Heart Failure: Living with a Hurting Heart

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Heart Failure Living with a Hurting Heart

• James T. DeVries, MD
• Dartmouth-Hitchcock Medical Center

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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 (ICDs)
• Future directions and exciting developments

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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
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Congestive Heart Failure

• Symptoms
• Shortness of breath
• Leg swelling (edema)
• Breathing worsens with lying flat (orthopnea)
• Fatigue

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Anatomy 101
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A normal heart pumps blood in a smooth and
synchronized way.
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Heart Failure Heart
A heart failure heart has a reduced ability to
pump blood.
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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

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Risk Factors for Heart Failure

• 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

CADcoronary artery disease LVHleft ventricular
hypertrophy.
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Epidemiology of Heart Failure in the US
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• 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

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Heart Failure Patients in US (Millions)
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4.7
3.5
4
2
0
1991
2000
2037
Rich M. J Am Geriatric Soc. 199745968974. Amer
ican Heart Association. 2001 Heart and Stroke
Statistical Update. 2000.
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• 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

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Classifying Heart FailureTerminology and Staging
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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

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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
C Structural 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.
20013821012113. 2New York Heart
Association/Little Brown and Company, 1964.
Adapted from Farrell MH et al. JAMA.
2002287890897.
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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)

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Pathophysiology
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Pathologic Progression of CV Disease
Sudden Death
Coronary artery disease
Pathologicremodeling
Low ejectionfraction
Myocardialinjury
Hypertension
Death
Diabetes
Cardiomyopathy
Pump failure
Valvular disease
SymptomsDyspneaFatigueEdema
Chronicheartfailure

• Neurohormonalstimulation
• Myocardial toxicity

Adapted from Cohn JN. N Engl J Med.
1996335490498.
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Compensatory MechanismsRenin-Angiotensin-Aldoste
rone 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
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Drug Therapy
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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 inhibitorlowers 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 hearts
  pumping function (EF)

• Diuretic
• Aldosterone blockade

• Filters sodium and excess fluid from the blood to
  reduce the hearts workload
• Blocks neurohormal activation and controls volume

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Rational for Medications(Why does my doctor have
me on so many pills??)

• Improve Survival
• Betablockers
• ACE-inhibitors
• Aldosterone blockers
• Angiotensin receptor blockers (ARBs)

• Improve Symptoms
• Diuretics (water pills)
• digoxin

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Lifestyle Changes
What Why

• 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

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• "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.

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Device TherapyBiventricular Pacing
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Biventricular PacingVentricular Dysynchrony

• Abnormal ventricular conduction resulting in a
  mechanical delay and dysynchronous contraction

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BiV Pacing
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Cardiac Resynchronization TherapyKey Points

• Indications
• Moderate to severe CHF who have failed optimal
  medical therapy
• EF
• Evidence of electrical conduction delay
• Timing of Referral Important
• Patients often not on optimal Medical Rx
• Patients referred too late- Not a Bail Out

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Defibrillators (ICDs)
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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

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How does a defibrillator for sudden cardiac death
work?
Device Shown Combination Pacemaker
Defibrillator
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Implantable Cardiac Defribrillators
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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)
• Patients who meet all current requirements for a
  cardiac resynchronization therapy (CRT) device
  and have NYHA Class IV heart failure

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Other Therapies?

• Transplant
• Artificial hearts
• New gadgets to help doctors manage heart
  failure

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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.

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Worldwide Heart Transplants
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Newer Generation Artificial Hearts
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Future Tech
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Intrathoracic Impedance for Heart Failure
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One of the Best Devices for Monitoring Heart
Failure
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What have we learned?
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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, ICDs
• Transplants remain rare, but technology for
  mechanical assist devices continues to improve-
  stay tuned!