Review of Literature

on
The Evolution of Heart Failure
Management
by
Lamidi M. Tunde
Matric No: AAA1700106
Seminar (PSG 891)
Supervisor- A.O Afolabi PhD
 Outline of the presentation
• Introduction
– Definition of HF
– Etiology of HF
– Prevalence of HF
– Classification of HF
• Management of HF
– Ancient period/ Pre 1980s
– HF management in 1980s
– Hf management in 1990s
– HF management in 2000s
– Mechanism of actions of Drugs used in Hf management
– Device therapy of HF management
• Future focuses of HF management
• Summary
• References
 Introduction
Definition
• The simplest definition of heart failure is "A
condition in which the heart fails to discharge its
contents adequately“(Davis et.al., 2000).
• Heart failure (HF) is a clinical syndrome
characterized by dyspnea, fatigue, and clinical
signs of congestion leading to frequent
hospitalizations, poor quality of life, and shortened
life expectancy (Gary et al., 2011). It is a final
common pathway to various heart diseases (Gary et
al., 2011).
 Introduction cont.
Etiology of heart failure
• Western word
The most common underlying cause of heart
failure in high-income countries is coronary artery
disease (Schocken et.al., 2008).
• In sub-Saharan Africa
– Hypertension (43.9%),
– Dilated cardiomyopathy (DCM) (19.5%); and
– Rheumatic heart diseases RHD (15%)
– Others 21.6
(Sliwa and Mayosi, 2013).
 Introduction cont.
Prevalence
• Available data show that more than 20 million people have
heart failure worldwide, and the prevalence of heart failure
in developed countries is estimated as 2% (Yamani and
Massie 1993).

• The prevalence of heart failure has been shown to follow an

exponential pattern, which rises with age and affects 6-10%
of people over age 65 in developed countries (American
Heart Association,2006; Elixhauser et. al.,1997 and Centers
for Disease Control and Prevention, 1999).
 Classification of Heart Failure
• Functional classification for heart failure following;
– New York Heart Association (NYHA) classification.
Class I-Class IV based on physical activities
(Ogah et.al., 2019)

-The American College of Cardiology/American

Heart Association- ACC/AHA stages of HF
stage A-D (Yancy et.al., 2013).
 Diagnosis of hf
• Medical history and review of symptom with
physical examination of the heart
• Systemic analysis- hemogram, renal function
and serum electrolytes, C-reactive protein,
glycemia and cholesterol,etc
• The ECG
• Chest x-ray
• The echocardiogram
 Management of HF

• Ancient Period-

It has been reported that the oldest Identified case of

HF was that examined by Andrew Nerlich, a
pathologist from Murich, Germany who examined the
histology of the lungs of a body and described the
presence of pulmonary oedema likely to due to ‘heart
failure’ (Bianucci et al., 2016).
 Pre 1980s Era
• Non pharmacological-
– bed rest, positioning, restriction of fliuds, digitalis and
diuretics
– Hirudinotherapy Hirudo medicinalis
(Blood letting by venesection or medicinal leeches)
–dropsy/edema in HF(Ventura and Mehra, 2005).
– Use of Southey’s tubes/cannula in draining edema of the limbs
(Walsh and Moyes 1964).
– Use of foxglove in 1785 by William Withering (Normal, 1985).
– Use of Organomercurial diuretics in 1920 and Thiazide diuretics
in 1958 (Davis et.al., 2000).
 HF anagement in 1980s
• Alprenolol and Practolol were reportedly tried as
beta blockers in 1975 (Waagstein et.al.,1975)
• Swedberg et.al.,(1979) reported initial success in
1979.
• Approval of beta blockers; Carvediol, Metoprolol
and Bisoprolol in 1993(Moss et.al.,2002)
 HF Management in 1990s
• Vasodialators
• Beta blockers;
• angiotensin Converting Enzyme inhibitors
(ACEI); and
• Minerallocorticoid inhibitors (Cohn et.al.,
1986)
 HF Management in 2000s
• Angiotensin receptor blockers-ARB (Cohn
et.al., 2001)
• Angiotensin-Nephrilysin inhibitors-ARNI
(McMurray et.al., 2014)
• Other Inotropes and vasodilator
 Mechanism of action of the drugs
• Diuretic
– They inhibit water reabsorption by blocking vasopressin
receptors along the collecting duct.
A second class of diuretics, act by diminishing sodium
reabsorption at different sites in the nephron, thereby
increasing urinary sodium and water losses.
• Inotropes
– They increase the force of contraction of the muscle of
the heart by inhibiting the activity of an enzyme
(ATPase).
Inhibiting ATPase increases calcium in heart muscle and
therefore increases the force of heart contractions.
 Mechanism of action of drugs cont.
• ACE inhibitors
– dilate arteries and veins by blocking angiotensin II
formation and inhibiting bradykinin metabolism.
– They serve as vasodilators by reducing arterial pressure,
preload and afterload on the heart.
• Beta-blockers
– They act by reducing the heart rate and allow more time
for heart to fill with blood. This allows the left ventricle
to fill more completely and increases the volume of
blood that the heart pumps with each heartbeat (ejection
fraction).
Mechanism of action of drugs cont.
 Device therapies of HF management
• Cardiac Resynchronization Therapy (CRT),
• Implantable Cardioverter-Defibrillators (ICD),
– The ICD was developed by Dr. Michel Mirowski and Dr.
Morton Mower in the 1970's as reported by their
publication Mirowski and Mower (1973)
– In 2010, the Heart Failure Society of America (HFSA)
laid down guidelines for CRT and ICD therapy in heart
failure (Lindenfedld et. al., 2010).
– The European Society of Cardiology and the ACC/AHA
also emphasized the importance of devices and
published guidelines for the same in 2010 and 2012
respectively (Sahasranam, 2017.)
 Device therapies of HF management
cont.
• Ventricular Assist Devices (VADs),
• totally implantable artificial hearts,
• cardiac reshaping devices,
• ultrafiltration,
• revascularization, and
• valve replacement/repair
 Future focuses on HF Management
• Cellular/Genetic Era –
– The next decade may see the era of stem cell
implantation and regeneration, gene therapy, and
xenotransplantation.
Summary
• Refferences
• Cohn JN, Archibald DG, Ziesche S et al.( 1986) Effect of vasodilator
therapy on mortality in congestive cardiac failure: Result
of a Veterans Administrative Cooperative study. N. Engl J Med. 314:
1547-1552.
• Cohn JN, Tognoni G(2001) for the Valsartan Heart Failure Trial
Investigators. A randomized Trial of the Angiotensin Receptor
blocker Valsartan in congestive heart failure. N Engl J Med. :
345: 1667-1675.
• McMurray JJV, Packer M, Desai AS et al (2014)Angiotensin-
Neprilysin Inhibition versus Enalapril in heart failure. N
Engl J Med. 371: 993- 1004.
• Davis RC, Hobbs FDR, Lip GYH (2000): History and Epidemiology
. ABC of Heart Failure : BMJ. : 320 (7226) 39 – 42.
• Gary SF, Tang WH, Walsh RA. (2011) Pathophysiology of Heart
Failure. In: Valentin Fuster RA, Harrington RA, editors.
Hurst's The Heart. 13th ed.. p. 719-38.
• Lindenfeld J, Albert NM,( 2010) Bochmer JP et al. The Heart
Failure Society of America Executive Summary. HFSA
comprehensive practice guidelines. J Card Fail 2010. June 16, (6)
e: 1-194.
• Mirowski M, Mower MM.( 1973) Transvenous Automatic
Defibrillator as an approach to prevention of sudden death
from ventricular fibrillation. Heart Lung..2: 867- 869.
• Moss AJ, Hall WJ, Cannom DS et al.( 1996) Improved
survival with an implanted defibrillator in patients with
coronary disease at high risk of ventricular arrhythmia.
Multicenter Automatic Defibrillator Implantation Trial
Investigators. N Engl J Med.. 355: 1933-1940.
• Normal JM : (2000)William Withering and the Purple foxglove: A
Bicentennial tribute. J Clin Pharmacol.. 25: no 7. 479-483.
• Ogah OS, Okpechi I, Chukwuonye II, Akinyemi JO, Onwubere
BJ, Falase AO, et al. (2012 ) Blood pressure, prevalence of
hypertension and hypertension related complications in
Nigerian Africans: A review. World J Cardiol;4:327-40.
• Sliwa K, Mayosi BM.( 2013) Recent advances in the epidemiology,
pathogenesis and prognosis of acute heart failure and
cardiomyopathy in Africa. Heart;99:1317-22.
• Swedberg K, Hjalmarson A, Waagstein F et al.(1979)
Prolongation of survival in congestive cardiomyopathy
in beta receptor blockade. Lancet.: 1: 1374 – 1376.
• Ventura HD, Mehra MR: Bloodletting as a cure for dropsy :
Heart failure down the ages: J Cardiac Failure 2005
May 11; (4) 247-252.
• Waagstein F, Hjalmarson A, Varnauskas E et al (1975)
Effect of Chronic beta adrenergic receptor
blockade in congestive cardiomyopathy. Br Heart J.: 37:
1022-1036.
• Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE,
Drazner MH, et al. 2013 ACCF/AHA guideline for
the management of heart failure: A report of the
American College of Cardiology Foundation/
American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol 2013;62:e147-239.