Current Update on Chronic Heart Failure

1. Current Update on Chronic Heart Failure 2nd ICCVD 21st March 2018 Jogjakarta Indonesia

2. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

3. Verily in the body there is a piece of meat. If it healthy , the whole body will be healthy. If it is diseased the whole body will be diseased. Verily it is the heart ( Prophet Muhammad pbuh )

4. Definition of Heart Failure ( 1950s ) A state in which the heart fails to maintain an adequate circulation for the needs of the body despite a satisfactory filling pressure

5. Definition of Heart Failure ( 1980s) A clinical syndrome caused by an abnormailty of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses

6. Definition of Heart Failure (Packer 1998) A complex clinical syndrome characterized by abnormalities of left ventricular function and neurohumoral regulation which are accompanied by effort intolerance, fluid retention and reduced longevity

7. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

8. CHF , a Global Burden 26million suffering world wide ( Ambrosy PA et al JACC 2014 ;63:1123-1133 ) 74% of patients suffers from at least 1 comorbidity worsening the patients overall health status ( van Duersen VM et al. Eur J Heart Fail 2014; 16:103-111)

9. CHF , a Global Burden ( Ponikowski P et al ESC Heart Failure 2014:1:4-25 )

10. Molecular Epidemiology of CHF

11. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

12. Cost of In Hospital Treatment Condition Total cost AMI no complication RM 3,699 AMI with complication RM 4,916 AMI with major complication RM 5,739 Heart Failure no complication RM 3,711 Heart Failure with complication RM 5,222 Heart Failure with major complication RM 6,253

13. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

14. Heart Failure Aetiology( Common ) • Hypertension • Ischaemic Heart Disease • Valvular Heart Disease • LVH • Diabetes

15. Heart Failure Aetiology( Less Common and easily forgotten ) • Thyrotoxicosis • Dilated Cardiomyopathy ( non ischaemic; viral, post traumatic ) • Post partum cardiomyopathy • Beriberi cardiomyopathy

16. Heart failure development:Population-attributable risk Prevalence (%) 6062 103 119 85 43 58 Attributable risk (%) 3959 3413 56 612 45 78 Hypertension MI Angina pectoris Diabetes LVH Valvular disease male 1 1.5 4.5 7.5 3.0 female Hazard Ratio Levy et al JAMA 1996

17. Asian Heart Failure Registry ( 11 countries, N = 5276 ) ( Lam CS et al. Eur Heart J 2016 Nov 1, 37 9 40 : 3143-3153)

18. Asian Heart Failure Registry ( 11 countries, N = 5276 ) ( Lam CS et al. Eur Heart J 2016 Nov 1, 37 9 40 : 3143-3153)

19. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

20. The Vicious Cycle of Congestive Heart Failure

21. Hypertension to Heart Failure Diastolic dysfunction ObesityDiabetes LVH CHF Death Systolic dysfunction Hypertension MI Smoking Dyslipidemia Diabetes Adapted from Kaplan NM. Clinical Hypertension 1998:41-49

22. Influence of LVH on incident heart failure % free of incident HF LV mass (g) Quartiles 100 98 1, 2 96 94 3 92 90 88 4 86 84 0 1000 2000 time to incident HF (days) Gardin et al Am J Cardiol 2001

23. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

24. Symptoms • Fatique • Reduce effort tolerance • Dyspnoea • Orthopnea • PND • Cough esp. nocturnal • Symptoms of poor circulation

25. Symptoms • Palpitation • Angina • Giddiness/ syncope • Weight loss • Muscle wasting • Peripheral edema • ascites

26. Symptoms • Epigastric / right hypochondriac pain • Nausea • Anorexia • Facial engorgement • Depression

27. Signs • Exhausted , ill looking patient • Cool hands and feet • Peripheral cyanosis • Raised JVP • Low volume pulse • Resting tachycardia • Displaced apex

28. Signs • RV heave • S3 gallop • Hepatomegaly ( pulsatile ) • Ascites • Ankle edema • Bilateral crepitations • Pleural effusion

30. Measuring Jugular Venous Pressure

31. Important Reminder When ever a patient presents with decompensated heart failure, always ask yourself TWO questions What is the underlying aetiology ?? What is the precipitating factor to cause the decompensation ??

32. Heart Failure Precipitating/ aggravating factors • Cardiac causes – MI,arrhythmia • Non cardiac causes – anaemia, accelerated hypertension, pulmonary embolism, pneumonia, acute renal failure • Treatment related – poor compliance, NSAIDs, steroids, beta blockers if used wrongly • Salt and liquorice intake including TCM

33. Differential Diagnosis Pulmonary edema due to • Mitral stenosis • Atrial myxoma • Low LA pressures due to sepsis, noxious gas inhalation, severe myxedema, hypoalbuminaemia, head injury, SAH , ARDS

34. Differential Diagnosis RV failure • Constrictive pericarditis • SVC obstruction • Malignant ascites

35. Investigations • ECG - to look for aetiology and precipitant • CXR – changes can precede signs • Urea and electrolytes – renal precipitant • FBC – anaemia and infection • BNP – if the cause of acute breathlessness is unclear from physical findings • ECHO – to quantify type and contributing lesions • Thyroid function – mandatory if A Fib is present

36. Pulmonary vessel congestion

37. Pulmonary Edema in acute Heart Failure

38. 100 90 80 Congestive HF 70 60 Treated but no Congestive HF Echo 50 Event-free survival (%) 40 p<0.01 Congestive HF + Appropriate therapy No-echo 30 20 10 0 0 12 24 36 48 60 72 Time (months) Importance of Echocardiography in diagnosis • Diagnosis of HF • Symptoms : dyspneoa or fatigue (rest or exer) • Objective evidence of cardiac dysfunction (echo) Senni et al., J Am Coll Cardiol 1999,33:164 Guidelines of the ESC 2005

39. Establishing the diagnosis of CHF • Is LV ejection fraction preserved or reduced ? • Is the LV structure normal or abnormal ? • Other structural abnormalities ?

40. Establishing the diagnosis of HFSystolic vs diastolic dysfunction Diagnosis of diastolic HF (up to 40%) Abnormal LV EF < 50%

41. Heart Failure - Classification • Acute or chronic or acute on chronic • Low- output or high- output • Left – sided or right- sided or biventricular • Systolic ( HFrEF ) or diastolic ( HFpEF )

42. OUTLINE OF LECTURE Epidemiology Economic Burden Etiology Pathophysiology Diagnostics Management Prognosis Prevention and challenges

43. Growth-promoting/ vasoconstrictors : Angiotensin 11 Sympathetic activation Aldosterone Endothelin Arginine Vasopressin Anti-proliferative / vasodilators: Natriuretic peptides Bradykinin Nitric oxide Adrenomedullin Changing concept in Heart Failure

44. Coronary artery disease Plaque rupture Atherosclerosis Angiotensin II Myocardial infarction Endothelial dysfunction Dilatation/Remodeling Risk factors Heart failure Hypertension Hyperlipidemia Diabetes End-stage heart disease

45. The Golden Era of ACE I in Heart Failure • CONSENSUS 1988 Enalapril • SOLVD - T 1991 Enalapril • SOLVD - P 1992 Enalapril • SAVE 1992 Captopril • AIRE 1993 Ramipril • GISSI 3 1994 Lisinopril • ISIS 4 1995 Captopril • CCS 1995 Captopril • SMILE 1995 Zofenopril • TRACE 1995 Trandolapril

46. Complete Blockade of the RAAS over and above ACEI • RALES 1999 Spironolactone • EPHESUS 2003 Eplerenone • Val- HeFT 2001 Valsartan • CHARM 2003 Candersartan • EMPHASIS HF 2011 Eplerenone

47. EMPHASIS – HF ( NEJM Apr 7, 2011 ) 2737 patients with EF < 35% with NYHA II Eplerenone ( upto 50mg od ) vs placebo Study stopped early after 21 months because of obvious benefits 37% reduction in CV death or hospitalisation from HF

48. Growth-promoting/ vasoconstrictors : Angiotensin 11 Sympathetic activation Aldosterone Endothelin Arginine Vasopressin Anti-proliferative / vasodilators: Natriuretic peptides Bradykinin Nitric oxide Adrenomedullin Neuroendocrine Imbalance in CHF

49. Norepinephrine Spillover in Heart Failure 1104% 1000 500 Spillover of Norepinephrineto Plasma (% of normal) 300 100 0 Total Heart Lungs Kidney Gut &Liver Esler et al. Hypertension 1988

50. b2 b1 b1 b2 b1 b1 b1 a1 b1 b1 b1 b1 b1 b1 b1 b1 b1 b2 b2 a1 b2 b1 b1 b1 b1 b1 b2 b2 b2 The Failing Heart Normal Heart failure