Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Andere mochten auch
Andere mochten auch (9)
Ähnlich wie Take home message
Ähnlich wie Take home message (20)
Mehr von drucsamal
Mehr von drucsamal (20)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Take home message
- 1. Take Home Message Prof. U. C. SAMAL MD, FICC, FACC, FIACM, FIAE, FISE, FISC, FAPVS Ex- Prof. Cardiology & Ex-HOD Medicine Patna Medical College, Patna, Bihar Past President, Indian College of Cardiology Permanent & Chief Trustee, ICC-Heart Failure Foundation National Convener Member, Heart Failure Sub Specialty -CSI Chairman, Heart Failure Council- CSI Past President, CSI Bihar Chairman, API, Bihar (2016-17) West Bengal Chapter
- 2. “The very essence of cardiovascular medicine is the recognition of early heart failure” ……… Sir Thomas Lewis 1933
- 3. Algorithm for the management of AHF European Journal of Heart Failure (2015) 14, 544-558 TRIAGE TNI BNP CKMB Myo G DDIM NGAL Co-peptin PCT
- 4. SOB TRIAGE METER PLATFORM Parameters Normal Range Price(Rs.) Timing CKMB 0.0-4.3 SOB PANEL Rs. 750 10-15 Min MYO 0.0-107 TNI 0.00-0.40 BNP 0.00-100 DDIM 0.1-400 NAGAL 0-149 Rs. 850 15 Min Samsung LABGEO IB10 GE Health Care VSCAN (Hand Held ECHO) Siemens Acuson Cypress
- 5. Parameters Pack size Test Range Normal Range Price Timing ASO 30 Test 50-1000 IU/ml 0-200 IU/ml 62 5 Min CRP 30 Test 0.5-250 mg/L 0.000-6.000mg/L 51 5Min RF 30 TEST 10-120 IU/ml 0.000-20.000/IU/ml 46 6 min CYSTATIN C 30 TEST 0.1-10 mg/L 0.000-1.149 mg/L 161 6 min HbA1C 30 TEST 3-13% 4.000-6.000 % 160 7 min D-DIMER 30 TEST 0-400 ng/mL 0.000-400 ng/ml 160 7 min IgE 30 TEST 0-1000 IU/mL 0.000-400 IU/mL 180 6 min FERRITIN 30 TEST 0-1000 ng/mL 0.000-230 ng/mL 200 6 min Lp(a) 30 TEST 1-100 mg/dL 0-30 mg/dL 180 7 min MICROALBUMIN 30 TEST 5-200 mg/L 0.000-25.000 mg/L 101 5 min Intelligent Double Chanel Nephlometry Technology
- 6. Triage® Meter: Three Simple Steps 1. Add whole blood to Test Device 2. Insert Test Device into Meter 3. Read results
- 7. ESC Guidelines – Diagnosis of HF HF = heart failure; HF-PEF = heart failure with ‘preserved’ ejection fraction; HF-REF = heart failure and a reduced ejection fraction ; LA = left atrial ; LV = left ventricular ; LVEF = left ventricular ejection fraction. a Signs may not be present in the early stage of HF (especially in HF-PEF) and in patients treated with diuretics S The diagnosis of HF-REF requires three conditions to be satisfied: 1. Symptoms typical of HF 2. Signs typical of HF 3. Reduced LVEF The diagnosis of HF-PEF requires four conditions to be satisfied: 1. Symptoms typical of HF 2. Signs typical of HF 3. Normal or only mildly reduced LVEF and LV not dilated 4. Relevant structural heart disease (LV hypertrophy / LA enlargement) and/or diastolic dysfunction
- 8. GE Health Care VSCAN (Hand Held ECHO) Would they replace stethoscope? Siemens Acuson Cypress
- 9. Devices ICDs b-Blockers Sensing Devices CRT, CRT-D MR-Antagonists Ivabradine Eras of Heart Failure Management Timeline Pre-1980 Neurohormonal Drugs 1980s 1990s 2000s 2010s Palliative Drugs Digitalis Diuretics ACE-I 2014 ARNI ARNI
- 10. Drugs that reduce mortality in Heart Failure with Reduced Ejection Fraction
- 11. HF PEF – Mortality Reduction By treatment D J Holland, JACC 2011;57:1676
- 12. Recommendations COR LOE Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines I B Diuretics should be used for relief of symptoms due to volume overload I C Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT IIa C Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic HF IIa C Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF IIa C ARBs might be considered to decrease hospitalizations in HFpEF IIb B Nutritional supplementation is not recommended in HFpEF III: No Benefit C Management of ACCF 2013/ HFpEF
- 13. Angiotensin Neprilysin Inhibition with LCZ696 Doubles Effect on Cardiovascular Death of Current Inhibitors of the Renin- Angiotensin System
- 14. LCZ696- A first-in-class Angiotensin Receptor Neprilysin Inhibitor- Simultaneously inhibits NEP and the RQS
- 15. Neprilysin Inhibition Potentiates Actions of Vasoactive Peptides Beneficial in Heart Failure
- 16. The incredible and consistent benefits of LCZ696 on all outcomes in HF
- 18. PARADIGM-HF Trial is poised to change clinical Practise in Heart Finerenone ZS-9: Harmonize , Patiromer : PEARL HF
- 19. I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them Feel. Thank You ……. What the take home message means to me?
- 22. ESC Guidelines • « HFpEF seems to have different epidemiological and aetiological profile from HFrEF. Patients with HFpEF are older, more often females and obeses (…), more likely to have atrial fibrillation and hypertension and less likely to have coronary heart disease than those with HFrEF ». • Better prognosis.
- 23. ESC Guidelines - Diagnosis HF with preserved EF : EF > 40 – 45% « Diagnosis is more difficult than the diagnosis of HFrEF because it is largely one of exclusion. i.e. potential non cardiac causes of the patient’s symptoms such as anaemia or chronic lung disease must first be discussed »
- 24. Eur Heart J, 2011 Meta-Analysis Global Group In Chronic Heart Failure (MAGGIC) HF PEF n = 10347 HF REF n = 31625 p-value Age 71 66 < 0.001 Female gender % 50 28 < 0.001 History hypertension % 51 41 < 0.001 Ischaemic aetiology % 43 59 < 0.001 Atrial fibrillation % 27 18 < 0.001
- 25. ESC guidelines 2012 « 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… » One paragraph of 31 lines….
- 26. Finerenone combines spironolactone’s potency with eplerenone’s selectivity 7 • Finerenone a oral, selective, non-steroidal MRA distributes equally to the heart and kidney • The shift kidney to heart would theoretically be associated with less hyperkalemia • In a prior comparison of finerenone up to 5mg bid and spironolactone 25mg or 50mg qd, finerenone was associated with lower hyperkalemia, and similar reduction in NT- proBNP Spironolactone Eplerenone Finerenone Selectivity POOR GOOD GOOD Affinity GOOD POOR GOOD Heart / Kidney +/+++ +/+
- 27. CRT in Heart Failure– What do the New Guidelines SayNYHA III/IV (ambulatory) NYHA II McMurray EHJ 2012
- 28. Indications for CRT in AFib McMurray et al., ESC Guidelines on HF EHJ 2012
- 29. CRT in Patients with AFib ESC Guidelines on Cardiac Pacing and CRT EHJ 2013
Hinweis der Redaktion
- Wow ! A great salutary dictum. But I would further submit Heart Failure care is the great arduous and challenging service, which needs a always vision with the passion and commitment!
- The first case is a typical example which fits into this algorithm. Perhaps two dictums, treat first and diagnose then “ and also the first step of the treatment is most live saving as AHF is not that deadly as ever imagined. Nothing much has happened in management of the AHF except in last 30 years and we are limited to oxygen diruetics and vasodilators and newer and novel vasodilators has not stood the test of time in practise it is NTG and anNTG. My heart Failure registry is built up over eight years with more than 8000 cases and my convictions in AHF most important adjunct clinical assessments is TRIAGE, TRIAGE and TRIAGE. AHF is an heterogenous conditions with multi organ involvement, and the early diagnosis would lead to better prognosis and outcome. I use BIOSITE SOB platform and see the result within less than 20 minutes time of the first contact of the patient, I can get quantitative answer to the biomarkers of myocardial injury , renal envolvment, evidence of the congestions and con committed pulmonary infection if any. And when done simultaneously we can include some more markers like Cystatin-C, CRP, Feritin, Hb1Ac and microalbumin.
- See time consumed and money spent. It is extremely cost effective and once you practice you would find it reduces practioner stress and phenomenon ally life saving.
- This is the Mispa Panel
- You will understand as the regards of sign and symptoms of HF two classic syndromes which are observed of equal incidence as present only differ at level of the ejection fraction and at the level of structural difference of the both the conditions. Understandably liberal and extensive application of the echocardiography is imperative and mandatory.
- In the clinic, at the bed side at the country side practice the Hand Held Echo to potable one would add a great creditability to Heart Failure Physicians. Be if first contact physicians “ or ED physicians “. They are much cheaper than luxury cars.
- Now we have reached a timeline beyond than 2014- 2015 and heading for the 2016 and hopefully guidelines are going to be rewritten ….
- In last 30 years GDMT has resulted in remarkable reduction in mortality in Heart Failure Reduced ejection fraction and did not have to present the graphic to tell you, we have very little to offer patients of heart failure with preserver ejection fraction except diruretics in acute cases and drugs to treat hypertension and treatment of co-morbidities and all the trials in Heart failure with preserved ejection fraction as the Milton Pakers quotes “ it once step forward, two step backward, and exercise in futility”. But as
- In 30 years of heart failure research there is unprecedented breakthrough angiotensin Neprilysin inhibition with LCZ696 has brought down further mortality more than 20 percentage over and above what we have achieved so far in Heart Failure with reduced ejection fraction and with ongoing Paramount HF study we are longing to have equal benefit for the patient of HFpEF.
- The story is simple and the concept is fantastic in heart failure there is neuroharmonal activation involving in maladaptive and beneficial neuroharmonal agents. Which is well depicted in this cartoon. The red axis is positive adaptive process mediated by the several vasoactive peptides inclusive of BNP and ANP and CNP but are unsustainable as they are degraded by NEP Neutral Endopeptidase Neprilysin. The grey axis is a maladaptive process principally steered by Angeotensin-II ATP receptor .
- Thus, neprilysin inhibition leads to beneficial effects of the vasoactive peptitides very well depicted in the cartoon. LCZ696 is the combination of Sacubitril and valsarten selective one antagonist of equal proportion approved by FDA and being marketed in the name of “Entresto, Novatitis” in the multiple strength. Average daily cost may be 800 bucks and considered to be a “yellow paint ” / is the panacea in the Heart Failure morbidity and may replace several necessary evils like ACI-I and ARBs.
- In the real sense Heart Failure Panacea .
- The best prove of the concept in terms of the absolute benefit when thousands of patients on ACE-I and ARBs changed over to LCZ696 over the period of median 27 months, the quantum of the benefits is well spelled out in this slide.
- Dear friends where are we at present. In the patient HFrEf we climbed the pyramid in this fashion to struggle at the level of MRAs with fear of hyperkalemila and renal injury. But, I hope from emerging evidence LCZ696/ ARNI would take the driver seat the first line treatment in the place of ACE-I and ARBs may be the treatment further built up with the addition of beta blockers and the MRAs. I further apprise you with newer non steroidal MRAs like Finerenone and newer hypokilemic agents like ZS-9 (in acute scenario and Patiromer in chronic scenario with the very well fight out the menace of hyperpotissimia . I am sure the golden days are ahead for our heart failure patients which are considered to be pariahs of nature (dejected child of nature).