CHF

Systolic Dysfunction

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Systolic Dysfunction, Left Ventricular Dysfunction, Left Ventricular Failure, Systolic Heart Failure, Left Ventricular Systolic Dysfunction, Heart Failure with Reduced Ejection Fraction

  • Causes
  • Types
  • High or Low Output
  1. Low output Heart Failure
    1. Classic Systolic Dysfunction with decreased Cardiac Output
    2. Example causes
      1. Coronary Artery Disease
      2. Severe Hypertension
      3. Cardiomyopathy
      4. Heart Valve Disorders
  2. High output Heart Failure
    1. Normal Cardiac Output, but demands of hypermetabolic state outpaces supply
    2. Example causes
      1. Thyrotoxicosis
      2. Severe Anemia
      3. Thiamine deficiency
      4. Valvular regurgitation
  • Types
  • Left or Right Sided
  1. Left-Sided Heart Failure
    1. Presents with pulmonary edema
    2. Causes (either Systolic Dysfunction or Diastolic Dysfunction)
      1. See Heart Failure Causes
  2. Right-Sided Heart Failure
    1. Presents with systemic edema (JVD, Leg Edema, Hepatomegaly)
    2. Causes
      1. Left sided Heart Failure (most common cause)
      2. Chronic lung disease (e.g. COPD)
      3. Coronary Artery Disease
      4. Right-sided Valvular disease (pulmonic stenosis, Tricuspid stenosis, tricuspid insufficiency)
      5. Pericardial Effusion
      6. Left-to-right shunt
  • Pathophysiology
  • Mechanism (with associated symptoms)
  1. Left Ventricular Systolic Dysfunction
    1. Results in decreased contractility and Cardiac Output
    2. Compensatory increase in Catecholamines to drive up cardiac ouput
    3. Catecholamines (e.g. Norepinephrine) increase Afterload (and increased Blood Pressure)
      1. Ultimately results in down-regulation of B-Adrenergic Receptors and decreased contractility
    4. Increased Afterload decreases renal perfusion
    5. Decreased renal perfusion stimulates ADH, Aldosterone and the renin-Angiotensin system
      1. Increases Preload and Afterload
      2. Increases Angiotensin II causing myocyte and endothelial proliferation
      3. Results in adverse ventricular remodeling
    6. Results in Sodium retention and Fluid Overload
      1. Acute: Increased myocardial wall tension causes Diastolic Dysfunction and increased oxygen demand
      2. Chronic: Ventricular dilation and decreased ejection fraction
  2. Decreased filling pressure (congestion)
    1. Increased left sided pressure: Dyspnea, Orthopnea, paroxysmal nocturnal Dyspnea (PND)
    2. Increased right sided pressure: Edema, Ascites, Jugular Venous Distention (JVD)
  3. Decreased Cardiac Output
    1. Fatigue
    2. Depression
  • History
  • Past Medical
  1. See Heart Failure Causes
  2. Primary heart or vascular conditions
    1. Prior Myocardial Infarction
    2. Hypertension
    3. Valvular heart disease
    4. Atrial Fibrillation
  3. Primary pulmonary conditions
    1. Cor Pulmonale
    2. Pulmonary Embolism
    3. Sleep Apnea
  4. Primary renal conditions
    1. Renal Failure
    2. Nephrotic Syndrome
    3. Glomerulonephritis
  5. Cardiotoxins
    1. Alcohol Abuse
    2. Doxorubicin
    3. Catecholamines
    4. Cobalt
    5. Cocaine Abuse
  6. Medications that cause fluid retention
    1. Chemotherapy
    2. COX2 Inhibitors
    3. Sex hormones (Androgens, Estrogens)
    4. Glitazones (e.g. actos)
  7. Other provocative factors
    1. Anemia
    2. Fluid Overload (excessive salt intake)
    3. Septic Shock
    4. Medications
      1. Beta Blocker
      2. Calcium Channel Blocker
    5. Thyroid disease (Hypothyroidism or Hyperthyroidism)
    6. Hepatic disease
  • Symptoms
  1. Early symptoms
    1. Decreased Exercise tolerance
    2. Dyspnea on Exertion
      1. Test Sensitivity: 100%
      2. Test Specificity: 17%
        1. See Dyspnea Causes
  2. Non-specific symptoms
    1. Unexplained confusion or lethargy (often in elderly)
    2. Weight gain
    3. Fatigue
      1. Most common presenting symptom of CHF in the elderly
  3. Left-sided Heart Failure symptoms (left = lung)
    1. Orthopnea
    2. Paroxysmal Nocturnal Dyspnea
      1. Not sensitive or specific for CHF
  4. Right-sided Heart Failure symptoms
    1. RUQ Abdominal Pain or fullness, early satiety
      1. Hepatic engorgement
      2. Ascites
    2. Lower extremity edema (often Dependent Edema)
      1. Venous Insufficiency
      2. Lymphedema
  1. Laterally displaced apical impulse (highly specific)
  2. S3 Gallop Rhythm
    1. Most specific CHF indicator over age 40
      1. Test Sensitivity: 24%
      2. Test Specificity: 99%
    2. CHF patients (n=19) with Ejection Fraction <30%
      1. S3 Gallop present in 68% of these patients
    3. Reference
      1. Mattleman (1983) J Am Coll Cardiol 1(2):417-20 [PubMed]
  3. Rales (nonspecific)
    1. Do not clear with cough
    2. Not sensitive or specific for CHF
  4. Pulsus Alternans
    1. Tachycardia accompanied by low volume pulse
  1. Elevated Jugular Venous Distention (highly specific)
    1. Consider hepatojugular reflex
  2. Pulsatile Liver
  3. Lower extremity edema
    1. Not attributable to Dependent Edema
    2. Not sensitive or specific for CHF
  4. Poor perfusion
    1. Poor Capillary Refill
    2. Cool distal extremities
    3. Altered Mental Status
  • Labs
  • Initial
  1. Complete Blood Count (CBC)
    1. Evaluate for Anemia
  2. Comprehensive Metabolic Panel or Chemistry panel
    1. Electrolytes
    2. Serum Calcium
    3. Renal Function tests
    4. Liver Function Tests
    5. Serum Magnesium
  3. Urinalysis
  4. B-Type Natriuretic Peptide (BNP) or NT-BNP
    1. Sensitive and specific marker for CHF
    2. Useful for its Negative Predictive Value (CHF is unlikely with a normal BNP)
  5. Serum Albumin
    1. Nephrotic Syndrome
  6. Thyroid Stimulating Hormone (TSH)
    1. Over age 65
    2. Atrial Fibrillation
  7. Troponin I
    1. Acute CHF presentation
  1. Urine Toxicologic screen
    1. If Cocaine Abuse suspected
  2. Lyme serology
  3. Parvovirus B19 serology
  4. Blood Cultures
    1. If endocarditis or Sepsis suspected
  5. Human Immunodeficiency Virus
  1. Findings suggestive of CHF
    1. Anterior Q waves
    2. Left Bundle Branch Block
    3. Efficacy
      1. Test Sensitivity: 94%
      2. Test Specificity: 61%
  2. Other findings
    1. Ventricular hypertrophy
    2. Atrial enlargement
    3. Conduction abnormality
    4. Arrhythmia
    5. Prior Myocardial Infarction
    6. Active ischemia Myocardial Ischemia
  • Diagnostics
  • Advanced
  1. See Bedside Lung Ultrasound in Emergency (Blue Protocol)
  2. See Rapid Ultrasound in Shock (RUSH Exam)
  3. See Inferior Vena Cava Ultrasound for Volume Status
  4. Echocardiogram
    1. See Echocardiogram in CHF
    2. Indicated in every Congestive Heart Failure patient
    3. Ejection Fraction 40% or less
    4. Other factors evaluated
      1. Chamber size and shape
      2. Wall thickness
      3. Valvular function
  5. Evaluation for Ischemic Heart Disease
    1. Precautions
      1. Suspected Angina and Left Ventricular Dysfunction warrants angiography
        1. High pretest probability of Ischemic Heart Disease
    2. Modalities
      1. Exercise Stress Testing
      2. Nuclear (Thallium or Cardiolyte-Technetium)
    3. Observe for reversible ischemic changes
      1. Consider cardiac catheterization and possible Angioplasty (PTCA)
      2. Consider Coronary Artery Bypass Graft (CABG)
  6. Ambulatory rhythm monitor (Holter Monitor)
    1. Observe for ventricular arrhythmia
    2. Consider patient for Implantable Defibrillator
  • Diagnosis
  1. Sensitive CHF markers (if absent, CHF is unlikely)
    1. Framingham Heart Failure Diagnostic Criteria
    2. Dyspnea on exertion
    3. EKG with anterior Q Waves or Left Bundle Branch Block
    4. B-Type Natriuretic Peptide elevation
      1. Best for its Negative Predictive Value
      2. BNP is more reliable than nt-BNP
      3. BNP <95 pg/ml
      4. nT-BNP <642 pg/ml
  2. Specific CHF markers (if present, suggest CHF)
    1. Displaced Cardiac Apex on palpation
    2. S3 Gallup Rhythm
    3. Jugular Venous Distention
      1. With or without hepatojugular reflex
    4. Chest XRay with cardiomegaly or vascular congestion
  3. References
    1. Dosh (2004) Am Fam Physician 70:2145-52 [PubMed]
      1. Also cited for efficacy under signs and symptoms
  • Management
  • General Measures
  1. See Congestive Heart Failure Exacerbation Management
  2. Limit salt intake: 2-3 gram Sodium Diet (no added salt)
    1. Also limit free water ONLY IF Hyponatremia is also present
  3. Graded Exercise program
    1. Reduces Heart Failure related mortality
    2. Piepoli (2004) BMJ 328:189-92 [PubMed]
  4. Disease Management
    1. Consider initiating after CHF hospital discharge
    2. Case management and disease monitoring programs
    3. Body weight and symptom monitoring
    4. Heart Failure education (self-care, lifestyle measures, Medication Compliance)
  5. Control comorbid conditions
    1. Hypertension
    2. Coronary Artery Disease
    3. Diabetes Mellitus
    4. Obstructive Sleep Apnea
    5. Major Depression
  6. Avoid Provocative Medications
    1. Avoid ARB combined with ACE Inhibitor and Beta Blocker
      1. Valsartan plus ACE Inhibitor showed no benefit
      2. Valsartan + ACE + Beta Blocker increased mortality
      3. Cohn (2001) N Engl J Med 345:1667-75 [PubMed]
    2. Avoid Medications that Exacerbate Heart Failure
      1. See Medications that Exacerbate Heart Failure
      2. Avoid Calcium Channel Blockers (except Amlodipine)
      3. Avoid Beta agonists (if possible, although COPD and Asthma requires these)
      4. Avoid Glitazones (e.g. Pioglitazone)
      5. Avoid Gliptins (e.g. Onglyza)
      6. Avoid Tricyclic Antidepressants (e.g. Amitriptyline)
      7. Avoid Nonsteroidal Anti-inflammatory drugs (NSAIDS)
      8. Avoid high Sodium medications (e.g. effervescent tabs)
      9. Avoid St John's Wort if on Digoxin or Eplerenone (Drug Interactions)
  7. Stop habits associated with hospital readmission
    1. Tobacco Cessation
    2. Alcohol cessation
  8. Establish target ideal volume status weight (not dry weight)
    1. Assess for too dry (Orthostatic Hypotension)
      1. Monitor standing Blood Pressure in clinic
      2. Evaluate Renal Function tests for Azotemia
    2. Assess for too wet
      1. No Orthopnea
      2. No paroxysmal nocturnal Dyspnea
    3. Assess for maintenance of ideal volume status weight
      1. Follow daily weight at home with weight diary
      2. Report weekly weight gain 3-5 lb (1.5 - 2.0 kg)
      3. Patient may adjust their lasix at home (see below)
  9. Sliding scale Diuretics (uses daily weights)
    1. Based on weight variation from maintenance weight
    2. Protocol 1
      1. Criteria: Weight gain of 2 pounds in one day or 5 pounds overall
      2. Increase Diuretics (and Potassium supplement) for 3 days
    3. Protocol 2
      1. Weight gain 1-3 pounds: No change to Diuretic dose
      2. Weight gain 3-5 pounds: Take extra Diuretic dose
      3. Weight gain >5 pounds: Call clinic nurse immediately
  • Management
  • Medications - Overall protocol (starting dosing listed)
  1. See Acute Pulmonary Edema Management
  2. Step 1: ACE Inhibitor or Angiotensin Receptor Blocker (NYHA Class 1+ or ACC/AHA Class B+)
    1. Lisinopril 2.5 to 5 mg PO daily (and titrate to 20-40 mg daily) OR
    2. Losartan 12.5 to 25 mg orally daily (and titrate to 50-100 mg daily)
  3. Step 2: Beta Blockers (NYHA Class 1+ or ACC/AHA Class B+)
    1. Metoprolol XL 12.5 mg orally daily (and slowly titrate every 2-4 weeks to 100-200 mg daily)
  4. Step 3: Loop Diuretic (if pulmonary congestion, NYHA Class 2+ or ACC/AHA Class C+)
    1. Furosemide (Lasix) 40 mg orally once daily
  5. Step 4: Add adjunct (NYHA Class 2+ or ACC/AHA Class C+)
    1. Aldosterone Antagonist: Spironolactone 12.5 mg daily OR
    2. Hydralazine 37.5 mg with Isordil 20 mg three times daily (especially effective in black patients)
  6. Step 5: Consider additional agents (NYHA Class 2+ or ACC/AHA Class C+)
    1. Thiazide Diuretic (Hydrochlorothiazide 25 mg daily or Metolazone 2.5 mg daily)
    2. Digoxin 0.125 mg orally daily
  7. Step: 6: Consider additional agents (NYHA Class 3+ or ACC/AHA Class C+)
    1. Ivabradine (Corlanor) 5 mg orally twice daily
  • Management
  • Medications - Primary Medical Management (Class I, II, III)
  1. ACE Inhibitor (most important agent in CHF)
    1. See ACE Inhibitor in CHF for management protocol
    2. See ACE Inhibitor in CHF for alternative agents
      1. Angiotensin Receptor Blocker is alternative if ACE Inhibitor cannot be used
      2. Do not combine ACE Inhibitors with Angiotensin Receptor Blocker
    3. Consider adding Spironolactone early (see below)
      1. Blocks aldosterone escape from ACE Inhibitor
  2. Beta Blocker
    1. Protocol
      1. Avoid in decompensated CHF (start when stable)
      2. Start with low doses
      3. Titrate doses slowly (double dose every 2-4 weeks)
      4. Evaluate worse Dyspnea, failure or Hypotension
        1. Decrease or discontinue Beta-Blocker dose
        2. Consider increasing Diuretic dose
      5. Expect initial drop in ejection fraction
        1. Patients will feel more Fatigued in first month
        2. Beta Blocker benefits realized by 3 months
    2. Agents
      1. Metoprolol (Toprol XL)
        1. Start at 12.5 to 25 mg daily (max: 200 mg/day)
      2. Bisoprolol (Zebeta)
        1. Start: 1.25 mg (25% of 5 mg tablet) daily (maximum: 10 mg/day)
      3. Carvedilol (Coreg)
        1. Start at 3.125 mg orally twice daily
        2. Slowly titrate to 12.5 - 25 mg orally twice daily over 2 weeks
        3. Superior to Metoprolol in increasing Ejection Fraction
          1. Raiput (2003) Am J Cardiol 92:218-21 [PubMed]
    3. Outcomes
      1. Safe and well tolerated even in Class IV CHF
      2. Reduces mortality and hospitalization rates
      3. Improved CHF related symptoms
      4. Goldstein (2001) J Am Coll Cardiol 38:932-8 [PubMed]
  1. Diuretics (reduce volume overload)
    1. First Line: Loop Diuretics
      1. Use as adjunct to other drugs above for pulmonary congestion
      2. Diuretics are not the primary CHF treatment
      3. Start Furosemide (Lasix) 40 mg orally daily (increase to 40 to 160 mg per dose, twice daily)
      4. Consider changing to more potent Loop Diuretics in CHF pulmonary congestion refractory cases
        1. Bumetanide (Bumex) 1 mg once daily (up to 10 mg daily)
        2. Ethacrynic Acid (Edecrin) 25 mg once daily (up to 200-400 mg daily)
        3. Torsemide (Demadex) 20 mg once daily (up to 100-200 mg daily)
    2. Second: Spironolactone or Eplerenone (Aldosterone Antagonists)
      1. Indicated for NYHA Class III or IV Heart Failure
        1. Consider 3-14 days after MI, if decreased EF and symptomatic Heart Failure or diabetes
      2. Serum Creatinine must be <2.5 mg/dl (GFR > 30 ml/minute/1.73m2)
      3. Serum Potassium must be normal (below 5.0 to 5.5 meq/L)
      4. Agents
        1. Spironolactone (Aldactone) 12.5 mg orally daily (may increase to 25 mg) OR
        2. Eplerenone (Inspra) 25 mg orally daily (may increase to 50 mg orally daily)
      5. Monitor Serum Potassium at 3 days, 7 days and then monthly for the first 3 months
      6. Bozkurt (2003) Am J Cardiol 41:211-4 [PubMed]
  2. Digoxin (Increased contractility)
    1. Consider as adjunct for symptomatic Heart Failure refractory to current management
    2. Typical dose: 0.125 mg daily (up to 0.25 mg daily)
      1. Decrease to 0.0625 if Drug Interactions or Chronic Renal Insufficiency
    3. Does not decrease mortality, but significantly improves quality of life
    4. Increased mortality if serum Digoxin >1.0 ng/ml
      1. Keep serum Digoxin level 0.5 to 0.8 ng/ml (measure 6-8 hours after dose)
      2. Rathore (2003) JAMA 289:871-8 [PubMed]
    5. May be associated with increased mortality in women
      1. Rathore (2002) N Engl J Med 347:1403-11 [PubMed]
  • Management
  • Medications - Adjunctive measures
  1. Coronary revascularization (e.g. PTCA) if ischemia
  2. Atrial Fibrillation treatment if present
  3. Cardiac resynchronization
    1. Indications
      1. Ejection fraction <=35% and
      2. QRS Duration >120 ms and
      3. Symptomatic despite maximal medical therapy
    2. Efficacy
      1. Reduces mortality and hospitalization rate
      2. Pacemaker with Defibrillator was most effective
    3. References
      1. Bristow (2004) N Engl J Med 350:2140-50 [PubMed]
      2. McAlister (2004) Ann Intern Med 141:381-90 [PubMed]
  4. Implantable Defibrillator
    1. Indications
      1. LVEF <35% due to Ischemic Heart Disease
      2. LVEF <35% with NYHA Class II and III
    2. Reduces mortality (Amiodarone does not)
      1. Bardy (2005) N Engl J Med 352:225-37 [PubMed]
  5. Warfarin (Coumadin)
    1. Aspirin is a reasonable alternative
    2. Indicated for arrhythmia
    3. Indicated for Thromboembolism risk (especially while hospitalized)
    4. Not indicated in standard Cardiomyopathy
    5. No data to support use in low ejection fraction
  6. Eplerenone (Inspra)
    1. Mechanism: Aldosterone blockade
    2. Effective in CHF from acute Myocardial Infarction
    3. See Spironolactone above for containdications (GFR<30, Serum Potassium >5)
    4. Start at 25 mg orally daily and may titrate to 50 mg orally daily
    5. Alternative to Spirinolactone, but more expensive
      1. Did not previously warrant additional cost, but is now generic ($65/month)
      2. Consider if severe Gynecomastia on Spironolactone
    6. References
      1. Pitt (2003) N Engl J Med 348:1309-21 [PubMed]
  7. Hydralazine and Isosorbide Dinitrate
    1. Especially effective in younger black patients
    2. Indicated for NYHA Class III or Class IV Heart Failure
    3. Start
      1. Hydralazine 12.5 mg orally and
      2. Isosorbide Dinitrate or Isosorbide Mononitrate
        1. Dinitrate 5-10 mg tid with 12 hour-free or
        2. Mononitrate 30 mg orally daily
    4. Maintenance
      1. BiDil 37.5/20 one orally three times daily (max two tabs per dose) or
      2. Hydralazine 37.5-75 mg/day and Dinitrate 20-40 mg/day
  8. Ivabradine (Corlanor)
    1. Sinus nodemodulator
    2. Indications
      1. Persistent symptoms in stable patients in sinus rhythm with Heart Rate >70, EF <35
      2. Adjunct following ACE Inhibitor, Beta Blocker, Aldosterone Antagonist
    3. Dose
      1. Start at 5 mg orally twice daily
      2. Increase to 7.5 mg twice daily after 2 weeks if Heart Rate >60/min
      3. Decrease to 2.5 mg twice daily after 2 weeks if Heart Rate <50/min
    4. Adverse effects
      1. Bradycardia (especially if combined with Beta Blockers, Amiodarone, Digoxin)
        1. Monitor carefully while titrating dose and avoid for Heart Rate <70
      2. Atrial Fibrillation (1%)
      3. Visual field increased brightness (2%)
    5. References
      1. (2015) Presc Lett 22(6): 31
      2. Swedberg (2010) Lancet 376(9744):875-85 +PMID:20801500 [PubMed]
  9. Sacubitril and Valsartan (Entresto)
    1. Sacubitril (neprilysin inhibitor) increases vasodilation and Sodium excretion
    2. Appears effective, but based on only one large trial
    3. Risk of Hypotension (NNH 21) and Angioedema (NNH 200)
    4. Consider as replacement for ACE Inhibitor or Angiotensin Receptor Blocker
    5. Dosing
      1. Valsartan 103 mg salt in Entresto is equivalent to 160 mg salt in Diovan
      2. Start at Sacubitril/Valsartan 49/51 mg twice daily
      3. Titrate to Sacubitril/Valsartan 97/103 mg twice daily
    6. References
      1. (2015) Presc Lett 22(9): 49
      2. McMurray (2014) N Engl J Med 371(11):993-1004 +PMID:25176015 [PubMed]
  • Management
  • Disproven therapies or serious adverse effects (avoid these)
  1. Avoid Nesiritide (Natrecor)
    1. Recombinant Human Brain Natriuretic Peptide
    2. Results in venous and arterial vasodilation
    3. Dosing
      1. Bolus: 2 mcg/kg IV bolus
      2. Maintenance: 0.01 mcg/kg/min for 24-48 hours
    4. Improved CHF symptoms at the expense of increased mortality
    5. Sackner-Bernstein (2005) JAMA 293:1900-5 [PubMed]
  2. Tolvaptan
    1. Mechanism: Vasopressin Receptor Antagonist
    2. Reduces volume overload and congestion immediately
    3. Appears to have longterm benefit in CHF
      1. Gheorghiade (2004) JAMA 291:1963-71 [PubMed]
    4. However, risk of Liver Failure and FDA limits to 30 days of use
      1. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm350185.htm
  • Management
  • Refractory CHF
  1. Indicated for lack of response to above measures
  2. Step 0: Maximize key agent doses
    1. Increase doses every 2-4 weeks and consider split daily dosing to prevent Hypotension
    2. Maximize ACE Inhibitor or Angiotensin Receptor Blocker dose
    3. Maximize Beta Blocker dose
  3. Step 1: Loop Diuretic
    1. Double dose (not twice daily) if no response
    2. Double dose if Serum Creatinine remains >2.0
  4. Step 2: Add second Diuretic with caution
    1. Spironolactone (offers aldosterone blockade)
      1. Dose: 25 mg orally daily
      2. Indicated in Class III or Class IV CHF
      3. Contraindicated if Serum Creatinine >2.5 mg/dl
      4. Alternative: Eplerenone
    2. Thiazide Diuretic
      1. Hydrochlorothiazide 25 mg orally daily
      2. Metolazone (Zaroxolyn)
        1. Dose 5-10 mg twice weekly 1 hour before Furosemide
  5. Step 3: Add Hydralazine with Isosorbide (see dosing above)
  6. Step 4: Loop Diuretic IV
  7. Step 5
    1. See Other agents above
    2. Dobutamine with low dose Dopamine
      1. Intermittent Dobutamine reduces mortality
      2. Nanas (2004) Chest 125:1198-204 [PubMed]
    3. Consider Milrinone
  8. Step 6
    1. Consider for Revascularization if indicated
    2. Bi-Ventricular Pacing (especially in Left Bundle Branch Block)
    3. Left Ventricular Assist Device (LVAD)
    4. Consider for Cardiac Transplantation
    5. Consider Palliative Care
  • Prognosis
  1. Congestive Heart Failure Exacerbation Decision Rule
  2. Six-Minute Walk Test
    1. Predicts mortality and hospitalization
  3. Survival for Hypertensive Heart Failure
    1. Men: 24% five-year survival
    2. Women: 31% five-year survival