Chronic Heart Failure –An Update

T P Chua

Royal Surrey County Hospital, Guildford

St George’s Hospital, London

• Common (1-5% of population)

• High Mortality

• Disabling symptoms

• Expensive (30% require

hospitalisation/year)

• Recent Advances

Chronic Heart Failure – ClinicallyImportant

Chronic Heart Failure• Ventricular dysfunction with chronic

symptoms of breathlessness and/or fatigue and/or fluid retention

• Signs of pulmonary or peripheral congestion

• Systolic heart failure more common and better defined than diastolic heart failure

Eur Heart J 1995; 16: 741-751

Diastolic Heart Failure• Normal ejection fraction/systolic function• Normal or even small left ventricular

chamber volumes• Reduced active relaxation and increased

passive stiffness of LV• More than 75% of these patients have

hypertension and ~40% have left ventricular hypertrophy

Zile MR, et al. NEJM 2004; 350:

Sensitivity & Specificity of Symptoms

Dyspnoea

Orthopnoea

PND

Oedema

Sensitivity (%) Specificity (%)

66

21

33

23

52

81

76

80

Value of the ECG in Identifying Heart Failure

ECG Impaired LV Normal LV Total

Abnormal* 90 169 259

Normal 6 269 275

Total 96 438 534

*Abnormal ECG: AF, Previous MI, LVH, BBB, LAD

Davie AP, McMurray JJV, et al. BMJ 1996;312:222

Negative Predictive Value: 269/275: 98%

Sensitivity & Specificity of ECG,NT-proBNP and Hand-held Echo

Abnormal ECG

Raised NTproBNP

Abnormal ECG or raised NTproBNP

Sensitivity (%)Specificity (%)

80

96

76

78

88

72

94

NPV (%)

Abnormal ECG and raised NTproBNP

92 99.6

99

99.8

99.7

Hand-held Echo 93 97 99.3

EHJ 2006; 27: 193-200

Natriuretic PeptidesThree types present:-• ANP (atrial natriuretic peptide) first discovered;

primarily released by atria; potent vasodilator and natriuretic

• BNP (B-type natriuretic peptide); predominantly released by left ventricle in response to high filling pressures; also a vasodilator and natriuretic

• CNP (C-type natriuretic peptide); released by atria and ventricles; vasodilatory property only

B-type Natriuretic Peptide

Clinical Use of BNP in CHF• Diagnosis of CHF in patients with acute

dypsnoea