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