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Michael L. Fisher, MD Professor Department of Medicine

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Michael L. Fisher, MD Professor Department of Medicine

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    1. Michael L. Fisher, MD Professor Department of Medicine Congestive Heart Failure Mini-Med School 2002

    3. Heart Failure This is a very frightening term! This is a very common medical problem! This can be successfully treated ? but many people (even some cardiologists) do not realize what really needs to be done!

    5. CHF ? Background The heart as a pump. The definition of heart failure. A syndrome … easier to recognize than define. Changing categories

    6. CHF ? Background Current focus on systolic versus diastolic – the concept of ejection fraction = EF Making the diagnosis Confirming the cause Who knows what evil lurks in the hearts of men?

    8. CHF ? Background The aging population Focus on systolic myocardial dysfunction – this is where the data is! How many in audience have a relative or friend with heart failure?

    9. Natural History of Dilated Cardiomyopathy (DCM)

    10. Schematic Course in CHF Acute Chronic This schematic shows that after an initial acute onset, there may be either progression to death (fortunately in a small minority) or return toward baseline. Typically, this is followed by periodic exacerbations and ultimately death after later deterioration. At any time, sudden death can intervene. Traditionally 5 year mortalities are quoted as 50-75% with almost all patients dead by 10 years.This schematic shows that after an initial acute onset, there may be either progression to death (fortunately in a small minority) or return toward baseline. Typically, this is followed by periodic exacerbations and ultimately death after later deterioration. At any time, sudden death can intervene. Traditionally 5 year mortalities are quoted as 50-75% with almost all patients dead by 10 years.

    11. This post-mortem pathologic image highlights the usually diffuse nature of the process (with dilation and increased mass) as well as the patchy fibrosis but does not show the endocardial clot.This post-mortem pathologic image highlights the usually diffuse nature of the process (with dilation and increased mass) as well as the patchy fibrosis but does not show the endocardial clot.

    12. Systolic Dysfunction is IRREVERSIBLE THAT IS A WELL-KNOWN FACT; SO WELL-KNOWN, THAT IT MAY NOT BE A FACT AT ALL! Mark Twain While clearly under-appreciated, there are REVERSIBLE forms of cardiomyopathy and even knowing this possibility exists can provide both pts and clinicians with some reason for optimism and the needed motivation to pursue the complex treatment required.While clearly under-appreciated, there are REVERSIBLE forms of cardiomyopathy and even knowing this possibility exists can provide both pts and clinicians with some reason for optimism and the needed motivation to pursue the complex treatment required.

    13. Schematic Course in CHF Acute Chronic This schematic shows that after an initial acute onset, there may be either progression to death (fortunately in a small minority) or return toward baseline. Typically, this is followed by periodic exacerbations and ultimately death after later deterioration. At any time, sudden death can intervene. Traditionally 5 year mortalities are quoted as 50-75% with almost all patients dead by 10 years.This schematic shows that after an initial acute onset, there may be either progression to death (fortunately in a small minority) or return toward baseline. Typically, this is followed by periodic exacerbations and ultimately death after later deterioration. At any time, sudden death can intervene. Traditionally 5 year mortalities are quoted as 50-75% with almost all patients dead by 10 years.

    15. CHF Treatment Options Diuretics Digitalis Vasodilators Spironolactone Beta-blockers Inotropes

    16. CHF “five–drug” Rx Achieving optimal outcomes - principles of “targets” in CHF Rx Much more complex process but also much more successful and rewarding long term -- if you and your patient are willing to work at it.Much more complex process but also much more successful and rewarding long term -- if you and your patient are willing to work at it.

    17. ­ EF with CHF therapy ® ? Diuretics or spironolactone ? ACE-I or Hydralazine-ISDN ? Digoxin ? b-blockers ?

    18. Mean ­ EF with CHF therapy ACE-I ® +2 % Diuretics = 0 (?) Spironolactone = 0 (?) Digoxin ® +5 % b-blockers ® +7 to 10 %

    19. Nobel committee recognizing Sir James Black, 1988 “b-blockers … the greatest breakthrough when it comes to pharma-ceuticals against heart illness since the discovery of digitalis 200 years ago.”

    20. CHF Treatment Diet Salt intake Fluid intake Exercise Travel Sex

    21. What about surgery? Heart transplantation LV assist device (LVAD) Artificial Heart Standard repairs (high risk) Experimental “repairs”

    22. Cardiac Surgery “Pushing the limits” Experimental “repairs” Myoplasty Batista Acorn Support Device Myosplint

    23. Cardiac Surgery “Pushing the limits” Experimental replacement Total artificial hearts Permanent support devices Many centers / “brands”

    25. My Biased Viewpoint * The “natural history” of CHF -- does not exist and is changing. CHF is reversible CHF is preventable Role of alcohol Home monitoring systems – simple to complex Defibrillators for everyone !

    30. Getting to the heart of the matter

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