Tag Archives: heart failure

PARADIGM-HF Trial

A new class of drug (Neprilysin inhibitor ) when combined with angiotensin receptor blocker , has been shown to be better than Enalapril.

Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure — NEJM.

cpr

Sudden cardiac death

What is sudden cardiac death (SCD) ?

Sudden cardiac death is defined as natural death from cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of an
acute change in cardiovascular status. Related terms are sudden cardiac arrest and cardiovascular collapse. Sudden cardiac arrest means abrupt cessation of cardiac
mechanical function, which may be reversed by prompt intervention but will lead to death in its absence. Cardiovascular collapse means sudden loss of effective
blood flow due to cardiac and/or peripheral vascular such as cardiac arrest or syncope.

What is the relation to heart disease?

preexisting heart disease may or maynot have been known to be present. The mode of death is natural rapid and unexpected.

What are the symptoms?

Prodromes occuring weeks or months before an event are not very accurate to predict SCD. Sudden onset of chest pain, dyspnea, palpitation, lightheadedness
often precede the onset of cardiac arrest and eventual death.

How big is the problem?

For an adult population 35 years of age and older, the overall incidence of sudden cardiac death is 0.1% to 0.2% per year (that means in a country like India
12,00,000 to 24,00,000 people die suddenly from natural cardiac causes each year). Among people who have disease of coronary arteries of heart around 50% die
suddenly and unexpectedly. Even in developed countries where there is a decrease in total number of deaths due to coronary artery disease, the proportion of
deaths that are sudden and unexpected has remained same. These examples highlight the extent of the problem.

Who are at increased risk?

The conditions increasing the risk of sudden cardiac death are

  1. Coronary artery disease- Myocardial infarction, Angina etc
  2. Myocardial diseases and heart failure- e.g. dilated cardiomyopathy, ischemic cardiomyopathy etc
  3. Hypertrophy of ventricular myocardium – hypertrophic cardiomyopathy, left ventricular hypertrophy due to hypertension, etc
  4. Inflammatory diseases of heart- viral myocarditis, sarcoidosis, amyloidosis,
  5. Arrhythmogenic right ventricular dysplasia
  6. Diseases of cardiac valves- Aortic stenosis/insufficiency, mitral valve prolapse
  7. Electrical diseases of heart – long QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation etc.
Mechanism of Sudden death

In 80% of cases sudden cardiac death is caused by ventricular tachycardia (VT) or ventricular fibrillation (VF) and in 20% of cases
SCD is caused by bradycardia. Patients having tachycardia have a relatively better outcome and chances of survival than those having bradycardia.

Management

The acute management of cardiac arrest is cardiopulmonary resusitation. More information about latest guidelines of CPR can be found
here

Prevention

Prevention of SCD is divided into two parts: Secondary prevention and Primary prevention. Secondary prevention means preventing further cardiac arrest
in people who have survived one cardiac arrest. Primary prevention means preventing cardiac arrest in people who have rish factors for cardiac arrest
but so far haven’t suffered a cardiac arrest.
Implantable cardioverter-defibrillator(ICD) is a device shown to be effective in secodary and primary prevention of SCD. This device is implanted like
a pacemaker and it gives an electrical shock from inside of the heart to abort an episode of VT or VF. It also has pacing function to support when the
heart rate falls.
Clinical trials like AVID, CASH, CIDS have shown effectiveness of ICD in secondary prevention of SCD. Clinical trials like MADIT, CABG-Patch, MUSTT, DEFINITE and
SCD-HeFT have shown benefit odf ICD in SCD.
Many modifications of the device has come like- subcutaneous ICD and wearable ICD.

Electrophysiological study
EPS and radiofrequency ablation can be done in selected patients to prevent further episodes of cardiac arrest.

Summary: sudden cardiac death is a devastating event resulting in rapid, unexpected and natural death due to cardiac causes. It can occur in persons
with known or unknown heart disease. Effective therapies are available. Increasing awareness about the condition and early therapy can result in
reduction of risk of sudden cardiac death
Keyword: Sudden cardiac death, sudden cardiac arrest, implantable cardioverter defibrillator (ICD), coronary artery disease, heart failure, heart disease, cardiology.

Implantable cardioverter defibrillator (ICD) – the others

Implantable cardioverter defibrillator (ICD) – the others

New ACC/AHA/HRS Expert consensus document for implantable cardioverter defibrillator (ICD) implantation in patients who are excluded or not well represented
in clinical trials.

A guideline has been published for ICD implantation. This new document is a good attempt at helping cardiologists in deciding about ICD.
There are some good points about the document.

Overview of the guideline:

1. The doument considers the published studies in ICD and makes recommendations.
2. Since the guideline considers only patients who are excluded or not well represented in clinical trials, there is no class of recommendations or level of evidence.
Rather there are categories like recommended, not recommended, can be done etc
3. Patients have been divided into different populations and recommendations are made for each patient population.

The broad categories considered are:

1. ICD Implantation in the Context of an Abnormal Troponin that Is Not Due to a Myocardial Infarction
2. ICD Implantation Within 40 Days of a Myocardial Infarction
3. ICD Implantation Within 90 Days of Revascularization
4. ICD Implantation <9 Months from the Initial Diagnosis of Nonischemic Cardiomyopathy

We will discuss the recommendations in each category

1. ICD Implantation in the Context of an Abnormal Troponin that Is Not Due to a Myocardial Infarction

First group of patients are those having elevated troponin levels but not fulfilling the  definition of MI (see other causes of elevated troponin e.g.kidney disease,
acute pulmonary embolus, heart failure, myocarditis, chest trauma, or tachyarrhythmia)and satisfying standard ICD indications for primary and
secondary prevention. ICD is recommended is such patients.
The idea is to define whether the elevated cardiac markers are due to MI or not. If not due to MI then go for ICD implatation early and no need to wait
for 40 days, like in a post MI setting.

2. ICD Implantation Within 40 Days of a Myocardial Infarction

 

1-Implantation of an ICD within the first 40 days following acute MI in patients with                       preexisting systolic ventricular dysfunction (who would have qualified for a
primary prevention ICD) is not recommended.
2-In patients who, within 40 days of an MI, require nonelective permanent pacing, who               also would meet primary prevention criteria for implantation of an ICD, and recovery of       left ventricular function is uncertain or not expected, implantation of an ICD  is                          recommended.
The basis of such recommendations has been explained by the writing group
“This reflects the fact that implantation of
a pacemaker or ICD is associated with some risk, especially
infection. If the likelihood that a patient requiring PPM implantation
early post-MI will ultimately require a second
procedure to extract the PPM and leads and replace it with
an ICD system 40 days later, it would seem inappropriate
not to implant an ICD rather than a PPM.”
3-Patients within 40 days of an MI who subsequently present sustained or hemodynamically significant ventricular tachyarrhythmias.

In this scenario the following recommendations are made
(i)In patients who, within 40 days of an MI, develop sustained (or hemodynamically significant) ventricular tachyarrhythmias >48 hours after an MI and
in the absence of ongoing ischemia, implantation of an ICD is recommended.

(ii)In patients who, within 40 days of an MI, develop sustained (or hemodynamically significant) VT >48 hours after an MI that can be treated by ablation,
implantation of an ICD can be useful.

(iii)In patients who, within 40 days of an MI, develop sustained (or hemodynamically significant) ventricular tachyarrhythmias where there is
clear evidence of an ischemic etiology with coronary anatomy amenable to revascularization (and appropriately treated), implantation
of an ICD is not recommended.
4- Patients within 40 days of MI who present with syncope that is thought to be due to ventricular arrhythmia – implantation of an ICD can be done.
In this recommendation quite a liberal one as there is no need to document ventricular arrhythmia. ICD can be done for suspected ventricular arrhythmia ( on the
basis of clinical history, documented NSVT or EP study). There are no studies that have specifically addressed whether ICD implantation is beneficial  in the setting of syncope thought to be due to a ventricular tachyarrhythmia in the first 40 days after MI. However, the consensus of the writing group is that syncope in the setting of a recent MI is a potentially serious issue, and ICD implantation can be useful if syncope is thought to be due to a ventricular tachyarrhythmia (by clinical history, documented NSVT, or EP study), regardless of timing in relationship to an MI (either <40 days or >40 days after MI).
5- Elective ICD replacement for battery depletion can be done in first 40 days after MI (in patients who have been previously implanted with ICD).
6- ICD implantation in patients within 40 days of an MI who have been listed for heart transplant or implanted with a left ventricular assist device is not recommended.

3. ICD Implantation Within 90 Days of Revascularization.

The ICD indications can be primary and secondary or patients requiring permanent pacing
1-ICD is recommended for primary prevention within 90 days of revascularization
a. In patients who have indication for ICD implantation for primary prevention of sudden cardiac death,and who have undergone revascularization
that is unlikely to result in an improvement in LVEF >0.35, and who are not within 40 days after an acute MI.
2-ICD is recommended for secondary prevention within 90 days of revascularization
a. In patients with abnormal left ventricular function and previous indication for ICD for            secondary prevention of sudden cardiac death (resuscitated from cardiac arrest due to        ventricular tachyarrhythmia) and have abnormal left ventricular function,
implantation of an ICD is recommended.
b. In patients with normal left ventricular function and previous indication for ICD for                  secondary prevention of sudden cardiac death  (resuscitated from cardiac arrest due to        ventricular tachyarrhythmia) that is unlikely related to myocardial ischemia/injury
c. ICD not indicated in patients whose cardiac arrest or VT/VF was due to acute myocardial        ischemia or injury.
3-ICD recommendations for patients with indication for permanent pacemaker

ICD is recommended in patients with indication for permanent  pacemaker + indication for ICD.
This indication is likely to come-up for further discussion in view of recent developments. The FDA has approved Medtronic CRT-D and CRT devices for patients with AV-block,NYHA I,II, III heart failure and LVEF<50% (based on data from BLOCK-HF trial)(http://www.medscape.com/viewarticle/823485).
So many of the patients with the above indication for ICD will receive CRT-D.

4-ICD is recommended in patients who develop  sustained VT/VF not related to myocardial ischemia ,syncope, patients needing pulse generator replacement, patients listed for heart transplant or implanted with ventricular assist devices, who are not within 40 days of acute myocardial infarction

4. ICD Implantation <9 Months from the Initial Diagnosis of Nonischemic Cardiomyopathy

ICD recommended in:
1-Implantation of an ICD for primary prevention is not recommended within the first 3 months after initial diagnosis of NICM.
2-If recovery of left ventricular function is unlikely, implantation of an ICD for primary prevention can be useful between 3 and 9 months after initial diagnosis of NICM.

3-ICD is indicated in patients having sustained VT/VF, syncope, indication for permanent pacing, listed for heart transplant, implanted with ventricular assist devices

Indications for putting an atrial lead:

1. In patients with symptomatic sinus node dysfunction, an atrial lead is recommended.
2. In patients with sinus bradycardia and/or AV conduction disturbances limiting the use and/or up-titration of necessary beta-blocker or other negative chronotropic drug therapy, an atrial lead is recommended.
3. In patients with sinus rhythm who have a documented second- or third-degree AV block, but who are not otherwise candidates for cardiac resynchronization therapy, an atrial lead is recommended.
4. In patients with bradycardia-induced or pause-dependent ventricular tachyarrhythmia (such as patients with long QT syndrome and torsades de pointes) an atrial lead can be useful.
5. In patients with a documented history of atrial arrhythmias (but not in permanent atrial fibrillation), an atrial lead may be considered.
6. In patients with hypertrophic cardiomyopathy and a significant resting or provocable left ventricular outflow tract gradient, an atrial lead may be considered.

Atrial lead not indicated in:

1. In patients with no documented history of atrial arrhythmias who have no other reason for requiring an atrial lead, an atrial lead is not recommended.
2. In patients with permanent or longstanding persistent atrial fibrillation in whom efforts to restore or maintain sinus rhythm are not planned, an atrial lead is not recommended.
3. In patients with conditions likely to result in VF (rather than monomorphic or polymorphic VT) without a bradycardia-induced or pause-dependent mechanism of
initiation and no other indication for an atrial lead, an atrial lead is not recommended. Conditions likely to result in VF – idiopathic ventricular fibrillation, Brugada syndrome, catecholaminergic polymorphous ventricular tachycardia, and short QT syndrome

This article adequately covers patients who really need an ICD, but have been excluded from trials. I have made a simplified version of the document which is easy to
understand. Your comments and questions are welcome

 

 

Note:

1. The diagnostic criteria for acute MI, established by the joint ESC/ACC/AHA/WHF Task  Force, are the following:

An appropriate rise and/or fall in cardiac biomarkers with at
least one value above the 99th percentile upper reference level, together with evidence of myocardial ischemia and with at least ONE of the following:
 1. Electrocardiographic evidence of new ischemia (ST
segment shift or development of left bundle branch
block [LBBB])
2.  Evolution of pathologic Q waves on the electrocardiogram
3.  Imaging evidence of new regional wall motion abnormality
or new loss of viable myocardium
4.  Ischemic symptoms
(J Am Coll Cardiol 2012;60:1581–98.)
2. BLOCK HF trial (N Engl J Med 2013;368:1585-93)

Percutaneous ventricular restoration therapy

Percutaneous ventricular restoration therapy

This is a new form of device therapy for heart failure. The device used is Parachute implant® (http://www.cardiokinetix.com/).

Parachute implant is an umbrella shaped device that is inserted into the left ventricle.

Pathophysiological basis of use:

–          In post MI patients there is progressive LV remodelling (progressive dilatation of the               left ventricle).

–          This dilatation of the ventricle increases the LV wall stress.

wall stress = (LV pressure  × LV diameter)÷  ( 2×LV wall thickness )

–          Increased LV wall stress increases LV afterload

–          Increased LV afterload worsens the LV dysfunction.

What the device does:

This device is useful in patients with old anterior and antero-apical infarctions and LV             dysfunction.

–          Parachute implant separates the dilated apical portion of the left ventricle from the                 normally contracting LV.

–          There by improves the LV geometry

–          Reduces the LV afterload

–          Improves LV function

Data regarding efficacy:

In a recent study presented at ESC heart failure congress,

–          There was a significant reduction in LV end-diastolic (120.8 vs 103.8) an end-systolic volumes (87.6 vs 73.2) at 12 months after parachute implant. There was significant increase in LVEF (28.4 vs 30.4).

–          Symptomatic improvement

–          Improvement in functional class

–          It might improve heart failure related admissions and mortality.

Risks:

–          Interference of the device with papillary muscles or apical chordae tendineae is unknown

–          Risks and consequences of dislocation.

–          Thrombo-embolic risk.

Ongoing Trials:

PARACHUTE IV

 Conclusion:

This device represents a percutaneous alternative for LV reduction surgeries. Long term safety and efficacy results to be seen.

CRT – the expanded indications

FDA Approves Medtronic CRT Devices for Mild HF With AV Block. This approval is based on the  BLOCK-HF trial. The approval expands the labeling on the defibrillating and pacing-only cardiac resynchronization therapy devices (CRT-D and CRT-P, respectively), which until now had been approved only for heart-failure patients with LVEF <35% and prolonged QRS intervals. The BLOCK-HF indications included a different niche of patients, those with first-, second-, or third-degree AV block, NYHA class 1-3 heart failure, and LVEF <50%. Read more @ http://www.medscape.com/viewarticle/823485
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The unheard-of symptom – Bendopnea

Characterization of a Novel Symptom of Advanced Heart Failure: Bendopnea

JCHF. 2014;2(1):24-31. doi:10.1016/j.jchf.2013.07.009

Objectives:  This study sought to examine the frequency and hemodynamic correlates of shortness of breath when bending forward, a symptom that has been named by the newly coined term “bendopnea.”

Background:  Many heart failure patients describe bendopnea such as when putting on their shoes. This symptom has not previously been characterized.

Methods: This was a prospective study of 102 subjects with systolic heart failure referred for right-heart catheterization. Time to onset of bendopnea was measured prior to catheterization. Forty-six subjects also underwent hemodynamic assessment when sitting and bending. Hemodynamic profiles were assigned on the basis of whether pulmonary capillary wedge pressure (PCWP) was ≥22 mm Hg and cardiac index (CI) was ≤2.2 l/min/m2.

Results: Bendopnea was present in 29 of 102 (28%) subjects with median (25th, 75th percentiles) time to onset of 8 (7, 11) seconds. Subjects with bendopnea had higher supine right atrial pressure (RAP) (p = 0.001) and PCWP (p = 0.0004) than those without bendopnea but similar CI (p = 0.2). RAP and PCWP increased comparably in subjects with and without bendopnea when bending, but CI did not change. In those with, versus without, bendopnea, there was more than a 3-fold higher frequency of a supine hemodynamic profile consisting of elevated PCWP with low CI (55% vs. 16%, respectively, p < 0.001) but no association with a profile of elevated PCWP with normal CI (p = 0.95).

Conclusions: Bendopnea is mediated via a further increase in filling pressures during bending when filling pressures are already high, particularly if CI is reduced. Awareness of bendopnea should improve noninvasive assessment of hemodynamics in subjects with heart failure.

Colchicine in Stable Chronic Heart Failure

Heart failure is associated with activation of inflammatory cascades. this trial examines the effects of usig colchicine in Hf.

American College of Cardiology Foundation | JACC: Heart Failure | Anti-Inflammatory Treatment With Colchicine in Stable Chronic Heart FailureA Prospective, Randomized Study.