Eskisehir Osmangazi University, Cardiology DepartmentEskisehir, Turkey
Prof. Dr. Yüksel ÇAVUŞOĞLU, MD, FESCBoard Member of the Working Group of Heart Failure
of Turkish Society of Cardiology
Joint Session UKBIH - TKD5th Congress of the UKBIH,
Bosnia and Herzegovina,
27 May 2010
Heart Failure Matters
The Invisible Part of the
Iceberg:Stage A and B Heart Failure
Davis RC et al. BMJ 2002; 325: 1156.Lloyd-Jones D et al. Circulation 2009;119:e21-e181.
Heart failure is a major public health problem that affects millions of people
Roger VL et al. JAMA 2004;292:344-50.Heart Disease and Stroke Statistics 2010 update.
HF is a progressive disease with a poor prognosis
The 1-year mortality rate for HF is estimated as 21% in men and 17% in women
Heart Disease and Stroke Statistics 2010 update.Circulation published online Dec 17, 2009
Hospital discharges for heart failure
n=399 000
n=1 106 000
“From 1979 to 2006, hospital discharges for HF have increased by 175%”
175% ↑
“HF causes a substantial economic burden on the healthcare system”
Heart Disease and Stroke Statistics 2010 update.Circulation published online Dec 17, 2009
Even if HF incidence remains constant, the total number of people with HF is expected to double during the next two decades
The risk of HF incidence increases with older age
The elderly population (≥65 y) is expected to grow in the community.
Heart Disease and Stroke Statistics 2010 update.Circulation published online Dec 17, 2009
The prevalence of HF will likely continue to increase in developed and developing countries
Heart failure will become a major public health burden
Clinical HF increases in prevalence with advancing age
InvisiblePart
VisiblePart
AgingHypertension
Diabetes
Atherosclerozis
ObesitySmoking
Genes
Dyslipidemia
MI
Valvular heart diseaseLVH
Toxins
LV Dilatation
Systolic/diastolic dysfunction
Symptomatic HF
Refractory HFDeath
The majority of people are in a preclinical stage of the disease
Symptomatic disease is only the tip of the iceberg
Prevention of Heart Failure
Prevention programs targeting this growing population will likely reduce HF incidence
Essential strategies for prevention of HF should focus on modification of risk factors for HF development
Objectives include:Early idendification of patients at high riskEarly detection of asymptomatic LV dysfunctionOptimal treatment plan for each individualsAgressive therapeutic lifestyle changesTargeted pharmacological interventionPersistent follow-up
Hunt, S. A. et al. J Am Coll Cardiol 2009;53:e1-e90
New Approach to the Classification of Heart Failure
Schocken DD et al. Circulation 2008;117:2544-65.
Prevention of Heart FailureA Scientific Statement From AHA
Stage A and stage B present ideal opportunities to intervene to prevent HF
Established and Possible Risk Factors for HFA Scientific Statement From AHA
Schocken DD et al. Circulation 2008;117:2544-65.
Age, male sex Hypertension, LVH Myocardial infarction Diabetes Valvular heart disease Obesity
Smoking Dyslipidemia Sleep-disordered breathing Chronic kidney disease Albuminuria Homocysteine Immune activation, IGF1,
TNFα, IL-6, CRP Natriuretic peptide Anemia Dietary risk factors Increased HR Sedentary lifestyle Low socieconomic status Phychological stress
Major Clinical Risk FactorsMinor Clinical Risk Factors
Chemotherapy Anthracyclines Cyclophosphamide 5-FU trastuzumab
Cocaine NSAIDs Thiazolidinediones Doxazosin Alcohol
Established and Possible Risk Factors for HFA Scientific Statement From AHA
Schocken DD et al. Circulation 2008;117:2544-65.
Increased LVID, mass Asymptomatic LV
dysfunction LV diastolic dysfunction
Single-nucleotide polymorphism
(eg, α2CDeI322-325, β1Arg389)
Toxic Risk Precipitants Morphological Risk Predictors
Genetic Risk Predictors
He, J. et al. Arch Intern Med 2001;161:996-1002.
Coronary heart disease is the leading cause of HFNHANES I Epidemiologic Follow-up Study
CAD is the underlying cause of HF in 62% of patients
n= 13 64319 years follow-up
Hypertension is a most common risk factor for HF
HT is associated with a 2- to 3-fold increase in the risk of HF
Seventy-five percent of HF cases have antecedent HT
The lifetime risk for people with BP >160/90 mmHg is double that of those with BP <140/90 mmHg
Heart Disease and Stroke Statistics 2010 update.Circulation published online Dec 17, 2009
Heart Failure Event Rate in HT Trials
Heart failure incidence may be higher than MI or stroke incidence
Risk of HF in Different HT Subgroups
Tocci G et al Hypertension 2008
Moser and Hebert J Am Coll Cardiol 1996Collins R et al. Lancet 1990
Results of Randomised Trials of Antihypertensive Drug Therapy
Adequate BP control reduces development of incident HF
Effect of Antihypertensive Therapy on CV EventsComparison of more or less intensive BP control
BPLTTC Lancet 2003
Reduction in HF Risk by SBP Reduction
26% risk reduction per 10 mmHg decrease in SBP (p<0.001)
56% risk reduction per 10 mmHg decrease in SBP in diabetics
Diabetes is an independent risk factor for HF
The Framingham study revealed a 2.4-fold increase in diabetic men and a 5-fold increase in diabetic women.
Approximately 12% of type 2 diabetics have established HF.
Approximately 3.3% of type 2 diabetics develop HF each year.
Incrementally increased risk for HF is seen at higher HbA1c levels
Velagaleti RS et al. Circulation 2009;120:2345-51.
Patients with high non-HDL-C have a 29% higher HF risk.Patients with low HDL-C have a 40% higher HF risk.
Abnormal Lipid Levels Increase Risk of HF
Framingham Heart Study
Hu G. Circulation. 2010;121:237-244.
BMI <25 25-29.9 >30 p
Male, n 10,984 13,375 4,483
HR 1.00 1.25 (1.12-1.39) 1.99 (1.74-2.27) <0.001
Female, n 14,254 10,357 5,725
HR 1.00 1.33 (1.16-1.51) 2.06 (1.80-2.37) <0.001
The multivariable-adjusted (age, study year, smoking, education, alcohol consumption, history of myocardial infarction, history of valvular heart disease, systolic blood pressure, total cholesterol, history of diabetes and physical activity) hazard ratios (HRs) of HF
BMI & Risk of heart Failure
The Finnish FINMONICA study59,178 participants, free of HF at baseline, 18.4 years follow-up
Obesity and overweight are independently associated withan increased risk of HF
Hu G. Circulation. 2010;121:237-244.
The Finnish FINMONICA study59,178 participants, free of HF at baseline, 18.4 years follow-up
The multivariable-adjusted (age, study year, smoking, education, alcohol consumption, history of myocardial infarction, history of valvular heart disease, BMI, systolic blood pressure, total cholesterol, and history of diabetes) hazard ratios (HRs) of HF
Physical activity Low Moderate High p
Male, n 2,269 8,745 17,828
HR 1.00 0.79 (0.68-0.92) 0.69 (0.60-0.80) <0.001
Female, n 2,900 9,226 18,210
HR 1.00 0.86 (0.75-0.99) 0.68 (0.59-0.78) <0.001
Physical activity & Risk of heart Failure
Physical activity is associated with a reduced risk of HF
Stage A Stage B
ACE Inhibitors HT, DN, CV Risk LVH, Post MI, Reduced EF
Angiotensin II Blockers HT, DN, CV Risk LVH, Post MI, Reduced EF
Beta Blockers HT Post MI, Reduced EF
Aldosterone Blockers HT Post MI
Digoxin - -
Rhythm or Rate Control SV Tachyarrhythmias SV Tachyarrhythmias
Coronary Revasculariza CAD CAD
Valve Surgery Valvular Heart Disease Valvular Heart Disease
In patients at high risk for developing HF, risk factors should becontrolled in accordance with contemporary guidelines
Recommended Therapy for Stage A and B HF
Conclusions
HF represents the final common pathway of many risk factors and cardiovascular diseases
Stage A and stage B HF confer ideal opportunities to intervene to prevent HF
Many risk factors and CV diseases can be prevented by aggressive lifestyle and pharmacologic interventions
Prevention of HF must begin with increasing public/professional awareness of HF and risk factors