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Heart Failure: Living with a Hurting Heart. James T. DeVries, MD Dartmouth-Hitchcock Medical Center. Outline. Definitions and scope of problem Diagnosing and classifying heart failure Approach to management of CHF Oral drug therapy (ACE-I, ARB, betablockers, aldosterone blockade, digoxin)

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Heart failure living with a hurting heart l.jpg

Heart Failure: Living with a Hurting Heart

James T. DeVries, MD

Dartmouth-Hitchcock Medical Center


Outline l.jpg
Outline

  • Definitions and scope of problem

  • Diagnosing and classifying heart failure

  • Approach to management of CHF

    • Oral drug therapy (ACE-I, ARB, betablockers, aldosterone blockade, digoxin)

    • Device therapy

      • Biventricular (BiV) pacers

      • Intracardiac defibrillators (ICD’s)

  • Future directions and exciting developments


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Congestive Heart Failure

  • Heart (or cardiac) failure is the state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only from high pressures

Braunwald 8th Edition, 2001


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Congestive Heart Failure

  • Symptoms:

    • Shortness of breath

    • Leg swelling (edema)

    • Breathing worsens with lying flat (orthopnea)

    • Fatigue




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Heart Failure Heart

A heart failure heart has a reduced ability to pump blood.


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Types of Heart Failure

  • Systolic (or squeezing) heart failure

    • Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure

  • Diastolic (or relaxation) heart failure

    • Involves a thickened and stiff heart muscle

    • As a result, the heart does not fill with blood properly

    • This results in fluid backup in the lungs and heart failure


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Coronary artery disease

Hypertension (LVH)

Valvular heart disease

Alcoholism

Infection (viral)

Diabetes

Congenital heart defects

Other:

Obesity

Age

Smoking

High or low hematocrit level

Obstructive Sleep Apnea

Risk Factors for Heart Failure

CAD=coronary artery disease; LVH=left ventricular hypertrophy.


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Epidemiology of Heart Failure in the US

12

  • More deaths from heart failure than from all forms of cancer combined

  • 550,000 new cases/year

  • 4.7 million symptomatic patients; estimated 10 million in 2037

10

10

8

Heart Failure Patients in US

(Millions)

6

4.7

3.5

4

2

0

1991

2000

2037*

*Rich M. J Am Geriatric Soc. 1997;45:968–974.

American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.


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“Wow! Brazil is big."

—George W. Bush, after being shown a map of Brazil by Brazilian president Luiz Inacio Lula da Silva, Brasilia, Brazil, Nov. 6, 2005


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Classifying Heart Failure:Terminology and Staging


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A Key Indicator for Diagnosing Heart Failure

Ejection Fraction (EF)

  • Ejection Fraction (EF) is the percentage of blood that is pumped out of your heart during each beat


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Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class

ACC/AHA HF Stage1

NYHA Functional Class2

None

A At high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease)

I Asymptomatic

B Structural heart disease but without symptoms of heart failure

CStructural heart disease with prior or current symptoms of heart failure

II Symptomatic with moderate exertion

III Symptomatic with minimal exertion

IV Symptomatic at rest

D Refractory heart failure requiring specialized interventions

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.


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How Heart Failure Is Diagnosed and NYHA Functional Class

  • Medical history is taken to reveal symptoms

  • Physical exam is done

  • Tests

    • Chest X-ray

    • Blood tests

    • Electrical tracing of heart (Electrocardiogram or “ECG”)

    • Ultrasound of heart (Echocardiogram or “Echo”)

    • X-ray of the inside of blood vessels (Angiogram)


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Pathophysiology and NYHA Functional Class


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Pathologic Progression of CV Disease and NYHA Functional Class

Sudden

Death

Coronary artery disease

Myocardialinjury

Pathologicremodeling

Low ejectionfraction

Hypertension

Death

Diabetes

Cardiomyopathy

Pump failure

Valvular disease

Symptoms:DyspneaFatigueEdema

Chronicheartfailure

  • Neurohormonalstimulation

  • Myocardial toxicity

Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.


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Compensatory Mechanisms: and NYHA Functional ClassRenin-Angiotensin-Aldosterone System

  • Beta

  • Stimulation

    • CO

    • Na+

Renin + Angiotensinogen

Angiotensin I

ACE

Angiotensin II

Kaliuresis

Fibrosis

Aldosterone Secretion

Peripheral Vasoconstriction

Salt & Water Retention

  • Plasma Volume

Edema

  • Afterload

  • Preload

  • Cardiac Output

  • Cardiac Workload

Heart Failure


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Drug Therapy and NYHA Functional Class


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Heart Failure Treatments: Medication Types and NYHA Functional Class

Type What it does

  • ACE inhibitor (angiotensin-converting enzyme)

  • Expands blood vessels which lowers blood pressure, neurohormonal blockade

  • Similar to ACE inhibitor—lowers blood pressure

  • ARB (angiotensin receptor blockers)

  • Beta-blocker

  • Reduces the action of stress hormones and slows the heart rate

  • Digoxin

  • Slows the heart rate and improves the heart’s pumping function (EF)

  • Diuretic

  • Aldosterone blockade

  • Filters sodium and excess fluid from the blood to reduce the heart’s workload

  • Blocks neurohormal activation and controls volume


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Improve Symptoms and NYHA Functional Class

Diuretics (water pills)

digoxin

Improve Survival

Betablockers

ACE-inhibitors

Aldosterone blockers

Angiotensin receptor blockers (ARB’s)

Rational for Medications(Why does my doctor have me on so many pills??)


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Lifestyle Changes and NYHA Functional Class

WhatWhy

  • Sodium is bad for high blood pressure, causes fluid retention

  • Eat a low-sodium, low-fat diet

  • Extra weight can put a strain on the heart

  • Lose weight

  • Exercise can help reduce stress and blood pressure

  • Stay physically active

  • Alcohol and caffeine can weaken an already damaged heart

  • Reduce or eliminate alcohol and caffeine

  • Smoking can damage blood vessels and make the heart beat faster

  • Quit Smoking


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"During my service in the United States Congress, I took the initiative in creating the Internet"

Al Gore said when asked to cite accomplishments that separate him from another Democratic presidential hopeful, former Sen. Bill Bradley of New Jersey, during an interview with Wolf Blitzer on CNN on March 9, 1999.


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Device Therapy: initiative in creating the Internet" Biventricular Pacing


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Biventricular Pacing initiative in creating the Internet" Ventricular Dysynchrony

  • Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction

Overview of Device Therapy


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BiV Pacing initiative in creating the Internet"


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Cardiac Resynchronization Therapy initiative in creating the Internet" Key Points

  • Indications

    • Moderate to severe CHF who have failed optimal medical therapy

    • EF<30%

    • Evidence of electrical conduction delay

  • Timing of Referral Important

    • Patients often not on optimal Medical Rx

    • Patients referred too late- Not a Bail Out


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Defibrillators (ICD’s) initiative in creating the Internet"


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Heart Failure and Sudden Cardiac Death initiative in creating the Internet"

Sudden Cardiac Death (SCD)

  • Your heart suddenly goes into a very fast and chaotic rhythm and stops pumping blood

  • Caused by an “electrical” problem in your heart

  • SCD is one of the leading causes of death in the U.S. – approximately 450,000 deaths a year

  • Patients with heart failure are 6-9 times as likely to develop sudden cardiac death as the general population


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How does a defibrillator for sudden cardiac death work? initiative in creating the Internet"

Device Shown:

Combination Pacemaker & Defibrillator


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Implantable Cardiac Defribrillators initiative in creating the Internet"


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Who should Consider an ICD? initiative in creating the Internet"

  • Patients with weakend heart, New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) < 35%

  • Patients who meet all current requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure;


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Other Therapies? initiative in creating the Internet"

  • Transplant

  • Artificial hearts

  • New “gadgets” to help doctors manage heart failure


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Heart Transplantation initiative in creating the Internet"

  • A good solution to the failing heart– get a new heart

  • Unfortunately we are limited by supply, not demand

  • Approximately 2200 transplants are performed yearly in the US, and this number has been stable for the past 20 years.


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Worldwide Heart Transplants initiative in creating the Internet"


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Newer Generation Artificial Hearts initiative in creating the Internet"


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Future Tech initiative in creating the Internet"


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Intrathoracic Impedance for Heart Failure initiative in creating the Internet"


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One of the Best Devices for Monitoring Heart Failure initiative in creating the Internet"


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What have we learned? initiative in creating the Internet"


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In Summary…. initiative in creating the Internet"

  • Heart failure is common and has high mortality

  • Drug therapy improves survival

    • Betablockers, ACE-I, aldosterone antagonists

  • Newer device therapies are showing promise for symptom relief and improved survival

    • Biventricular pacing, ICD’s

  • Transplants remain rare, but technology for mechanical assist devices continues to improve- stay tuned!


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