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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

Heart Failure: Living with a Hurting Heart

James T. DeVries, MD

Dartmouth-Hitchcock Medical Center

  • 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
congestive heart failure
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

congestive heart failure4
Congestive Heart Failure
  • Symptoms:
    • Shortness of breath
    • Leg swelling (edema)
    • Breathing worsens with lying flat (orthopnea)
    • Fatigue

Heart Failure Heart

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

types of heart failure
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
risk factors for heart failure
Coronary artery disease

Hypertension (LVH)

Valvular heart disease


Infection (viral)


Congenital heart defects





High or low hematocrit level

Obstructive Sleep Apnea

Risk Factors for Heart Failure

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

epidemiology of heart failure in the us
Epidemiology of Heart Failure in the US


  • 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




Heart Failure Patients in US











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

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

“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

a key indicator for diagnosing heart failure
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
classification of hf comparison between acc aha hf stage and nyha functional class
Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class


NYHA Functional Class2


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.

how heart failure is diagnosed
How Heart Failure Is Diagnosed
  • 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)
pathologic progression of cv disease
Pathologic Progression of CV Disease



Coronary artery disease



Low ejectionfraction





Pump failure

Valvular disease



  • Neurohormonalstimulation
  • Myocardial toxicity

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

compensatory mechanisms renin angiotensin aldosterone system
Compensatory Mechanisms:Renin-Angiotensin-Aldosterone System
  • Beta
  • Stimulation
    • CO
    • Na+

Renin + Angiotensinogen

Angiotensin I


Angiotensin II



Aldosterone Secretion

Peripheral Vasoconstriction

Salt & Water Retention

  • Plasma Volume


  • Afterload
  • Preload
  • Cardiac Output
  • Cardiac Workload

Heart Failure

heart failure treatments medication types
Heart Failure Treatments: Medication Types

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
rational for medications why does my doctor have me on so many pills
Improve Symptoms

Diuretics (water pills)


Improve Survival



Aldosterone blockers

Angiotensin receptor blockers (ARB’s)

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


  • 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
"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.

biventricular pacing ventricular dysynchrony
Biventricular PacingVentricular Dysynchrony
  • Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction

Overview of Device Therapy

cardiac resynchronization therapy key points
Cardiac Resynchronization TherapyKey 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
heart failure and sudden cardiac death
Heart Failure and Sudden Cardiac Death

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
how does a defibrillator for sudden cardiac death work
How does a defibrillator for sudden cardiac death work?

Device Shown:

Combination Pacemaker & Defibrillator

who should consider an icd
Who should Consider an ICD?
  • 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;
other therapies
Other Therapies?
  • Transplant
  • Artificial hearts
  • New “gadgets” to help doctors manage heart failure
heart transplantation
Heart Transplantation
  • 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.
in summary
In Summary….
  • 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!