DIAGNOSIS OF HEART FAILURE Aaron Sverdlov

DIAGNOSIS OF HEART FAILURE

Aaron SverdlovMBBS PhD FRACP FCSANZ FESC FHFA FACC

Heart Foundation Future Leader Fellow

Associate Professor & Director of Heart Failure

• University of Newcastle & HMRI

Clinical Lead

• Heart Failure Service HNELHD

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Outline• Definition of Heart Failure• Burden of Heart Failure• Types of Heart Failure and why do we care• Diagnosis of Heart Failure• Important co-morbidities to consider

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Definition

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HF is a clinical syndrome characterized by typical

symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonarycrackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or

elevated intracardiac pressures at rest or during stress.

Ponikowski P et al, Eur Heart J 2016; 37, 2129–2200

HF represents global health burden

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HF is common and the prevalence is

growing

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• 1 in 5 people aged 40 years and over will develop heart failure in their lifetime1

• It is the most rapidly growing cardiovascular condition2,3

• Prevalence of HF is predicted to increase in developed countries because of ageing populations: in the US is estimated to increase by 46% between 2012-20304

Projections of HF prevalence in the US (2010-2030)4

2010 2015 2020 2025 2030

Year

Pre

vale

nce

of H

F %

HF= heart failure.1. Lloyd-Jones DM, et al. Circulation. 2002;106(24):3068-72; 2. McMurray JJV, Stewart S. Eur Heart J Suppl. 2002;4:D50–D58; 3. Ponikowski, P, et al. ESC 2014. Available at: http://www.escardio.org/communities/HFA/Documents/whfa-whitepaper.pdf; 4. Heidenreich PA, et al. Circulation. 2013;6:606-619.

46%

2.8

3.0

3.1

3.33.5

http://www.escardio.org/communities/HFA/Documents/whfa-whitepaper.pdf

Australian data

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Additional 536,000 with

HFPEF

NSW burden of Heart Failure

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Probability of survival with HF compared to 4 common cancers

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• Approx 2000 admissions per annum• 69% annual re-admission or death• 29% 30-day re-admission or death• 50% mortality at 2.7 years• 20% 30-day re-admission rate

Not decreasing over time

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Australian statistics

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Australian Institute of Health and Welfare:Bulletin 141; September 2017 Trends in cardiovascular deaths

Why is heart failure such a serious problem?

Heart Failure is a price we pay for the successful

treatment of other forms of heart disease

• Most successful treatments of heart disease do not CURE heart disease• ACS• Chronic CAD• Hypertension• Valvular heart disease• Congenital heart disease

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Classification of Heart Failure - I

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Classification of Heart Failure - II

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Yancy CW et al, JACC 2013; 62:1495-539

Why is classification important?Newest guidelines

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ESC Heart Failure Guidelines for HFrEF (2016)

HFREF – Heart failure with reduced ejection fraction (EF<40%)1. Ponikowski P et al. Eur Heart J 2016.

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Treatment of HFpEF

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• “No treatment has yet been shown, convincingly, to reduce morbidity and mortality in patients with HFPEF”.

Diuretics are used to control sodium and water retention and relieve breathlessness and oedema. Adequate treatment of hypertension and myocardial ischaemia is also considered to be important, as is control of the ventricular rate in patients with AF.

ESC Guidelines. European Heart Journal (2016) 37,2129-2200.

• 2166 patients followed over 3 years

• 62% HFrEF

• 38% HFpEF

• 16.2% had HFpEF with previous

evidence of LVEF < 40%

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Kalogeropoulos, A. et al. JAMA Cardiology 2016;1(5):510-518

HFpEF: Disease on the rise

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Shah SJ, Curr Heart Fail Rep 2013; 10(4): 401-10

N=110,621 patients hospitalized with HF;P<0.0001 for trend of increased HFpEF prevalence*

Proposed mechanisms

Altered calcium signaling

Impaired energetics

Altered matrix

Altered titin fx

Altered sarcomeric fx

Etc, etc

Metabolic syndrome

ObesityDiabetes

Hypertension

Increased TG

Decreased HDL

HFpEF: Clinical causes and mechanisms

Adapted from Shah, A. M. & Pfeffer, M. A. (2012) Nat. Rev. Cardiol. doi:10.1038/nrcardio.2012.1230

Diastolic dysfunctionLeft ventricular hypertrophy

Energetic Impairment

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HFpEF: SurvivalDismal survival rate at 5 years after heart failure hospitalization, significantly worse for elderly patients

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Owan T et al. N Engl J Med 2006;355:251-259

35% survival at 5 years after HF hospitalization, regardless of LVEF

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25

30

35

40

45

50

55

60

50 55 60 65 70 75 80 85

Pre

dic

ted

% m

ort

alit

y w

ith

in 3

ye

ars

Age (years)

EF:40+

EF:<30

Mortality rate increases with age, especially in patients with EF > 40

Pocock et al Eur. Hart J 2013; 34 1404-1413

HFpEF: NOTHING WORKS WELL

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Definition

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HF is a clinical syndrome characterized by typical

symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonarycrackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or

elevated intracardiac pressures at rest or during stress.


Key features of a heart failure diagnosis

• IS IT HF & WHY?

• WHAT TYPE?

• WHY NOW?

• SEVERITY?

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How do we diagnose heart failure?27


Breathlessness is

almost universal

Consider aetiologies of heart failure28


Diagnostic algorithm for non-acute HF29


Natriuretic peptide evidence

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Roberts E et al. The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta-analysis in the acute care setting. BMJ 2015;350:h910.

2016 ESC Key diagnostic criteria for HFpEF

• Preserved EF

• Structural alterations

• Functional alterations

• Natriuretic peptides

• ≥ 50%

• LAVI > 34ml/m2 or• LVMI ≥ 115 (M)/ ≥95 (F)

• E/e` ≥ 13• e` < 9 cm/s

• NT-proBNP > 125pg/ml or• BNP > 35pg/ml

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Presented by Prof Burkert Pieske at Heart Failure 2018, Vienna, Austria on 28th of May 2018

Key diagnostic imaging tests in non-acute setting• CXR – predominantly only useful for diagnosis of alternative

causes• Echocardiography – single most useful diagnostic test in

Heart Failure• Systolic and diastolic function• Evidence of past MIs• Valvular function• Pulmonary pressures/RV function

• Stress testing/CTCA – to exclude ischaemic aetiology• CMR – gold standard for volumes, mass and EF. Indicated

where good quality echo cannot be obtained and for certain specific causes of HF (infiltrative/non-compaction/Fabry etc)

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Ponikowski P et al, Eur Heart J 2016; 37, 2129–2200Yancy CW et al, JACC 2013; 62:1495-539

Other tests to address: Why Now?Ischaemia / ACSArrhythmiaUncontrolled hypertensionInfectionWorsening renal failureAdverse medication usage (NSAIDs)Non-complianceNon-pharmacological (salt, fluid, alcohol) MedicationsOther (anaemia)

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Comorbidities among chronic conditions

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HFpEF: Projected burden of risk factors

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Common & commonly forgotten comorbidities

• Hypertension• Coronary Artery Disease • Renal failure• Obesity• Diabetes• Thyroid dysfunction• Iron deficiency• Sleep apnoea

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Iron Supplementation in HF• Iron deficiency is associated with a worse prognosis• Only IV ferric carboxymaltose has been shown to be effective!• FAIR-HF: improvement in NYHA class and global assessment• CONFIRM-HF: improvement in exercise capacity &

hospitalization

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61%

Anker SD, et al. N Engl J Med 2009;361:2436–2448Ponikowski P, et al. Eur Heart J. 2015;36:657-68.Jankowska EA ,et al. Eur Heart J 2014; 35:2468–2476

Yancy et al. 2017 ACC/AHA/HFSA focused update to the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017

Sleep apnoea in HF

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Khayat R, et al. Eur Heart J 2015;36:1463–1469.

Adaptive servo-ventilation for CSA in HFrEF

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Angermann C, et al. N Engl J Med 2015;373:1095–1105.

Sleep apnoea50

Yancy et al. 2017 ACC/AHA/HFSA focused update to the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017

Summary I

• HF is common with various aetiologies, leading to a global burden and significant medical costs

• Despite improvements in overall CVD mortality, outcomes for patients with HF are poor and have not improved in the last decade

• HF prevalence is on the rise mainly due to HFpEF• HFpEF is not easy to diagnose and even harder to treat• Identification and management of co-morbidities is paramount

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Summary – Diagnosis 101The key components of HF diagnosis are:• Thorough history including attention to:

• Potential aetiologies of HF• Conditions know to co-exist frequently with HF• Conditions which can precipitate HF

• Physical examination• ECG & CXR (more useful in acute HF)• Natriuretic peptides if available (and may reduce

unnecessary echocardiography)• Echocardiography, echocardiography,

echocardiography

• Advanced assessment, including access to Cardiologists, CMR, CPET, Cathlab

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