Hjertesvikt og nye europeiske retningslinjer Dagens medisin 7/9-2016
Definisjon (Nytt)
Algoritme for utredning (ny) «Hjertesviktpakke» 21 dager probnp >125pg/ml=15 pmol/l BNP >35 pg/ml=10 pmol/l
Forebygge utvikling av HF (nytt)
Progression of heart failure ACC/AHA HF guidelines. Forekomst Olmstedt Stage A At risk (HT,DM) Genetisk anlegg Miljø Hormoner Immunsystem ACC/AHA guidelines JACC 2001 Stage B 22% av folk >45 år No symp (LVH) Ammar Circulation 2007;115:1563:prevalense 34% Stage C, Symptoms Progression of HF Stage D 12% Severe symptoms 0.2%
Behandling av HF (ny)
Medikamenter ved HFrEF Klasse IA
Other pharmacological treatment in selected patients
Balance angiotensin-neprilisyn Angiotensin II
PARADIGM-HF: Study design Stabil HF EF <40 (35%) probnp>71 pmol/l egfr>30 Single-blind active run-in period Randomization n=8442 Double-blind Treatment period LCZ696 200 mg BID Enalapril 10 mg BID* LCZ696 100 mg BID LCZ696 200 mg BID Enalapril 10 mg BID 2 Weeks 1 2 Weeks 2 4 Weeks Median of 27 months follow-up On top of standard HFrEF therapy (excluding ACEIs and ARBs) *Enalapril 5 mg BID (10 mg TDD) for 1 2 weeks followed by enalapril 10 mg BID (20 mg TDD) as an optional starting run-in dose for those patients who are treated with ARBs or with a low dose of ACEI; 200 mg TDD; 400 mg TDD; 20 mg TDD. McMurray et al. Eur J Heart Fail. 2013;15:1062 73; McMurray et al. Eur J Heart Fail. 2014;16:817 25; McMurray, et al. N Engl J Med 2014; epub ahead of print: DOI: 10.1056/NEJMoa1409077.
PARADIGM study KM plots for Outcomes, According to Study Group (primary outcome: CV death or first hosp for HF). McMurray JJ et al. N Engl J Med 2014. DOI: 10.1056/NEJMoa1409077
2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of 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 Recommendations for Renin-Angiotensin System Inhibition With ACE Inhibitor or ARB or ARNI 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 (19). JACC august 2016
Hvilke pasienter kan man gi Entresto Følgende vilkår for refusjon: NYHA II-IV EF<40% NYHA II-IV og EF<40% påvist under behandling med ACE-I/ARB ved utilstrekkelig effekt Krav til tidligere behandling: ACE-I eller ARB Spesialistkrav: spesialist i Indremedisin eller lege ved tilsvarende sykehusavdeling
The cumulative probability of a first hospitalization for heart failure during the first 30 days after randomization 1.5 Enalapril (N=4,212) LCZ696 (N=4,187) Kaplan-Meier estimate of cumulative rate 1.0 0.5 HR 0.60 (95% CI: 0.38 0.94) p=0.027 0 0 10 20 30 Days after randomization Packer et al. Circulation. 2015 Jan 6;131(1):54-61
CRT ved HF HFrEF, EF<35%, QRS > 130 ms, venstre grenblokk Aller best effekt ved QRS > 150 ms Kontraindisert ved QRS<130 ms
ICD Overlevende etter hjertestans Primærprofylakse: HFrEF, EF<35%, >3mnd medikamentell beh Ischemisk HF: minst 40 d etter infarkt
DANISH: flow chart 1116 pas med CMP EF<35, NYHAII-IV 58% CRT probnp: ca 135 pmol/l ACE/ARB: 97% BB: 92% Aldost ant:58% Amiodaron 6% Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
DANISH: Primary outcome: death from any cause Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
DANISH: CV death and sudden death CV death: 13.8% (ICD) vs 17.0% (control) Sudden death: 4.3% (ICD) vs 8.2% (control) Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
Effect according to age Køber L et al. N Engl J Med 2016
Komorbiditet
Recommendations to prevent or delay the development of overt heart failure or prevent death before the onset of symptoms 2016 ESC Guidelines for the Diagnosis and treatment of on Acute & Chronic HeartFailure
EMPA-REG OUTCOME Randomised, double-blind, placebo-controlled CV outcomes trial, to examine the long-term effects of empagliflozin versus placebo, in addition to standard of care, on CV morbidity and mortality in patients with type 2 diabetes and high risk of CV events(prior myocardial infarction, coronary artery disease, stroke, unstable angina or occlusive peripheral arterial disease) Placebo (n=2333) Screening (n=11531) Randomised and treated (n=7020) Empagliflozin 10 mg (n=2345) B Zinman et al New Engl J Med 2015; Empagliflozin 25 mg (n=2342) 23
Primary outcome: 3-point MACE HR 0.86 (95.02% CI 0.74, 0.99) p=0.0382* Cumulative incidence function. MACE, Major Adverse Cardiovascular Event; HR, hazard ratio. 24 * Two-sided tests for superiority were conducted (statistical significance was indicated if p 0.0498)
CV death HR 0.62 (95% CI 0.49, 0.77) p<0.0001 Cumulative incidence function. HR, hazard ratio 25
Hospitalisation for heart failure HR 0.65 (95% CI 0.50, 0.85) p=0.0017 Cumulative incidence function. HR, hazard ratio 26
HFmrPEF og HFpEF
NORSTENT: Flow chart 9013 pas med stabil eller ustabil AP, ACS Randomisert: DES eller BMS Prim outcome: composite: død+ nonfatal MI Sekundært: Ny revaskularisering Stenttrombose QoL K Bønaa New Engl J Med 2016
NORSTENT: Primary outcome Død eller MI: ingen forskjell Død: ingen forskjell QoL: Ingen forskjell Ny revaskularisering 34% (NNT 30 pas) Stent trombose K Bønaa New Engl J Med 2016
NORSTENT: Main results K Bønaa New Engl J Med 2016
Back up
Atrieflimmer: frekvenskontroll Snarlig elektrokonvertering ved hemodynamisk ustabil situasjon Betablokker som grunnbehandling Digoxin som neste medikament for å kontrollere frekvens Ablasjon uavklart Dronedarone kontraindisert
Atrieflimmer: rytmekontroll
Atrieflimmer: antikoagulasjon Regn ut risiko etter CHA2DS2-VASc og HAS-BLED Antikoagulasjon anbefalt ved CHA2DS2- VASc >2 NOAC (eller Marevan) Marevan ved kunstige klaffer
Behandling som er kontraindisert ved ulik komorbiditet
Behandling av stabil angina ved HF
Velazquez EJ et al. N Engl J Med 2016;374:1511-1520. Randomization and Follow-up.
Kaplan Meier Estimates of the Rates of Death from Any Cause, Death from Cardiovascular Causes, and Death from Any Cause or Hospitalization for Cardiovascular Causes. Velazquez EJ et al. N Engl J Med 2016;374:1511-1520.
Behandling av klaffefeil