et al. Am J Physiol
1999276(3 pt 2)H1049-57. 3. Tamura N et al.
Proc Natl Acad Sci USA. 2000974239-44. 4.
Abraham WT et al. J Card Fail 1998437-44. 5.
Clemens LE et al. J Pharmacol Exp Ther
199828767-71. 6. Rayburn BK, Bourge RC. Rev
Cardiovasc Med 20012(Suppl 2)S25-31. 7. Akerman
MJ et al. Chest 200613066-72.
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Causes of Increased BNP

• LV systolic dysfunction
• LVH with diastolic abnormalities
• Significant pulmonary embolism
• Cor pulmonale
• Pulmonary HTN
• Aging (modest increases)
• Renal insufficiency

Moe GW. Heart Fail Monitor 20054(4)116-22.
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BNP Concentration for the Prediction of Clinical
Events
Death or Heart Failure Hospitalization
Harrison A et al. Ann Emerg Med 200139(2)131-38.
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The BNP Study First Evidence that Adding BNP to
Testing Improves Diagnostic Accuracy
Strunk A et al. Am J Medic 200611969. e1-11
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Earlier BNP Studies

• Breathing Not Properly Study1
• US sites with BNP gt1000 patients
• Improved diagnostic accuracy and AUC
• BASEL study2
• Single centre Swiss study of BNP with 500
  patients
• Improved accuracy, shorter ER times, less cost
• PRIDE3
• Single city Boston (US) study with NT-pro-BNP and
  approximately 1,000 patients
• Improved diagnostic accuracy, age-related
  cutpoints

1. Maisel A et al. J Am Coll Cardiol
200341(11)2018-212. 2. Mueller C et al. N Engl
J Med 2004350(7)647-54. 3. Januzzi JL et al.
Am J Cardiol 200595(8)948-54.
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Do BNP Levels Help Diagnose Those with Acute
Dyspnea?
Knudsen CW et al. Am J Med 2004116(6)363-8. .
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The IMPROVE-CHF Study
Moe GW et al. Circulation 20071153103-10.
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Moe GW et al. Circulation 20071153103-10.
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IMPROVE-CHF NT-proBNP and Dyspnea
Moe GW, et al. Circulation 20071153103-10.
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NT-proBNP Complements Clinical Judgment
Moe GW et al. Circulation 20071153103-10.
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Clinical Outcomes, Evaluation With and Without
Natriuretic-Peptide-Test Guidance
Moe GW et al. Circulation 20071153103-10.
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Average Direct Medical Costs (in US) Through
60 Days, Evaluation With and Without BNP
Guidance
Moe GW et al. Circulation 20071153103-10.
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What Does the CCS Say about BNP Testing?

• Recommendations
• BNP or NT-proBNP should be measured to help
  confirm or rule out a diagnosis of HF in the
  acute or ambulatory care setting in patients in
  whom the clinical diagnosis is in doubt
  (Class I, Level A)
• Measurement may also be considered in patients
  with known HF for prognostic stratification
• (Class IIa, Level A)
• Sequential measurement of BNP/NT-proBNP levels
  may be considered to guide therapy in HF patients
  
• (Class IIb, Level B)

Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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BNP/NT-proBNP in Heart Failure

• Practical Tips
• Biomarkers such as BNP and NT-proBNP are
  complementary to, but do not replace, good
  clinical evaluation
• No compelling factors favor the use of BNP versus
  NT-proBNP
• The choice of assay is dictated by
• availability
• clinicians familiarity and ability to interpret
  the results

Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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BNP and NT-proBNP In HF
Cut Points for HF Diagnosis
Arnold JMO et al. Can J Cardiol 200723(1)21-45.
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First Medications Used in the ED
1. Tsuyuki R et al. Can J Cardiol 200521(Suppl
C)93C, Abstract 225. 2. Steinhart B et al.
Annals of Emerg Med 200851(4)509. 3. ADHERE
Final Cumulative Report 2006.
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Hospital Course

• Admitted
• Treated with O2, lasix (40 mg IV)
• No heparin
• No antibiotics
• Bronchodilators
• Morning diuresed 2.5 litres
• feel better than in months

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Case Study 3 Mr. S Is this Heart Failure?

• 57 year old obese, type 2 DM, hypertensive,
  ex-smoker (30
  packs/year)
• Biopsy proven stage 3 sarcoid Jan 02
• Prednisone with good effect, tapered off Nov 02
• Dec 02 increasing cough, SOBOE, wheeze, orthopnea

Fictitious patient profile. May not be
representative of all patients with ADHF.
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Case 3

• 1/52 PTA (Mar 03) increasing dyspnea
• Respirology may need to restart prednisone but
  little change in CXR
• Presents to the ER complaining of increased SOB
• Meds
• Adalat XL 60
• HCTZ
• Flovent 2 puffs BID

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Case 3

• BP140/80 mm Hg HR112 beats/min T37.6 C
• RR28 breaths/min in moderate distress
• O2 78 increased to 90 with FiO2 0.4
• JVP 7-8 cm, cool extremities
• Crackles at both bases
• ? Increased P2
• Mild edema
• Cr 155 µmol/L (was normal)
• WBC 15K
• pH7.45 PCO2 39 PO2 59 Bicarb 27 on
  Sat 40 (A-a 177)

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EKG
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Mar 03
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Aug 02
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Case 3

• Reviewed by attending respirologist who notes
• acute decline
• change in exam and feels she must be in CHF due
  to rapidity of decline and physical findings

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Q6 Is this CHF?

• Definitely yes
• Possibly
• Probably not
• Definitely no

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Q7 What Test Should be Done Next?

• Serum ACE
• Bronchoscopy
• High resolution CT chest
• Echocardiogram
• BNP

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Results

• BNP was 20 pg/mL
• Echo revealed normal LV function and moderate
  pulmonary hypertension (RVSP 55)
• CT angiogram showed no evidence of PE

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What Features Suggested This was Not CHF?

• Degree of hypoxia in a stable patient?
• Extent of CXR abnormality discordant with
  clinical assessment?
• Course of clinical worsening?

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Conclusions

• Diagnosis of CHF in multi-system disease is
  challenging
• Co-morbidities are common, mask the diagnosis of
  CHF, limit therapeutic options, and negatively
  impact prognosis
• BNP may aid in the diagnosis of CHF in this
  patient population