Heart Failure: Living with a

Hurting Heart
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




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 8
th
Edition, 2001

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

Anatomy 101

A normal heart pumps blood in a smooth and synchronized way.
Heart Failure Heart
A heart failure heart has a reduced ability to pump blood.
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
CAD=coronary artery disease; LVH=left ventricular hypertrophy.
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
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
*Rich M. J Am Geriatric Soc. 1997;45:968974.
American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.
3.5
4.7
10
0
2
4
6
8
10
12
1991 2000 2037*
H
e
a
r
t

F
a
i
l
u
r
e

P
a
t
i
e
n
t
s

i
n

U
S

(
M
i
l
l
i
o
n
s
)

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
Classifying Heart Failure:
Terminology and Staging
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
1
Hunt SA et al. J Am Coll Cardiol. 2001;38:21012113.


2
New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890897.
ACC/AHA HF Stage
1
NYHA Functional Class
2

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)
B Structural heart disease but without
symptoms of heart failure
C Structural heart disease with prior or
current symptoms of heart failure
D Refractory heart failure requiring
specialized interventions
I Asymptomatic
II Symptomatic with moderate exertion
IV Symptomatic at rest
III Symptomatic with minimal exertion
None
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)


Pathophysiology
Adapted from Cohn JN. N Engl J Med. 1996;335:490498.
Pathologic
remodeling
Low ejection
fraction
Death
Symptoms:
Dyspnea
Fatigue
Edema
Chronic
heart
failure
Neurohormonal
stimulation
Myocardial
toxicity
Sudden
Death
Pump
failure
Coronary artery
disease
Hypertension
Cardiomyopathy
Valvular disease
Myocardial
injury
Pathologic Progression of CV Disease
Diabetes
Compensatory Mechanisms:
Renin-Angiotensin-Aldosterone System
Renin + Angiotensinogen
Angiotensin I
Angiotensin II
Peripheral
Vasoconstriction
Afterload
Cardiac Output
Heart Failure
Cardiac Workload
Preload
Plasma Volume
Salt & Water Retention
Edema
Aldosterone Secretion
ACE
Kaliuresis
Beta
Stimulation
CO
Na
+
Fibrosis
Drug Therapy
Heart Failure Treatments:
Medication Types
ACE inhibitor
(angiotensin-converting
enzyme)
ARB (angiotensin receptor
blockers)
Beta-blocker
Digoxin
Diuretic

Aldosterone
blockade
Type What it does
Expands blood vessels which lowers
blood pressure, neurohormonal
blockade
Similar to ACE inhibitorlowers
blood pressure
Reduces the action of stress
hormones and slows the heart rate
Slows the heart rate and improves the
hearts pumping function (EF)
Filters sodium and excess fluid from the
blood to reduce the hearts 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)
digoxin
Improve Survival
Betablockers
ACE-inhibitors
Aldosterone blockers
Angiotensin receptor
blockers (ARBs)
Lifestyle Changes

Eat a low-sodium, low-fat
diet
Lose weight
Stay physically active
Reduce or eliminate alcohol
and caffeine
Quit Smoking
What Why
Sodium is bad for high blood pressure,
causes fluid retention
Extra weight can put a strain on
the heart
Exercise can help reduce stress
and blood pressure
Alcohol and caffeine can weaken an
already damaged heart
Smoking can damage blood vessels and
make the heart beat faster
"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.

Device Therapy:
Biventricular Pacing
Overview of Device Therapy 25
Biventricular Pacing
Ventricular Dysynchrony
Abnormal ventricular conduction resulting
in a mechanical delay and dysynchronous
contraction
BiV Pacing
Cardiac Resynchronization Therapy
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




Defibrillators (ICDs)
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?
Device
Shown:
Combination
Pacemaker &
Defibrillator
Implantable Cardiac Defribrillators
EBM Therapies Relative Risk
Reduction
Mortality
2 year
ACE-I 23% 27%
-Blockers 35% 12%
Aldosterone
Antagonists
30% 19%
ICD 31% 8.5%
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?
Transplant
Artificial hearts
New gadgets to help doctors manage
heart failure

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.
Worldwide Heart Transplants


Newer Generation Artificial Hearts

Future Tech
Intrathoracic Impedance for Heart
Failure
One of the Best Devices for
Monitoring Heart Failure

What have we learned?
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!