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Chronic Heart Failure –
An Update
T P Chua
Royal Surrey County Hospital, Guildford
St George’s Hospital, London
Chronic Heart Failure – Clinically
Important
•
Common (1-5% of population)
•
High Mortality
•
Disabling symptoms
•
Expensive (30% require hospitalisation/year)
•
Recent Advances
Chronic Heart Failure
•
Ventricular dysfunction with chronic
symptoms of breathlessness and/or
fatigue and/or fluid retention
•
Signs of pulmonary or peripheral
congestion
Systolic heart failure more common
and better defined than diastolic heart
failure
•
Eur Heart J 1995; 16: 741-751
Diastolic Heart Failure
•
•
•
•
Normal ejection fraction/systolic function
Normal or even small left ventricular chamber
volumes
Reduced active relaxation and increased
passive stiffness of LV
More than 75% of these patients have
hypertension and ~40% have left ventricular
hypertrophy
Zile MR, et al. NEJM 2004; 350:
Sensitivity & Specificity of Symptoms
Sensitivity (%)
Specificity (%)
Dyspnoea
66
52
Orthopnoea
21
81
PND
33
76
Oedema
23
80
Value of the ECG in Identifying
Heart Failure
ECG
Impaired LV
Normal LV
Total
Abnormal*
90
169
259
Normal
6
269
275
Total
96
438
534
*Abnormal ECG: AF, Previous MI, LVH, BBB, LAD
Negative Predictive Value: 269/275: 98%
Davie AP, McMurray JJV, et al. BMJ 1996;312:222
Sensitivity & Specificity of ECG,
NT-proBNP and Hand-held Echo
Sensitivity (%) Specificity (%) NPV (%)
Abnormal ECG
92
78
99.6
Raised NTproBNP
80
88
99
Abnormal ECG or
raised NTproBNP
96
72
99.8
Abnormal ECG and
raised NTproBNP
76
94
99.7
93
97
99.3
Hand-held Echo
EHJ 2006; 27: 193-200
Natriuretic Peptides
Three types present:•
•
•
ANP (atrial natriuretic peptide) first discovered;
primarily released by atria; potent vasodilator
and natriuretic
BNP (B-type natriuretic peptide);
predominantly released by left ventricle in
response to high filling pressures; also a
vasodilator and natriuretic
CNP (C-type natriuretic peptide); released by
atria and ventricles; vasodilatory property only
B-type Natriuretic Peptide
Clinical Use of BNP in CHF
•
Diagnosis of CHF in patients with acute dypsnoea