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Heart Failure:

Heart Failure:. Case 1. 67 year old man Presented with anterior wall MI in May. Underwent stent placement in the LAD. The other arteries were patent. Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis

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Heart Failure:

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  1. Heart Failure:

  2. Case 1 • 67 year old man • Presented with anterior wall MI in May. Underwent stent placement in the LAD. The other arteries were patent. • Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis • Unremarkable recovery. Started on aspirin, plavix, simvastatin, atenolol 25mg and discharged home

  3. November 1 • Acute onset of shortness of breath • Wife called Mada, • HR 94 BP 114/60 RR 28 sat 91% • Bibasilar crackles

  4. ECG

  5. Chest x-ray

  6. Echo • Dilated LV with moderately-severely decreased function. • Anteroseptal and apical dyskinesis • Moderate-severe mitral regurgitation • Normal RV size and function • Mild pulmonary hypertension

  7. What happened?

  8. Cardiac Remodeling ↑Afterload Vasoconstriction × ↑Preload Neurohormonal Activation Sodium & Water Retention ↑Contractility × Beta Blockers Sympathetic Stimulation Diuretics × × Renin-Angiotensin Aldosterone ACE-I ARB Spironolactone Biomechanical Model of Heart Failure Myocardial Dysfunction

  9. What didn’t happen that should have happened?

  10. Stages in Heart Failure Prevention Life style modification ACE-I/ARB Beta Blockers Restrict Diet Diuretics Aldospirone Digoxin CRT ± ICD Assist devices Transplantation A B Patients at Risk C Structural Heart Disease D Heart Failure Symptoms Refractory Symptoms AHA / ACC HF guidelines

  11. Hospital Course • Admitted with a diagnosis of acute decompensated heart failure. • What is the first thing you do?

  12. Comprehensive inhibition of neurohormonal activation • achieve euvolemia with diuretics and salt restriction • ACE-inhibitors • Beta-blockers (so far only carvedilol, bisoprolol and extended release metoprolol) • Careful spironolactone

  13. 100 90 Placebo Enalapril 80 70 Survival % ACE-Inhibitor 60 50 31% 40 Enalapril Placebo 30 0 0 1 2 3 4 5 6 7 8 9 10 11 12 CONSENSUS NEJM 1987 Months 100 Carvedilol 90 80 Beta Blocker 70 Survival % 35% 60 50 Placebo 0 4 8 12 16 20 24 28 COPERNICUS NEJM 2001 Months

  14. Spironolactone RALES NEJM 1999

  15. If... • If the patient cannot tolerate ACE-inhibitor, ARB may be substituted (valsartan) • If the patient cannot tolerate beta blocker, ACE-I and ARB may be combined • Isosorbide and hydralazine can be considered in patients who cannot tolerate ACE-I

  16. Now what should we do? • A. Cardiac catheterization to see if the stent is patent • B. Stress thallium to see if there is residual ischemia • C. Exercise echo to see if the mitral regurgitation and pulmonary hypertension worsen with exercise • D. Transesophageal echo to determine severity of mitral regurgitation

  17. Other considerations • A. Put in a defibrillator • B. Put in a pacemaker to allow for target doses of beta blocker • C. Put in a biventricular pacemaker • D. Add amiodarone for the prevention of sudden cardiac death

  18. Implantable Cardiac Defibrillator (ICD) N=2,521 IHD/NIHD NYHA class II-III LVEF < 35% 23% ICD • ICD implantation: • Patients with LVEF<30% • NYHA II-IV SCD-HeFT N Engl J Med 2005

  19. Biventricular Pacing

  20. Cardiac Function: EF↑ LV size↓ MR ↓ Exercise Capacity Quality of life Hospitalizations Mortality Cardiac-Resynchronization Therapy (CRT) • Ventricular conduction delays cause dysynchronous contraction • Biventricular pacing synchronizes ventricle contraction

  21. Cardiac-Resynchronization Therapy (CRT) N = 813 NYHA III-IV 36% Survival • CRT Implantation: • Patients with LVEF<35% • NYHA III-IV • Optimal Medical Therapy • QRS >120 ms CARE-HF N Engl J Med. 2005

  22. What other therapies are available • Prevention - Control risk factors • Life style modifications • Treat etiologic cause / aggravating factors • Optimized Drug therapy • Specialized care – egShikum Lev or Heart Failure clinics

  23. What is the prognosis?

  24. 66% 26% 27% (%) One Year Clinical Event Rate in Heart Failure

  25. Acute event Ventricular function Time Acute Exacerbations Contribute to the Progression of Heart Failure Am J Cardiology 2005

  26. Treatment – All Patients • Prevention - Control risk factors • Life style modifications • Treat etiologic cause / aggravating factors • Optimized Drug therapy • Specialized care – Increase compliance • Advanced Treatment

  27. Next patient • 76 year old man • CABG and AVR 10 years ago • Normal LV systolic function on most recent echo • Presents to the ER with acute decompensated heart failure.

  28. In the ER • HR 118 and irregular • Blood pressure 132/64 • RR 22 • O2 Sat 94%

  29. The ECG

  30. What happened?

  31. diastolic dysfunction Fills Empties  LA pressure Empties Atrial fibrillation Fills CHF Heart Failure with preserved EF Inability to fill normally

  32. HFPEF- Etiology • Left ventricular hypertrophy • Hypertension • Aortic stenosis • Coronary artery disease • Diabetes • Elderly • Infiltrative/restrictive • Unexplained

  33. Distribution of LV Functionin Patients Age>65 yrs with CHF Gottdiener et al 2002. AIM 137(8):631-639

  34. Pressure/Volume Relationship Burkhoff et al 2003. Circ 107(5):656-658.

  35. Diastolic Heart Failure - Diagnosis Is there a test that will diagnose diastolic heart failure? NO!

  36. 100 Preserved LVF 90 80 Survival (%) Reduced LVF 70 Adjusted Survival P=0.26 60 50 0 2 4 6 8 10 12 Months Heart Failure One Year Survival

  37. World’s Literature of Large or Randomized Trials of the Treatment of Systolic Heart Failure • CONSENSUS I • VeHFT I • SOLVD • SAVE • VeHFT II • CONSENSUS II • ATLAS • PROVED • RADIANCE • DIG • MDC • CIBIS I • CIBIS II • ANZ • PRECISE • MOCHA • MERIT-HF • COPERNICUS • CAPRICORN • CHF-STAT • ELITE • ValHFT • ELITE II • CHARM • RESOLVD • PRAISE • WATCH • RALES • GESICA • COMET

  38. Randomized Trials of Treatment of D-CHF Zile et al 2002. Circ 105(12):1503-1508.

  39. CHARM – PreservedPrimary Endpoints P=0.072

  40. Diastolic CHF – Goals of Therapy • Reduce preload • Decrease heart rate • Normalize blood pressure • Maintain atrial contraction • Improve relaxation • Cause regression of LVH • Decrease interstitial fibrosis • Treat ischemia • Decrease neurohumoral activation

  41. In the ER • The patient was given IV beta blocker and digoxin, with slowing of his heart rate to the 80s. • Echo demonstrated : • Dilated atria • Normal LV chamber size with mild hypertrophy. Normal RV size and function • Normally functioning aortic prosthesis • Mild-moderate mitral regurgitation • Mild pulmonary hypertension

  42. What do you do now? • A. Begin anticoagulation, and plan to cardiovert the patient in 3 weeks • B. Begin anticoagulation and plan for TEE cardioversion in the next few days • C. Begin anticoagulation, and initiate amiodarone therapy in preparation for cardioversion • D. Give digoxin in order to lead to spontaneous cardioversion

  43. Case Presentation • 66 year old male • Shortness of breath – few months • FC NYHA I  III • Chest CT: enlarged lymph nodes • Biopsy: Sarcoidosis • Treated with Steroids

  44. Case Presentation • Systolic murmur on the apex • Echo 1 year previously: • Mod-severe Mitral Regurgitation • LV size and Function normal • Moderate PHT (50 mmHg) • Started on Enalapril, metoprolol & Fusid

  45. LA MV LV Trans-EsophagealEcho • Prolapse of posterior mitral leaflet • Rupture Chordea: • Severe Mitral Regurgitation

  46. Course • Surgery - Flail P2 • Repair of mitral valve by resection of P2and suture and implantation of ring • Two weeks after surgery: NYHAI-II • Echo 1 months later: noMR, noPHT

  47. Next case • 41 year old woman • Previously healthy • Presents with acute decompensated heart failure

  48. Echo

  49. Patient begins to deteriorate, and is in low grade cardiogenic shock • What are possible causes? • What do you do?

  50. A Stepwise Approach

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