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Heart Failure: Living with a Hurting Heart

Heart Failure: Living with a Hurting Heart. James T. DeVries, MD Dartmouth-Hitchcock Medical Center. Outline. Definitions and scope of problem Diagnosing and classifying heart failure Approach to management of CHF Oral drug therapy (ACE-I, ARB, betablockers, aldosterone blockade, digoxin)

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Heart Failure: Living with a Hurting Heart

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  1. Heart Failure: Living with a Hurting Heart James T. DeVries, MD Dartmouth-Hitchcock Medical Center

  2. Outline • Definitions and scope of problem • Diagnosing and classifying heart failure • Approach to management of CHF • Oral drug therapy (ACE-I, ARB, betablockers, aldosterone blockade, digoxin) • Device therapy • Biventricular (BiV) pacers • Intracardiac defibrillators (ICD’s) • Future directions and exciting developments

  3. 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

  4. Congestive Heart Failure • Symptoms: • Shortness of breath • Leg swelling (edema) • Breathing worsens with lying flat (orthopnea) • Fatigue

  5. Anatomy 101

  6. A normal heart pumps blood in a smooth and synchronized way.

  7. Heart Failure Heart A heart failure heart has a reduced ability to pump blood.

  8. Types of Heart Failure • Systolic (or squeezing) heart failure • Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure • Diastolic (or relaxation) heart failure • Involves a thickened and stiff heart muscle • As a result, the heart does not fill with blood properly • This results in fluid backup in the lungs and heart failure

  9. Coronary artery disease Hypertension (LVH) Valvular heart disease Alcoholism Infection (viral) Diabetes Congenital heart defects Other: Obesity Age Smoking High or low hematocrit level Obstructive Sleep Apnea Risk Factors for Heart Failure CAD=coronary artery disease; LVH=left ventricular hypertrophy.

  10. Epidemiology of Heart Failure in the US 12 • More deaths from heart failure than from all forms of cancer combined • 550,000 new cases/year • 4.7 million symptomatic patients; estimated 10 million in 2037 10 10 8 Heart Failure Patients in US (Millions) 6 4.7 3.5 4 2 0 1991 2000 2037* *Rich M. J Am Geriatric Soc. 1997;45:968–974. American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

  11. “Wow! Brazil is big." —George W. Bush, after being shown a map of Brazil by Brazilian president Luiz Inacio Lula da Silva, Brasilia, Brazil, Nov. 6, 2005

  12. Classifying Heart Failure:Terminology and Staging

  13. A Key Indicator for Diagnosing Heart Failure Ejection Fraction (EF) • Ejection Fraction (EF) is the percentage of blood that is pumped out of your heart during each beat

  14. 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) I Asymptomatic B Structural heart disease but without symptoms of heart failure CStructural heart disease with prior or current symptoms of heart failure II Symptomatic with moderate exertion III Symptomatic with minimal exertion IV Symptomatic at rest D Refractory heart failure requiring specialized interventions 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.

  15. 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)

  16. Pathophysiology

  17. Pathologic Progression of CV Disease Sudden Death Coronary artery disease Myocardialinjury Pathologicremodeling Low ejectionfraction Hypertension Death Diabetes Cardiomyopathy Pump failure Valvular disease Symptoms:DyspneaFatigueEdema Chronicheartfailure • Neurohormonalstimulation • Myocardial toxicity Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.

  18. Compensatory Mechanisms:Renin-Angiotensin-Aldosterone System • Beta • Stimulation • CO • Na+ Renin + Angiotensinogen Angiotensin I ACE Angiotensin II Kaliuresis Fibrosis Aldosterone Secretion Peripheral Vasoconstriction Salt & Water Retention • Plasma Volume Edema • Afterload • Preload • Cardiac Output • Cardiac Workload Heart Failure

  19. Drug Therapy

  20. Heart Failure Treatments: Medication Types Type What it does • ACE inhibitor (angiotensin-converting enzyme) • Expands blood vessels which lowers blood pressure, neurohormonal blockade • Similar to ACE inhibitor—lowers blood pressure • ARB (angiotensin receptor blockers) • Beta-blocker • Reduces the action of stress hormones and slows the heart rate • Digoxin • Slows the heart rate and improves the heart’s pumping function (EF) • Diuretic • Aldosterone blockade • Filters sodium and excess fluid from the blood to reduce the heart’s workload • Blocks neurohormal activation and controls volume

  21. Improve Symptoms Diuretics (water pills) digoxin Improve Survival Betablockers ACE-inhibitors Aldosterone blockers Angiotensin receptor blockers (ARB’s) Rational for Medications(Why does my doctor have me on so many pills??)

  22. Lifestyle Changes WhatWhy • Sodium is bad for high blood pressure, causes fluid retention • Eat a low-sodium, low-fat diet • Extra weight can put a strain on the heart • Lose weight • Exercise can help reduce stress and blood pressure • Stay physically active • Alcohol and caffeine can weaken an already damaged heart • Reduce or eliminate alcohol and caffeine • Smoking can damage blood vessels and make the heart beat faster • Quit Smoking

  23. "During my service in the United States Congress, I took the initiative in creating the Internet" Al Gore said when asked to cite accomplishments that separate him from another Democratic presidential hopeful, former Sen. Bill Bradley of New Jersey, during an interview with Wolf Blitzer on CNN on March 9, 1999.

  24. Device Therapy:Biventricular Pacing

  25. Biventricular PacingVentricular Dysynchrony • Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction Overview of Device Therapy

  26. BiV Pacing

  27. Cardiac Resynchronization TherapyKey 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

  28. Defibrillators (ICD’s)

  29. 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

  30. How does a defibrillator for sudden cardiac death work? Device Shown: Combination Pacemaker & Defibrillator

  31. Implantable Cardiac Defribrillators

  32. 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;

  33. Other Therapies? • Transplant • Artificial hearts • New “gadgets” to help doctors manage heart failure

  34. 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.

  35. Worldwide Heart Transplants

  36. Newer Generation Artificial Hearts

  37. Future Tech

  38. Intrathoracic Impedance for Heart Failure

  39. One of the Best Devices for Monitoring Heart Failure

  40. What have we learned?

  41. 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 improve- stay tuned!

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