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Heart Failure: Living with a Hurting Heart

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Congestive Heart Failure ... Congestive Heart Failure. Symptoms: Shortness of breath. Leg swelling (edema) ... in fluid backup in the lungs and heart failure ... – PowerPoint PPT presentation

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Title: Heart Failure: Living with a Hurting Heart


1
Heart Failure Living with a Hurting Heart
  • James T. DeVries, MD
  • Dartmouth-Hitchcock Medical Center

2
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 (ICDs)
  • Future directions and exciting developments

3
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
4
Congestive Heart Failure
  • Symptoms
  • Shortness of breath
  • Leg swelling (edema)
  • Breathing worsens with lying flat (orthopnea)
  • Fatigue

5
Anatomy 101
6
A normal heart pumps blood in a smooth and
synchronized way.
7
Heart Failure Heart
A heart failure heart has a reduced ability to
pump blood.
8
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

9
Risk Factors for Heart Failure
  • 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

CADcoronary artery disease LVHleft ventricular
hypertrophy.
10
Epidemiology of Heart Failure in the US
12
10
  • 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
8
Heart Failure Patients in US (Millions)
6
4.7
3.5
4
2
0
1991
2000
2037
Rich M. J Am Geriatric Soc. 199745968974. Amer
ican Heart Association. 2001 Heart and Stroke
Statistical Update. 2000.
11
  • 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

12
Classifying Heart Failure Terminology and Staging
13
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

14
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
C Structural 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.
20013821012113. 2New York Heart
Association/Little Brown and Company, 1964.
Adapted from Farrell MH et al. JAMA.
2002287890897.
15
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)

16
Pathophysiology
17
Pathologic Progression of CV Disease
Sudden Death
Coronary artery disease
Pathologic remodeling
Low ejection fraction
Myocardial injury
Hypertension
Death
Diabetes
Cardiomyopathy
Pump failure
Valvular disease
Symptoms Dyspnea Fatigue Edema
Chronic heart failure
  • Neurohormonal stimulation
  • Myocardial toxicity

Adapted from Cohn JN. N Engl J Med.
1996335490498.
18
Compensatory Mechanisms Renin-Angiotensin-Aldoste
rone 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
19
Drug Therapy
20
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 inhibitorlowers 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 hearts
    pumping function (EF)
  • Diuretic
  • Aldosterone blockade
  • Filters sodium and excess fluid from the blood to
    reduce the hearts workload
  • Blocks neurohormal activation and controls volume

21
Rational for Medications (Why does my doctor have
me on so many pills??)
  • Improve Survival
  • Betablockers
  • ACE-inhibitors
  • Aldosterone blockers
  • Angiotensin receptor blockers (ARBs)
  • Improve Symptoms
  • Diuretics (water pills)
  • digoxin

22
Lifestyle Changes
What Why
  • 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

23
  • "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.

24
Device Therapy Biventricular Pacing
25
Biventricular Pacing Ventricular Dysynchrony
  • Abnormal ventricular conduction resulting in a
    mechanical delay and dysynchronous contraction

26
BiV Pacing
27
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28
Cardiac Resynchronization Therapy Key Points
  • Indications
  • Moderate to severe CHF who have failed optimal
    medical therapy
  • EF
  • Evidence of electrical conduction delay
  • Timing of Referral Important
  • Patients often not on optimal Medical Rx
  • Patients referred too late- Not a Bail Out

29
Defibrillators (ICDs)
30
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

31
How does a defibrillator for sudden cardiac death
work?
Device Shown Combination Pacemaker
Defibrillator
32
Implantable Cardiac Defribrillators
33
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)
  • Patients who meet all current requirements for a
    cardiac resynchronization therapy (CRT) device
    and have NYHA Class IV heart failure

34
Other Therapies?
  • Transplant
  • Artificial hearts
  • New gadgets to help doctors manage heart
    failure

35
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.

36
Worldwide Heart Transplants
37
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38
Newer Generation Artificial Hearts
39
Future Tech
40
Intrathoracic Impedance for Heart Failure
41
(No Transcript)
42
One of the Best Devices for Monitoring Heart
Failure
43
What have we learned?
44
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, ICDs
  • Transplants remain rare, but technology for
    mechanical assist devices continues to improve-
    stay tuned!
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