HEART FAILURE

Prevalence  2%
o	Diabetes 16%
o	Hypertension 12%
o	Myocardial infarct 30%

5 year mortality 50-60%

Profound limitations on quality of life

Poorly managed, 50% undetected, 50% of those detected treated, 50% treated do not have adequate control.

Diagnosis:
o	Echo is gold standard – poor access, especially in primary care
o	Early and accurate diagnosis is essential to guide treatment and improve outcome, particularly in respect to altering the neurohormonal changes and remodelling 
o	Many doctors, esp in primary care rely on clinical ground alone to diagnose, leading to high rates of misdiagnosis (25-50% range of accuracy)
o	Possibility of using NT-proBNP

AIMS OF MANAGEMENT (European Guidelines)

Establish diagnosis
Ascertain presenting features
Determine aetiology
Identify other diseases relevant to heart failure and its management
Assess severity of symptoms
Establish prognosis
Anticipate complications
Council patients and relatives
Chose appropriate treatment
Monitor progress and manage accordingly

AIMS OF TREATMENT (European Guidelines)

Prevent cardiac dysfunction
Prevent progression to heart failure once cardiac dysfunction developed
Maintain or improve quality of life
Mortality

PHARMACOLOGY
DIURETICS
Essential for treatment of symptoms of overload
Loop diuretics
No randomised controlled trials on mortality, would now be unethical
Combine with ACE inhibitor when possible
Thiazides have been shown to have synergistic benefits in those with severe heart failure
Occasionally metolazone is used

Spironalactone: With ACE inhibitors can increase K+
RALES:		low dose spironalactone (25mg)		
		Severe heart failure
		On ACE inhibitor and a diuretic

		Generally no hyperkalaemia
		↓ in hospitalisation by 36%
		↓ in mortality by 27%

DIGOXIN
Use in AF
DIG trial in NSR	Prevent clinical deterioration
			Improve functional capacity
			No effect on mortality

Consider in those symptomatic with or unable to tolerate ACE I / β Blocker

ACE INHIBITORS
CONSENSUS 1987: Improved mortality
Indicated in all stages of symptomatic failure due to systolic dysfunction
Irrespective of presence or absence of signs of fluid overload
Combine with diuretic
Consider first line in those with asymptomatic impaired left ventricular function SOLVD (ACE inhibitors in asymptomatic LVD)
o	↓ hospitalisation
o	↓ the development of heart failure
o	↓ the risk of reinfarction
o	no benefit on mortality

Side Effects
o	Dry cough withdrawal 15-20%
o	Hypotension
o	Syncope
o	Renal insufficiency – monitor renal function 7-10 days after start and change dose, annually in those at risk
o	Hyperkalaemia
o	Angioedema

ACE inhibitors are underused due to many doctors having an exaggerated perception of risk. BMJ 2000 published a study showing that the introduction of these drugs very rarely cause problems.

ANGIOTENSION II RECEPTOR ANTAGONISTS
Currently under investigation
ELITE showed good tolerability
ELITE 2 failed to show any benefit of lorsartan over captopril
ValHeFT showed 13% RR reduction in the combined end point of all cause mortality and morbidity when comparing valsartan to placebo. But valsartan failed to show a significant effect on the endpoint of mortality alone. In this trial valsartan was added to conventional treatment, including ACE inhibitor.

Currently comparing with ACE I and in combination with ACE 
Presently used as an alternate to ACE I if unable to tolerate
Occasionally in addition to ACE I if unable to tolerate β Blocker

β BLOCKER
1973 low dose β blocker in idiopathic dilated cadiomyopathy
Once CI, now becoming established as evidence based treatment
After 3 months – improvement in LV function
Long term – reverse modelling

Clinical benefits
o	Significant ↓ hospitalisation
o	Significant improvement in mortality
o	Conflicting effects on exercise tolerance and quality of life

Trials >20 RCT
o	CIBIS II total mortality ↓ of 34%, sudden death ↓ by 40%
o	MERIT-HF total mortality ↓ by 32%, sudden death ↓ by 50 %
o	US CARVEDILOL PROGRAM ↓ total mortality by 65% (Pooled data from 4 studies)

Treat patient with
o	Chronic 
o	Stable
o	Mild to moderate
o	Symptomatic heart failure
o	Decreased LV function

??	Mild
Severe heart failure
Elderly

Start
o	Stable patients
o	Low dose
o	Titrate up
o	Often is an initial deterioration before improvement
o	Generally started only by experienced drs or in specialist clinics

The choice of which β blocker remains controversial and is currently under investigation – see below for dose 

Papers

BJGP May 2001
Diagnosis of heart failure in primary care: an assessment of international guidelines

13 guidelines were identified, only 7 referred to diagnosis. Quality variable, but there was a consensus over the main symptoms and diagnostic tests. Only 2 guidelines scored >50% for rigour of development.
Urgent need to look at studies in primary care that explore the reliability of diagnosis of heart failure.

BMJ June 2002
Reliability of NT-proBNP assay in diagnosis of heart failure: cohort study in representative and high risk community populations

591 patients randomly sampled, in these patients they took blood and investigated for heart failure, including an echo
The NT-proBNP assay seems to have value in the diagnosis of heart failure in the community.
Sensitivity 100%
Specificity 70%
PPV 7%
NPV 100%
High negative predictive values indicate main use would be to rule out heart failure in those with suspected heart failure, but normal concentrations of NT-proBNP
Very high levels effectively diagnose heart failure, intermediate values require conformation by echo
Authors suggested 3 uses:
o	Screening patients with existing label of heart failure
o	Triage patients presenting with symptoms suggestive of heart failure for echo
o	Screening high risk patients

BMJ August 2002
Management of chronic heart failure – clinical review

Key points
Transthoracic echo is the key investigation to confirm structural and functional abnormalities
Patients with heart failure due to left ventricular dysfunction should be treated with diuretic, ACEI, β blocker (unless CI)
Patients with more severe symptoms, should add spironalactone
Monitor the control and biochemistry to reduce risk of complications and decompensation
High quality and timely communication between patients and all the healthcare professionals involved in their care is essential

Recommended starting and maintenance dose ranges for selected angiotensin converting enzyme inhibitors and  blockers used in clinical trials for the treatment of heart failure

Drug 
	Starting dose 
	Maintenance dose 
	
Angiotensin converting enzyme inhibitors	
Captopril	6.25 mg three times daily	25-50 mg three times daily	
Enalapril	2.5 mg once daily	10 mg twice daily	
Lisinopril	2.5 mg once daily	5-20 mg once daily	
Perindopril	2 mg once daily	4 mg once daily	
Ramipril	1.25-2.5 mg once daily	2.5-5 mg twice daily	
Trandolapril	1 mg once daily	4 mg once daily	
blockers	
Bisoprolol	1.25 mg once daily	10 mg once daily	
Carvedilol	3.125 mg twice daily	25 mg twice daily	
Metoprolol tartrate	5 mg three times daily	50 mg three times daily	
Metoprolol succinate CR	12.5-25 mg once daily	200 mg once daily	

Key ongoing clinical trials 
•	CHARM (candesartan in heart failureassessment of reduction in mortality and morbidity)investigating the clinical efficacy of candesartan in reducing mortality and morbidity in three groups of patients: those with left ventricular systolic function treated with an angiotensin converting enzyme inhibitor, those with systolic dysfunction intolerant of an angiotensin converting enzyme inhibitor, and those with non-systolic heart failure. Reporting 2003-4 
•	CARE-HF (cardiac resynchronisation in heart failure)large multicentre randomised study to evaluate the long term effects of cardiac resynchronisation on mortality and morbidity in patients with heart failure. Approximately 800 patients followed for 18 months. Reporting 2004 
•	UK natriuretic peptide studya pragmatic multicentre UK study of the diagnostic value of measuring plasma B type natriuretic peptide (or N-terminal pro-B type natriuretic peptide) in patients presenting to primary care with a suspected diagnosis of heart failure. Approximately 300 patients will be recruited. Reporting 2003