HEARTFAILURE Living with a hurting heart HELDERBERG CARDIAC

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 (Bi. V) 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 •

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 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 DM 2 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

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

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 70 m. L of blood/ beat Averages between 4 -8 L/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

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 (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 already damaged heart • Quit Smoking • Smoking can damage blood vessels and make the heart beat faster

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 1 kg 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 “ 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 Countries 1 –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.