Download Update in Heart Failure

Heart Failure: Living with a
Hurting Heart
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
Heart Failure Heart
A heart failure heart has a reduced ability to pump blood.
Risk Factors for Heart Failure
• Coronary artery
• Diabetes
disease
• Congenital heart defects
• Hypertension (LVH)
• Valvular heart disease • Other:
– Obesity
• Alcoholism
– Age
• Infection (viral)
– Smoking
– High or low hematocrit level
– Obstructive Sleep Apnea
CAD=coronary artery disease; LVH=left ventricular hypertrophy.
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)
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
III Symptomatic with minimal exertion
IV Symptomatic at rest
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
• 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)
Heart Failure Treatments:
Medication Types
Type
What it does
•ACE inhibitor
(angiotensin-converting
enzyme)
•Expands blood vessels which lowers
blood pressure, neurohormonal
blockade
•ARB (angiotensin receptor
blockers)
•Similar to ACE inhibitor—lowers
•Beta-blocker
•Reduces the action of stress
blood pressure
hormones and slows the heart rate
•Digoxin
•Slows the heart rate and improves the
heart’s pumping function (EF)
•Diuretic
•Filters sodium and excess fluid from the
blood to reduce the heart’s workload
•Aldosterone
blockade
•Blocks neurohormal activation and controls
volume
Device Therapy:
Biventricular Pacing
Biventricular Pacing
Ventricular Dysynchrony
• Abnormal ventricular conduction resulting
in a mechanical delay and dysynchronous
contraction
Overview of Device Therapy
9
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 (ICD’s)
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%
Β-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, ICD’s
• Transplants remain rare, but technology for
mechanical assist devices continues to improvestay tuned!