Best of heart failure

64 3. Solomon SD, Dobson J, Pocock S, Skali H, McMurray JJV, Granger CB, Yusuf S, Swedberg K, Young JB, Michelson EL, Pfeffer MA, for the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Investigators (2007) Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation 116(13):1482 – 1487 4. Ramirez A, Abelmann WH (1974) Cardiac decompensation. NEJM 290(9):499 – 501 5. Peacock WF, Braunwald E, Abraham W, Albert N, Burnett J, Christenson R, Collins S, Diercks D, Fonarow G, Hollander J, Kellerman A, Gheorghiade M, Kirk D, Levy P, Maisel A, Massie BM, O'Connor C, Pang P, Shah M, Sopko G, Stevenson L, Storrow A, Teerlink J (2010) National Heart, Lung and Blood Institute working group on emergency department management of acute heart failure: research challenges and opportunities. JACC. 56(5): 343 – 351 6. Hamo CE, Butler J, Gheorghiade M, Chioncel O (2016) The bumpy road to drug development for acute heart failure. Eur Heart J Supp 18(Supplement G):G19 – G32 7. Gheorghiade M, Braunwald E (2011) A proposed model for initial assessment and management of acute heart failure syndromes. JAMA 305:1702 – 1703 8. Ponikowski P, Voors AA, Anker SD et al (2016) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association of the ESC. Eur Heart J 37(27):2129 – 2200 9. Cleland JG, Pennel D, Ray S, Murray G, MacFarlane P, Cowley A, Coats A, Lahiri A (1999) The Carvedilol Hibernation Reversible Ischemia Trial: Marker of Success (CHRISTMAS). Eur J Heart Fail 1:191 – 196 10. Cleland JG, Pennell DJ, Ray SG, Coats AJ, Macfarlane PW, Murray GD, Mule JD, Vered Z, Lahiri A, Carvedilol hibernating reversible ischaemia trial: marker of success investigators, On be- half of the CHRISTMAS (Carvedilol Hibernating Reversible Ischaemia Trial: Maker of Success) investigators (2003) Myocardial viability as a determinant of the ejection fraction re- sponse to carvedilol in patients with heart failure (CHRISTMAS trial): randomised controlled trial. Lancet 362:14 – 21 11. Greene SJ, Vaduganathan M, Gheorghiade M (2017) Finding the road to recovery: therapeutic and clinical trial implications of dys- functional viable myocardium in heart failure with reduced ejection fraction. Eur J Heart Fail 19(7):870 – 872 12. Adamsom PB, Magalski A, Braunschweig F et al (2003) Ongoing right ventricular hemodynamics in heart failure: clinical value of measurements derived form an implantable monitoring system. J Am Coll Cardiol 41:565 – 571 13. Zile MR, Bennett TD, St John Sutton M et al (2008) Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 118(14):1433 – 1441 14. Stevenson LW, Perloff JK (1989) The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 261:884 – 888 15. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen D, Zannad F, Anker SD, Rhodes A, McMurray J, Filippatos G, European Society of Cardiology, European Society of Intensive Care Medicine (2010) Assessing and grading congestion in acute heart failure. Eur J Heart Fail 12(5):423 – 433 16. Ambrosy AP, Khan H, Udelson JE, Mentz RJ, Chioncel O, Greene SJ, Vaduganathan M, Subacuis HP, Konstam MA, Swedberg K, Zannad F, Maggioni AP, Gheorghiade M, Butler J (2016) Changes in dyspnea status during hospitalization and post- discharge health-related quality of life in hospitalized patients with heart failure: findings from the EVEREST trial. Circ Heart Fail. 9: e002458 17. Pang PS, Collins SP, Sauser K, Andrei AC, Storrow AB, Hollander JE, Tavares M, Spinar J, Macarie C, Raev D, Nowak R, Gheorghiade M, Mebazaa A (2014) Assessment of dyspnea early in acute heart failure: patient characteristics and response differ- ences between Likert and visual analog scales. Acad Emerg Med 21(6):659 – 666 18. AbouEzzeddine OF, Lala A, Khazanie PP et al (2016) Evaluation of a provocative dyspnea severity score in acute heart failure. Am Heart J 172:34 – 41 19. McGee S, Abernethy WB, Simel DL (1999) The rational clinical examination. Is this patient hypovolemic? JAMA 281:1022 – 1029 20. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen D, Zannad F, Anker SD, Rhodes A, McMurray J, Filippatos G, European Society of Cardiology, European Society of Intensive Care Medicine (2010) Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 12:423 – 433 21. Felker GM, Cuculich PS, Gheorghiade M (2006) The Valsalva maneuver: a bedside ‘ biomarker ’ for heart failure. Am J Med 119: 117 – 122 22. Knowles JH, Gorlin R, Storey CF (1956) Clinical test for pulmonary congestion with use of the Valsalva maneuver. JAMA 160:44 – 48 23. Weilenmann D, Rickli H, Follath F, Kiowski W, Brunner-la Rocca HP (2002) Noninvasive evaluation of pulmonary capil- lary wedge pressure by BP response to the Valsalva maneuver. Chest 122:140 – 145 24. Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW, ESCAPE Investigators and ESCAPE Study Coordinators (2005) Evaluation study of congestive heart failure and pul- monary artery catheterization effectiveness: the ESCAPE trial. JAMA 294:1625 – 1633 25. Chioncel O, Collins SP, Greene SJ, Ambrosy AP, Vaduganathan M, Macarie C, Butler J, Gheorghiade M (2016) Natriuretic peptide- guided management in heart failure. J Cardiovasc Med 17(8): 556 – 568 26. Seino Y, Ogawa A, Yamashita T, Fukushima M, Ogata KI, Fukumoto H, Takano T (2004) Application of NT-proBNP and BNP measurements in cardiac care: a more discerning marker for the detection and evaluation of heart failure. Eur J Heart Fail 6(3): 295 – 300 27. Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M, ADHERE Scientific Advisory Committee and Investigators (2007) Admission B-type natriuretic peptide levels and in-hospital mortal- ity in acute decompensated heart failure. JACC. 49:1943 – 1950 28. Cohen-Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A (2009) Lowered B-type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with im- proved survival in patients with severe acutely decompensated heart failure. JACC 53(25):2343 – 2348 29. Ferre RM, Chioncel O, Pang PS, Lang RM, Gheorghiade M, Collins SP (2015) Acute heart failure: the role of focused emergen- cy cardiopulmonary ultrasound in identification and early manage- ment. Eur J Heart Fail 17:1223 – 1227 Heart Fail Rev (2018) 23:597 – 607 605 recommended to be increased after 2 – 4 weeks as tolerated to reach the target 97/103 mg twice daily. Sacubitril-valsartan should not be given concomitantly it ACE in ibitors due to risk for ngioedema, and ACE inhibitor treatment should be stopped for 36 h before starting treatment with ARNI. For patients with eGFR < 30 mL/min/1.73 m 2 or moderate hepatic impairment, the starting dosage of ARNI is 24/26 mg twice daily and ARNI is n t recommended for patients with sever hepatic impairment [ 38 ]. With the results of the PARADIGM trial, several new rec- ommendations have been added to the 2017 Focused Update HF Guidelines. First, for patients who are not treated with ACE inhibitors or angiotensin receptor blockers, the initial strategy of RAS inhibition can include either an ACE inhibitor or ARB or ARNI. The guidelines specify that the clinical strategy of inhibition of the RAS wi h ACE inhibitors (level of evidence: A), or ARBs (level of evidence: A), or ARNI (level of evidence: B – R) in conjunction with evidence-based beta-blockers and aldosterone antagonists in selected patients is recommended fo atients with chronic HFrEF to r duce morbidity and mortality [ 1 •• ]. In the 2017 Focused Update of HF Guidelines, in patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality [ 1 •• , 36 •• ]. In those patients who are being considered to be switched to ARNI from ACE inhibitors, it is very important to note that ARNI should not be administer d concomitant y with ACE inhibitors or within 36 h of the last dose of an ACE inhibitor due to angioedema risk [ 1 •• , 35 ]. Similarly, ARNI should not be administered to patients with a history of angio- edema [ 1 •• ]. In the studies with combine neprilysin a ACE inhibition, blacks and smokers were particularly at risk for angioedema [ 35 ]. It is helpful for patients receiving ARNI to be educated about recognition of the symptoms of angioede- ma and to ale t health care providers against concomitant pre- scription of ACE inhibitors with ARNI. In a phase II trial in patients with heart failure with pre- served ejection fraction, LCZ696 reduced NT-proBNP to a greater extent than did val artan at 12 weeks and was well tolerated [ 39 ]. The efficacy and safety of ARNI in acute de- compensated HF, in advanced HF patients with NYHA class IV symptoms, or in patients with HF-PEF is unclear at this time and is being tested in large-scale trials. Ivabradine Ivabradine is a specific and selective inhibitor of the If ion channel. If ion channel (the fu ny current) is highly expressed in spontaneously active cardiac regions, such as the sinoatrial node, the AV node, and the Purkinje fibers. The funny current is a mixed Na/K current that activates upon hyperpolarization at voltages in the diastolic range, and controls the rate of spontaneous activity of sinoatrial myocytes, hence the cardiac rate [ 40 ]. In the Systolic HF treatment with the If inhibitor Ivabradine Trial (SHIFT), among HFrEF with normal sinus rhythm and baseline heart rate ≥ 70 bpm despite treatment with beta-blockers, ivabradine treatment was associated with reduction in combined end point of cardiovascular death or HF hospitalization when compared against placebo [ 41 •• ]. Interestingly, though the trial inte ded to recruit patients on target or maximally tolerat d doses of β -blockers, 26% of patients were on full-dose β -blockers. The treatment effect reflected a reduction only in the risk of hospitalization for worsening HF; there was no benefit observed for the mortality compone t of the primary end point [ 41 •• ]. Patients enrolled included a small number with paroxysmal atrial fibrillation (< 40% of the time) but otherwise in sinus rhythm and a small number experiencing ventricular pacing but with a predomi- nant sinus rhythm [ 41 •• ]. Ivabradine patie ts had higher rates of symptomatic bradycardia, atrial fibrillation, and visual side effects (phosphenes) compared to placebo [ 41 •• ]. According to the FDA drug label, ivabradine is approved to reduce hospi- talization risk for worsening HF in patients with stable, symp- tomatic chronic HF with LVEF ≤ 35% in sinus rhythm with resting HR of ≥ 70 bpm or higher and on maximally tolerated doses of beta-blockers and is contraindicated for patients with acute decompensated HF, BP < 90/50 mmHg, patients with sick sinus syndrome, sinoatrial, or t ird-degree AV block [ 42 ]. In the 2017 Focused Update of HF Guidelines, iv bradine is identified as a treatment that can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II and III) stable chronic HFrEF (LVEF ≤ 35%) who are receiv- ing guideline-directed medical treatment, including a beta- blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of ≥ 70 bpm at rest (class IIa recom- mendation, with level of evidence: B – R). It should be noted that the recommendation does not entail a statement regard ng mortality benefit. Contrary to the ESC Guidelines [ 43 ], in the 2017 AHA/ACC Focused Update of HF Guidelines, there is no recommendation for ivabradine in beta-blocker intolerant patients [ 1 •• ]. SHIFT trial w s not designed to exa in the efficacy of ivabr dine in patients intolerant to bet -blockers. Efficacy and benefit of ivabradine in beta-blocker intolerant patients need to be tested in future trials. The current treatment strategies for management of patients with HF and re uced EF are summarized in Figs. 1 and 2 . Update on the Treatment of HFpEF Unfortunately there are no treatment strategies with proven benefit to reduce mortality in patients with HF with preserved EF. Current treatment strategies target treatment of the underly- ing etiology for HF-pEF and comorbidities. Thus, most of the recommendations that were present in 2013 AHA/ACC HF 39 Page 4 of 9 Curr Cardiol Rep (2018) 20: 39 emission compute tomography (SPECT) t ass ss or viabl myocardium, and dobutamine stress echocardiography to de- termine contractile reserve. This information can provide im- portant information for therapies to initiate before discharge. In pati nts with HFrEF and dysfunctional but viable myocar- dium, a robust body of evidence supports the potential to im- prove systolic function with the optimization for guideline- directed medical therapy. For example, the CHRISTMAS (Carvedilol Hibernation Reversible Ischaemia Trial, Marker of Success) study demonstrated that patients with HFrEF and viable myocardium determined by SPECT had an increase in EF when treated with carvedilol [ 9 ]. There is also a relation- ship betw en the leve of myocard al vi bility and the percent of improvement in EF with carvedilol [ 10 , 11 ]. Lastly, the inpatient setting allows for easier communication between consulting services to optimize comorbidities. Each HF patient has varying degrees of the aforementioned conditions contributing to their specific disease process. Occam ’ s Razor — the idea that a singular entity as causal is preferred over multiple contributors — is generally not the ap- propriate approach in HF patients. Evalua ion of all pos ible components is necessary to develop individualistic treatment plans with multiple therapeutic targets which may confer po- tential for reversibility of cardiac dysfunction. Treat beyond clinical congestion Clinical congestion in HF encomp sses the lo g-recognized signs and symptoms of HF, namely, dyspnea, orthopnea, rales, and peripheral edema. However, much less appreciated is the situation of hemodynamic congestion, defined as elevated left ventricular diastolic pressur despite minimal to absent clinical evidence of HF. The development of clinical and hemodynamic congestion falls on a spectrum of disease severity; as hemodynamic congestion continues to progress, symp- toms f clinic l congestio start to present thems lves up to weeks later [ 12 , 13 ] (Fig. 3 ). A number of patients lay somewhere on this continuum complaining of dyspnea but not presenting with systemic signs. In one study of 50 patients, the aforementioned signs were absent in 42% f congested patients with proven levated pulmonary capil- lary wedge pressure (PCWP) [ 14 ]. Many patients may be discharged with improved symptoms but with persistently high left ventricular filling pressures as demonstrated with elevated N-terminal pro-brain-type natriuretic peptide (NT-proBNP), provoked orthopnea, and poor exercise ca- pacity [ 15 ]. Outlined below are additional tools and tech- niques to increase the sensitivity of evaluation for persis- tent congestion. Dyspnea and orthopnea measurement scales Dyspnea and orthopnea are common presenting symptoms that act as sub- jective marker for congestion in a patient with ADHF. The current standard assessment of dyspnea is a poor surrogate outcome. In hospital, physician-assessed and patient- reported dyspnea was not independently associated with post-discharge quality of life, survival, or readmissions [ 16 ]. Although dyspnea relief remains a goal of therapy for hospi- talized patients with heart failure with reduced ejection frac- tion, this measure may not be a reliable surrogate for long- term patient-centered clinical outcomes with the current as- sessment approach. The Likert sc le an the v sual nalogue c re (VAS) are tools that minimize subjectivity while assessing the level of orthopnea or dyspnea. Using both scales in conjunction results in an increased strength in sensitivity of evaluation by mea- suring multiple specific aspects of yspnea [ 17 ]. Fo exampl , the provocative dyspnea severity score combines both dys- pnea and orthopnea assessments into a single scale [ 18 ]. Initial ED phase In-hospital phase Transition/ pre-discharge phase Post-discharge FU visit IV therapies Initiation/ uptitration GDMT Fig. 2 Transiti n to expanded eight-axis assessment model. ED, emergency department; FU, follow-up; IV, intravenous; GDMT, guideline-directed medical therapy Heart Fail Rev (2018) 23:597 – 607 599 o c o E o a p r c l e v a ro n n H i - n i e o r t H h v l i a t e o t r e i a s r p a b t t t n . n a o l t mp m f i r d e e n l r o a n o i st n e a e m ry c l a N 1 i a nd c e t t t o t l e r o c e p s s s f o t j o h m n r o f r e u o o e A o at i im ss s e c c a s o y v pn i ED e h i i t-discharge I th I / t s g a 2