John N. Hamaty D.O. FACC,
FACOI

Heart Failure

Final common pathway in most heart diseases

550,000 new cases each year

20.1/100,000 mortality rate

No change in mortality

Diastolic Heart Failure




Impaired ability to accept blood and relax during diastole
Both types increase with age, African
Americans
40-70% incidence more often female, obese, older HTN and less likely to have
CAD
Less symptomatic and lower morbidity and mortality

B-Adrenergic Receptor Blockers







Improve survival
Improve ejection fraction
Remodeling
Quality of life
Reduce SCD
Inhibiting adverse effects of the sympathetic nervous system
Diminish RAAS activation

Angiotensin-Converting Inhibitors

Decrease conversion of angiotensin I-II

Improve survival

Decrease rate of hospitalization

Improve symptoms

Inhibit neurohormonal activation

Reverse remodeling

Decrease incidence of SCD?

Angiotensin Receptor Blockers

Efficacy similar to ACE inhibitors

Alternative to ACEI in patients not tolerant of ACEI

VAL-HeFT- ACEI +B-BL+ARB increase morality

CHARM- improve mortality

Competitive Aldosterone
Antagonists

Aldosterone stimulates renal sodium retention and myocardial hypertrophy

Spironolactone decreases mortality and morbidity in NYH class III and IV

Selective Aldosterone Blockers

Eplerenone (EPHESUS Trial)-post acute myocardial infarction trial

When added to optimal medical therapy excluding spirnolactone

Reduced morbidity and mortality in patients with acute MI with left ventricular dysfunction and heart failure

Future: New Insights

Tissue doppler-decreased flow velocities predict LVH before it occurs

Ultrasonic tissue character-tissue edema, fibrosis and calcification. Can predict tissue damage before it occurs in HTN

Myocyte enhancer factor 2-developmental gene for CAD/nonischemic HF

Pharmacogenetics

Alpha-adducin gene-found it 2/3 HTN patients. Diuretics will not reduce risk

Adrenergic receptors- 2 variants in African
Americans. 10 fold risk of developing HTN and candidates for early tx with b-blockers

Conclusions

Antagonizing this neurohormonal cascade has been the focus of recent clinical trials.
Further directions in HF therapy are likely to focus on limiting or preventing activation of the neurohormonal cascade through earlier recognition and treatment of patients at risk for HF.