Heart FailureHeart Failure

Khalid F AlHabib.MBBS.FRCPCKhalid F AlHabib.MBBS.FRCPCCardiology ConsultantCardiology Consultant

King Fahad Cardiac CentreKing Fahad Cardiac CentreKing Saud UniversityKing Saud University

Wednesday, April 19, 2023Wednesday, April 19, 2023

Heart Failure: OutlineHeart Failure: Outline

Definition Definition CausesCauses Epidemiology Epidemiology PathophysiologyPathophysiology Clinical AssessmentClinical Assessment ManagementManagement Prognosis Prognosis

Heart FailureHeart Failure: Definition: Definition

Complex syndrome in which abnormal Complex syndrome in which abnormal heart function results in, or increases the heart function results in, or increases the subsequent risk of, clinical symptoms and subsequent risk of, clinical symptoms and signs of low cardiac output &/or pulmonary signs of low cardiac output &/or pulmonary or systemic congestion. or systemic congestion.

CAUSES & FORMSCAUSES & FORMS

Systolic versus Diastolic HF

PREVALENCE & COSTPREVALENCE & COST

The number of CHF patients will almost double between the years 1990-2030, from these 3 million cases of overt CHF to about 6 million.

Heart Failure: a major public health problemHeart Failure: a major public health problem

Prevalence of HF Prevalence of HF Increases with AgeIncreases with Age

US, 1988–1994AHA. Heart Disease and Stroke Statistics—2004 Update

0

2

4

6

8

10

20–24 25–34 35–44 45–54 55–64 65–74 75+

Age (yr)

Po

pu

lati

on

(%

)

Males

Females

Estimated Direct and Indirect Costs of HF in USEstimated Direct and Indirect Costs of HF in US

8%

8% 10%

7%

14%

53%

Hospitalization$13.6

Lost Productivity/Mortality*

$2.1

Home Healthcare$2.1

Drugs/Other Medical Durables

$2.7

Physicians/Other Professionals

$1.8

Nursing Home$3.5

*Lost future earnings of persons who will die in 2004, discounted by 3%AHA. Heart Disease and Stroke Statistics—2004 Update

Total Cost$25.8 billion

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

CLINICAL EVALUATIONCLINICAL EVALUATION

ACUTE VS. CHRONIC HEART FAILURE

FEATURE ACUTE HEART FAILURE DECOMPENSATED CHRONIC HEART FAILURE

CHRONIC HEART FAILURE

Symptom severity Marked Marked Mild to moderate

Pulmonary edema Frequent Frequent Rare

Peripheral edema Rare Frequent Frequent

Weight gain None to mild Frequent Frequent

Whole-body fluid volume load No change or mild increase Moderate to marked increase Mild to marked increase

Cardiomegaly Uncommon Usual* Common*

Ventricular systolic function Reduced, normal, or hypercontractile

Reduced* Reduced*

Wall stress Elevated Markedly elevated Elevated

Activation of sympathetic nervous system Marked Marked Mild to marked

Activation of renin-angiotensin-aldosterone system

Often increased Marked Mild to marked

Reparable, reversible causative lesion(s) Common Occasional Occasional

*Patients with diastolic heart failure may have little to no cardiomegaly and normal systolic function.

Clinical and pathophysiological characteristics of the two major categories of unstable heart failure (acute heart failure and decompensated chronic heart failure) are compared with those of chronic heart failure.

Adapted from Leier CV: Unstable heart failure. In Colucci WS (ed): Heart Failure: Cardiac Function and Dysfunction. 2nd ed. In Braunwald E (series ed): Atlas of Heart Diseases, vol 4. Philadelphia, Current Medicine, 1999, pp 9.1–9.17.

                                                                                                         

A, Pulmonary blood flow redistribution. Enlargement of the upper lobe vessels is seen in a patient with ischemic cardiomyopathy and elevated pulmonary venous pressure. B, Pulmonary interstitial edema. The vessels are indistinct and enlarged, and peribronchial cuffing is present. C, Pulmonary alveolar edema in a patient with congestive cardiomyopathy. The central perihilar distribution of edema, termed “bat wing” edema, is typical of pulmonary alveolar edema caused by cardiovascular or fluid overload (uremic). D, Preferential right upper lobe distribution of pulmonary edema in a 65-year-old man with mitral regurgitation. E, Right pleural effusion and residual right upper and bilateral lower lobe edema in a patient with acute mitral regurgitation.

MANAGEMENTMANAGEMENT

PROGNOSISPROGNOSIS

Causes of Hospital Readmission for Causes of Hospital Readmission for Congestive Heart FailureCongestive Heart Failure

17%Other

19%Failure to Seek

Care

16%Inappropriate Rx

Rx Noncompliance 24%

Diet Noncompliance24%

Annals of Internal Medicine 122:415-21, 1995

Over 2/3 of HF Hospitalizations Preventable

Prognosis with Heart Failure: Prognosis with Heart Failure: More “Malignant” Than CancerMore “Malignant” Than Cancer ! !

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10

Su

rviv

al %

Women

Men

AHA, 1998 Heart and Statistical UpdateNCHS, National Center for Health Statistics

Survival after the onset of congestive heart failure in Framingham Heart Study subjects

Ho Circulation 1993;88:107-115

Years

Overall5-year mortality 50%

In Summary..In Summary..