ControversisControversis Controversies in Cardiac Failure Alan
Gass, M.D., F.A.C.C. Director, Cardiac Transplantation and
Mechanical Circulatory Support Westchester Medical Center Slide 2
Controversies in Cardiac Failure Does adding an ARB to an
ACE-inhibitor help? Is there a role for aldactone / eplerenone in
class I or II HF? Do I need to check a dig level? Which should you
start first, an ACE-inhibitor or BB? Which ACE-inhibitor is the
best? Which BB is better, coreg or toprol xl? Lasix intermittent
bolus or drip? When a patient is admitted for acute decompensated
HF, should you hold, continue, or decrease the BB? For cardiogenic
shock? When a patient is admitted for acute decompensated HF (with
volume overload; assuming no acute renal failure), should you hold,
continue, or decrease the ACE-inhibitor (or ARB)? Does renal dose
dopamine work? Should Lasix be given with hypotension? Are all
Inotropes created equal? PA catheter yes or no? Slide 3
Controversies and Subtleties in HF Does adding an ARB to an
ACE-inhibitor help? Do I need to check a dig level? Which should
you start first, an ACE-inhibitor or BB? Which ACE-inhibitor is the
best? Which BB is better, coreg or toprol xl? Lasix intermittent
bolus or drip? When a patient is admitted for acute decompensated
HF, should you hold, continue, or decrease the BB? For cardiogenic
shock? When a patient is admitted for acute decompensated HF (with
volume overload; assuming no acute renal failure), should you hold,
continue, or decrease the ACE-inhibitor (or ARB)? Does renal dose
dopamine work? Should Lasix be given with hypotension? Are all
inotropes created equal? Slide 4 Valsartan in CHF: ValHeFT. Cohn et
al. NEJM 2001 NYHA II-IV HF, 5010 pts, RCT, Valsartan 160 BID vs
placebo Slide 5 In 1610 pts on both Ace and BB, increased mortality
Slide 6 2548 pts class II-IV HF, EF Rathore et. Al. Association of
Serum Dig Concentration and Outcomes JAMA 2003 Post-hoc analysis of
DIG trial, anlaysis of only men 0.5-0.8: 29.9% mortality (6.3%
lower mortality compared with placebo) 0.9-1.1: 38.8% mortality (no
sig difference from placebo) >1.2: 48% (p=0.006 for trend);
11.8% higher mortality compared with placebo Slide 14 >1.2 ng/ml
0.5-0.8 ng/ml Conclusion: dig level 0.5-0.8 likely represents ideal
target for men and especially women Slide 15 Class IIa In 2005
update digoxin changed from class I to IIa recommendation because
of narrow therapeutic window and no affect on mortality Digitalis
can be beneficial in pts with current or prior HF symptoms and
reduced EF to decrease hospitalizations LOE B Slide 16
Controversies in Cardiac Failure Does adding an ARB to an
ACE-inhibitor help? Do I need to check a dig level? Which should
you start first, an ACE-inhibitor or BB? Which ACE-inhibitor is the
best? Which BB is better, coreg or toprol xl? Lasix intermittent
bolus or drip? When a patient is admitted for acute decompensated
HF, should you hold, continue, or decrease the BB? For cardiogenic
shock? When a patient is admitted for acute decompensated HF (with
volume overload; assuming no acute renal failure), should you hold,
continue, or decrease the ACE-inhibitor (or ARB)? Does renal dose
dopamine work? Should Lasix be given with hypotension? Are all
inotropes created equal? PA catheter yes or no? Slide 17 ACE-I vs
beta blocker first? Most common practice is to start with ACE-I,
then add BB (since historically, the BB trials were done with
ACE-inh as background therapy) CIBIS III 1010 pts (mean EF 28%, age
72, mild to mod HF, stable, randomized to bisoprolol or enalapril
for 6 months then combination for 6-24 months Willenheimer et al.
Effect on Survival and Hosp. of Initiating Treatment for CHF with
Bisoprolol followed by Enalapril as comparted with opposite
sequence. CIBIS III Circ 2005 Slide 18 Slide 19 SUDDEN DEATH PUMP
FAILURE DEATH BISOPROLOL FIRST Slide 20 Guidelines Class I
recommendation for both ACE-inh and BB for any LV dysfunction No
comment on the order, but discussion does state that ACE-inh were
historically already on-board when BB started; and that ACE-inh
dose can be low, so as to allow starting BB to decrease arrhythmic
death rate Slide 21 Controversies in Cardiac Failure? Does adding
an ARB to an ACE-inhibitor help? Do I need to check a dig level?
Which should you start first, an ACE-inhibitor or BB? Which
ACE-inhibitor is the best? Which BB is better, coreg or toprol xl?
Lasix intermittent bolus or drip? When a patient is admitted for
acute decompensated HF, should you hold, continue, or decrease the
BB? For cardiogenic shock? When a patient is admitted for acute
decompensated HF (with volume overload; assuming no acute renal
failure), should you hold, continue, or decrease the ACE-inhibitor
(or ARB)? Does renal dose dopamine work? Should Lasix be given with
hypotension? Are all inotropes created equal? PA catheter yes or
no? Slide 22 1987 1992 1991 1993 Slide 23 Controversies and
Subtleties in HF Does adding an ARB to an ACE-inhibitor help? Do I
need to check a dig level? Which should you start first, an
ACE-inhibitor or BB? Which ACE-inhibitor is the best? Which BB is
better, coreg or toprol xl? Lasix intermittent bolus or drip? When
a patient is admitted for acute decompensated HF, should you hold,
continue, or decrease the BB? For cardiogenic shock? When a patient
is admitted for acute decompensated HF (with volume overload;
assuming no acute renal failure), should you hold, continue, or
decrease the ACE-inhibitor (or ARB)? Does renal dose dopamine work?
Should Lasix be given with hypotension? Are all inotropes created
equal? PA catheter yes or no? Slide 24 Which beta blocker is
better? No direct comparison of the three approved drugs:
carvedilol (alpha/beta nonselective), metoprolol succinate (b1
selective), bisoprolol (b1 selective) By having more adrenergic
blockade, does coreg have more/less side effects? Alpha blockade
with Coreg? Slide 25 Comparison of carvedilol and metoprolol on
clinical outcomes in patients with CHF: COMET Lancet 2003 Primary
outcome: all-cause mortality or all-cause mortality or all-cause
admission Results: 58 months, all cause mortality 34 vs 40% (coreg
vs metop, p=0.0017, HR 0.83) Slide 26 Decreased arrhythmic deaths
from carvedilol in COMET Slide 27 Guidelines Class 1: Use of 1 of
the 3 beta blockers proven to reduce mortality (i.e., bisoprolol,
carvedilol, and sustained release metoprolol succinate) is
recommended for all stable patients with current or prior symptoms
of HF and reduced LVEF, unless contraindicated No comment about
which beta blocker is best Slide 28 Controversies and Subtleties in
HF Does adding an ARB to an ACE-inhibitor help? Do I need to check
a dig level? Which should you start first, an ACE-inhibitor or BB?
Which ACE-inhibitor is the best? Which BB is better, coreg or
toprol xl? Lasix intermittent bolus or drip? When a patient is
admitted for acute decompensated HF, should you hold, continue, or
decrease the BB? For cardiogenic shock? When a patient is admitted
for acute decompensated HF (with volume overload; assuming no acute
renal failure), should you hold, continue, or decrease the
ACE-inhibitor (or ARB)? Does renal dose dopamine work? Should Lasix
be given with hypotension? Are all inotropes created equal? PA
catheter yes or no? Slide 29 Salvatore et al. Cochrane Database:
meta-analysis of Continuous Infusion vs bolus injection of loop
diuretics in CHF, 2005 8 trials (254 pts) included More urine
output with continuous infusion Hypokalemia/hypomag not
significantly different Based on 2 studies, no difference in
mortality (RR 0.47) Less tinnitus and hearing loss with continuous
infusion (RR 0.06) Insufficient data to recommend one strategy over
the other Felker, GM et al. Circulation: Heart Failure, 2009
Observational data suggest that higher diuretic doses may be
associated with risk of worsening renal function, heart failure
progression, or death Slide 30 Thomson et al. Continuous vs
Intermittent Infusion of Furosemide in ADHF. J Card Fail 2010
Prospective, randomized, parallel-group study, 56 pts ADHF; Primary
outcome: net urine output Results: more urine output with gtt
Length of stay shortened 6.9 +/- 3.7 vs 10.9 +/- 8.3 d Lasix drip
Slide 31 Acute Heart Failure (1 symptom AND 1 sign) Home diuretics
dose 80 mg and 240 mg furosemide
