HEARTFAILURE
Living with a hurting heart
HELDERBERG CARDIAC
SUPPORT GROUP
DR M J NIENKEMPER
VERGELEGEN MEDICLINIC
2012-07-18
Outline
• Definitions and scope of problem
• Diagnosing and classifying heart failure
• Approach to management of CHF
– Oral drug therapy (ACE-I, ARB, betablockers,
aldosterone blockade, digoxin)
– Device therapy
• Biventricular (BiV) pacers
• Intracardiac defibrillators (ICD’s)
• Future directions and exciting developments
DEFINITION
Anatomy 101
Cardiac (Heart) Failure:
A state that develops when the heart fails to
maintain an adequate cardiac output to meet
the demands of the body.
What is Heart Failure?
• Heart failure is NOT a heart attack
• Heart failure means the heart is:
• Weakened
• Cannot pump enough blood
to supply the body’s needs
© 2008 Heart Failure Society of America, Inc.
Heart Failure Does NOT Mean...
• Your heart has stopped working
• Your heart is about to stop working
• You have had a heart attack
© 2008 Heart Failure Society of America, Inc.
Definition
• Heart failure is a clinical syndrome usually due to
left ventricular dysfunction, resulting in acute or
chronic symptoms of cardiac pump failure.
• The most common causes of heart failure are
coronary heart disease, hypertension, alcohol abuse,
and idiopathic dilated cardiomyopathy
• Other causes are valvular and pericardial disease; or
anaemia, thyrotoxicosis, septicaemia, Paget's disease
of bone, and arteriovenous fistulae.
HFSA 2010
• Left untreated, it is usually a progressive disease.
• Severity of clinical symptoms may vary substantially
during course of the disease process and may not
correlate with changes in underlying cardiac
function.
INCIDENCE
How Many People Have
Heart Failure?
•
Heart failure is very common and unrecognized
•
Heart failure affects nearly 5 million Americans
•
An estimated 500 000 new cases are diagnosed each
year and increasing(survivors of MI/elderly)
© 2008 Heart Failure Society of America, Inc.
• The male to female ratio is about 2:1.
• The median age of presentation is 76 years.
• The prevalence of heart failure is increasing because
of the improved treatment of coronary heart disease
(e.g. thrombolysis resulting in more people surviving
a myocardial infarct but left with residual left
ventricular dysfunction), and the ageing population .
Heart Failure Demographics
8
7
Millions
6
5
4
3
2
1
0
1970
1980
1990
2000
2010
2020
2030
2040
The graph shows an increasing incidence of heart failure patients from 1970 to
2040
Epidemiology of Heart Failure
in the US
Heart Failure Patients in US
(Millions)
12
10
10
8
• 550,000 new cases/year
6
4
• More deaths from heart failure
than from all forms of cancer
combined
4.7
• 4.7 million symptomatic
patients; estimated 10 million in
2037
3.5
2
0
1991
2000
2037*
*Rich M. J Am Geriatric Soc. 1997;45:968–974.
American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.
CAUSES
Risk Factors for Heart Failure
• Coronary artery disease
• Diabetes
• Hypertension (LVH)
• Congenital heart defects
• Valvular heart disease
Other: lifestyle factors
• Alcoholism
– Obesity
• Infection (viral)
– Age
– Smoking
– High or low hematocrit level
– Obstructive Sleep Apnea
CAD=coronary artery disease; LVH=left ventricular hypertrophy.
What Causes Heart Failure?
Heart failure results after injury to the heart.
The remaining uninjured part has to work
harder to compensate for the loss. The
remaining heart muscle cannot cope and
heart failure develops
© 2008 Heart Failure Society of America, Inc.
Hypertension is the No. 1 risk factor for HF
Framingham Heart Study
60
40
Populationattributable
risk (%)
20
0
Hazard ratio
HTN
MI
Angina
VHD
LVH
Diabetes
M
2.1
6.3
1.4
2.5
2.2
1.8
W
3.3
6.0
1.7
2.1
2.8
3.7
Men
VHD = valvular heart disease
Women
Treating Hypertension to Prevent HF
• Aggressive blood
pressure control:
Decreases
risk of
new HF
by ~ 50%
56% in DM2
Lancet 1991;338:1281-5 (STOP-Hypertension
JAMA 1997;278:212-6 (SHEP)
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
• Aggressive BP control
in patients with prior
MI:
Decreases
risk of
new HF
by ~ 80%
Diabetes-CVD Facts
• Up to 60% of adults with diabetes have high blood
pressure.
• Nearly all adults with diabetes have one or more
cholesterol problems, such as:
– high triglycerides
– low HDL (“good”) cholesterol
– high LDL (“bad”) cholesterol
4
Diabetes-CVD Facts
• More than 65% of all deaths in people with
diabetes are caused by cardiovascular
disease.
• Heart attacks occur at an earlier age in people
with diabetes and often result in premature
death.
3
Key Points Review
• People with diabetes are at a very high risk for
heart attack and stroke.
• More than 2 out of 3 of people with diabetes die of
heart disease or stroke.
• Diabetes is more than managing blood glucose.
It’s managing blood glucose and blood pressure
and cholesterol.
• More treatments are available than ever before.
17
Mechanisms of Heart failure
• Impaired ventricular contraction & thus
function.
• Ventricular outflow obstruction (pressure
overload).
• Ventricular volume overload.
SYMPTOMS
What Are The Symptoms
of Heart Failure?
Think FACES...
•
•
•
•
•
Fatigue
Activities limited
Chest congestion
Edema or ankle swelling
Shortness of breath
© 2008 Heart Failure Society of America, Inc.
Classification
• The New York Heart Association (NYHA) has classified chronic heart
failure according to the following functional criteria:
– Grade I - no limitation of physical activity
– Grade II - slight limitation of physical activity; comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or dyspnoea.
– Grade III - marked limitation of physical activity; comfortable at rest,
but less than ordinary activity causes fatigue, palpitation, or dyspnoea
– Grade IV - unable to carry out any physical activity without
discomfort; symptoms of cardiac insufficiency at rest; if any physical
activity is undertaken.
DIAGNOSIS
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)
Types of Heart Failure
• Systolic (or squeezing) heart failure
– Decreased pumping function of the heart, which results in
fluid back up in the lungs and heart failure
• Diastolic (or relaxation) heart failure
– Involves a thickened and stiff heart muscle
– As a result, the heart does not fill with blood properly
– This results in fluid backup in the lungs and heart failure
Cardiac (Heart) Failure:
WHAT HAPPENS
Diminished cardiac output (forward failure)
Damming back of blood in the venous system
(backward failure), or
Both
How Does Heart Failure
Affect the Body?
• Not enough blood circulates
• Fluid builds up, creating congestion
© 2008 Heart Failure Society of America, Inc.
A Key Indicator for Diagnosing Heart Failure
Ejection Fraction (EF)
• Ejection Fraction (EF) is the percentage of blood that
is pumped out of your heart during each beat
Heart failure
Normal heart
Heart failure
Volume – overload
hypertrophy
Normal heart
Pressure –
overload
Hypertrophy
Cardiac Output
CO = Stroke volume X heart rate
=70 ml X 60 beats/min
=4,200 ml/min.
Volume of blood ejected per minute
– Each ventricle ejects approximately 70mL of blood/
beat
Averages between 4-8L/min
• Control of HR:
• Control of SV:
- autonomic nervous system
- preload
- hormonal(humoral) control
- contractility
- afterload
Principles of Cardiac dysfunction
Failure of the pump : Damaged muscle
contracts or relaxes weakly or inadequately.
An obstruction to flow : This overworks the
chamber behind obstruction(hypertension)
Regurgitation flow: Some of the output from
each contraction is flows back—volume
workload to ventricles(leaking valves)
Disorders of cardiac conduction(atrial
fibrillation)
Pathophysiology
• death of heart muscle cells
• “normal” regions of cardiac muscles are
overworked.
Causes leading to changes of number and size
of cardiomyocytes
Diastolic and systolic dysfunctions
Normal
Diastolic
dysfunction
Systolic
dysfunction
Pathophysiology
 Systolic dysfunction:
• Progressive
deterioration of
myocardial contraction
• Occurs in cases of
Ischemic injury,
pressure or volume
overload and DCM.
Diastolic dysfunction:
• Inability of the heart
chamber to relax,
expand, and fill
sufficiently during
relaxation to
accommodate an
adequate ventricular
blood volume.
Pathophysiology
Adaptive mechanisms by which the CVS maintains
circulation
1. The Frank-Starling mechanism : >preload of dilation
helps to sustain cardiac performance by enhancing
contractility.
2. Myocardial structural change : Augmented muscle
mass = hypertrophy.
3. Activation of neurohumoral system :
• Release of norepinephrine – >heart rate—augments
myocardial contractility.
• Fluid retension
Pathophysiology
Failure of adaptive
mechanisms
Heart
failure
Differential Diagnosis
• Other causes of shortness of breath on exertion e.g. lung disease, obesity, unfitness, volume overload
from kidney failure, angina, anxiety.
• Other causes of peripheral oedema - e.g. dependent
oedema, nephrotic syndrome.
• Non-cardiac diseases causing cardiac failure - e.g.
anaemia, thyrotoxicosis, septicaemia.
Acute Heart Failure
• Often precipitated by a myocardial infarction.
• Signs include:
–
–
–
–
–
–
–
–
–
Severe breathlessness
Frothy pink sputum
Cold clammy skin
Tachycardia
Low blood pressure
Lung crepitations
Raised jugular venous pressure
Third heart sound
Confusion
Types of heart failure
• Left sided, right sided & biventricular heart
failure.
• Acute & chronic heart failure.
• Compensated & decompensated HF.
• Systolic & diastolic dysfunction.
Heart failure
LHF
RHF
• Pulmonary congestion and
oedema.
• Cough
• Dyspnoea(shortness breath)
• Orthopnea(needs pillows)
• PND(waking up feeling
breathless)
• Absence of respiratory
symptoms/insignificant.
• Systemic (and portal) venous
congestive syndrome.
• Hepatosplenomegaly
(liver + spleen enlarging)
• Peripheral oedema(swelling)
• Pleural effusion
• Ascites.
Left sided heart failure
Progressive damming of the blood within the lung
circulation and the consequences of diminished
peripheral BP and flow.
Causes :
Ischaemic heart disease with infarction
Hypertension
Valvular disease
Heart muscle diseases
Right sided heart failure.
• Usually as a consequence of left sided heart
failure.
• Cor pulmonale: heart disease secondary to
lung disease(emphysema/smoking damage)
• Other causes : deep vein thrombosis with
pulmonary emboli
TREATMENT
Management
• Manage other risk factors
• Manage coexisting coronary heart disease (CABG, Valve
surgery)
• Avoid aggravating factors
–
–
–
–
Non-steroidal anti-inflammatory drugs
Advise low salt diet
Advise a moderate alcohol intake
Limiting fluid intake may be appropriate in advanced heart failure, but
care is needed to avoid dehydration.
• Vaccinate people against influenza annually and
pneumococcus as a one-off, as they are at increased risk of
infective complications.
• Consider cardiac rehabilitation, palliative care, and longterm social support if appropriate.
Rational for Medications
(Why does my doctor have me on so many
pills??)
• Improve Symptoms
– Diuretics (water pills)
– Digoxin
• Improve Survival
–
–
–
–
Betablockers
ACE-inhibitors
Aldosterone blockers
Angiotensin receptor
blockers (ARB’s)
Medicines to Control Symptoms...
• Diuretics or “water pills”:
decrease fluid retention and reduce swelling
• Digoxin:
improves blood circulation
© 2008 Heart Failure Society of America, Inc.
Medicines That Save Lives...
• ACE Inhibitors: dilate or widen blood
vessels, increase blood flow
• Beta blockers: help strengthen the heart’s
pumping ability, block the body’s response
to substances which can damage the heart
© 2008 Heart Failure Society of America, Inc.
Is There a Cure For Heart Failure?
•
No, currently there is not a cure
•
BUT, early diagnosis and proper treatment can:
• Slow the progression of disease
• Keep you out of the hospital
• Save your life!
© 2008 Heart Failure Society of America, Inc.
HFSA 2010 Practice Guideline (9.7)
Device Therapy:
Biventricular Pacing
• Biventricular pacing therapy is recommended for
patients with all of the following:
•
– Sinus rhythm
– A widened QRS interval (≥120 ms)
– Severe LV systolic dysfunction (LVEF < 35%)
– Persistent, moderate-to-severe HF (NYHA III)
despite optimal medical therapy.
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
Device Therapy:
Prophylactic ICD Placement
• Prophylactic ICD placement should be
considered in patients with an LVEF ≤35% and
mild to moderate HF symptoms:
– Ischemic etiology
– Non-ischemic etiology
Therapies
Relative Risk
Reduction
Mortality
2 year
ACE-I
23%
27%
Β-Blockers
35%
12%
Aldosterone
Antagonists
30%
19%
ICD
31%
8.5%
Lifestyle Changes
What
Why
•Eat a low-sodium, low-fat
diet
•Sodium is bad for high blood pressure,
causes fluid retention
•Lose weight
•Extra weight can put a strain on
the heart
•Stay physically active
•Exercise can help reduce stress
and blood pressure
•Reduce or eliminate alcohol
and caffeine
•Alcohol and caffeine can weaken an
•Quit Smoking
•Smoking can damage blood vessels and
make the heart beat faster
already damaged heart
Other Therapies?
• Transplant
• Artificial hearts
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
Can a Person Live
with Heart Failure?
YES!
• See your physician regularly
• Limit your salt intake
• Weigh yourself each day
- Contact your healthcare provider if your weight changes
more than 1kg in one day
• Take your medications
• Exercise at levels recommended
by your physician
© 2008 Heart Failure Society of America, Inc.
PROGNOSIS
Heart Failure Rates and Heart Attack
Deaths Are Declining
20%
19.5%
1999
2005
15%
10%
11.0%
8.4%
5%
4.6%
4.8%
2.0%
0%
In-Hospital Heart
Attack Deaths
In-Hospital
Heart Attack within 6
Congestive Heart months of Hospital
Failure or
Discharge
Pulmonary Edema
“
Factors contributing to the
decline in heart disease and
stroke mortality include
better control of risk
factors, improved access to
early detection, and better
treatment and care,
including new drugs and
expanded uses for
existing drugs.2
“
Adverse Events Among Patients with
Coronary Disease* in a Study of 14 Countries1
–Centers for Disease Control
and Prevention
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!
Evander Holyfield
It is not the size of a man but the size of his heart that
matters.
H. L. Mencken
As the arteries grow hard, the heart grows soft
The Land Before Time
Let your heart guide you. It whispers, so
listen closely
Bernard M. Baruch
Two things are bad for the heart--running
up stairs and running down people.