Heart Failure: Living with a Hurting Heart

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

Heart Failure Heart

A heart failure heart has a reduced ability to pump blood.

CAD=coronary artery disease; LVH=left ventricular hypertrophy.

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

Classification of HF: Comparison Between ACC/AHA HF Stage and

NYHA Functional Class

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.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

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)

Heart Failure Treatments: Medication Types

• ACE inhibitor (angiotensin-converting enzyme)

• ARB (angiotensin receptor blockers)

• Beta-blocker

• Digoxin

• Diuretic

• Aldosterone blockade

Type What it does• Expands blood vessels which

lowers blood pressure, neurohormonal blockade

• Similar to ACE inhibitor—lowers blood pressure

• Reduces the action of stress hormones and slows the heart rate• Slows the heart rate and improves the heart’s pumping function (EF)

• Filters sodium and excess fluid from the blood to reduce the heart’s workload

• Blocks neurohormal activation and controls volume

Device Therapy:Biventricular Pacing

Overview of Device Therapy 9

Biventricular PacingVentricular Dysynchrony

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

BiV Pacing

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

Defibrillators (ICD’s)

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

How does a defibrillator for sudden cardiac death work?

Device Shown:

Combination Pacemaker & Defibrillator

Implantable Cardiac Defribrillators

EBM Therapies Relative RiskReduction

Mortality2 year

ACE-I 23% 27%

Β-Blockers 35% 12%

Aldosterone Antagonists

30% 19%

ICD 31% 8.5%

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;

Other Therapies?

• Transplant• Artificial hearts• New “gadgets” to help doctors manage

heart failure

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.

Worldwide Heart Transplants

Newer Generation Artificial Hearts

Future Tech

Intrathoracic Impedance for Heart Failure

One of the Best Devices for Monitoring Heart Failure

What have we learned?

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!