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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