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Heart Failure
Claire B. Hunter, MD
Heart Failure is the inability of the heart to pump sufficient blood to the body tissue to meet ordinary metabolic demands.
Heart Failure
• 400,000 new cases annually
• 5 million Americans have congestive heart failure
• 200,000 deaths annually
• Leading hospital dismissal diagnosis after age 65
• Cost over 20 billion dollars annually
Heart Failure
• Incidence 10/1000 over age 65
• Heart failure most common discharge group diagnosis
• Direct and indirect costs $27.9 billion dollars in 2005
• $2.9 billion annually for drugs for treatment of heart failure
Readmission after Hospitalization for
HF Among Medicare Beneficiaries• 17,448 survivors of hospitalization for CHF• 7,596 re-hospitalized at least once in 6 months (44%)• 2,855 re-hospitalized at least twice in 6 months *16%)
Risk Factors: Age >75, Male, Admission in previous 6 months, Co-morbidities, LOS >7 days
Krumholtz et al. Arch of Internal Med 1997;157:99-104
Factors Leading to the Increased Incidence of Heart
Failure• Successful therapies for other
cardiovascular diseases– Lytics: Decreased deaths due to Myocardial
Infarction– Implantable Cardioverter Defibrillators:
Decreased deaths due to arrhythmias– Statins: Decreased deaths due to Coronary
Artery Disease
• Advancing age of the population
6-year Mortality (Framingham)
• 82% in men (29% sudden death)
• 67% in women (13% sudden death)
Some Factors Influencing the Progression of Heart Failure
• History of Hypertension
• Development of Left Ventricular Hypertrophy
• Ischemia / Myocardial Infarction
• Neurohormonal Activation
CHF: Prognosis
• Etiology
• LV function
• Therapy
Heart Failure
• Hypertension
• Coronary artery disease
Table 1 continued
CHF: Etiologic Classification
• Direct myocardial damage
• Pressure/volume overload
• LV filling restriction
CHF due to direct myocardial damage
• Ischemic cardiomyopathy: Extensive or multiple Mis with or without ventricular aneurysms
• Nonischemic cardiomyopathy: The result of myocardial toxins (alcohol or adriamyacin)
CHF due to pressure or volume overload
• Pressure overload– Aortic stenosis– Hypertension– Coarctation of the aorta
• Volume overload– Mitral regurgitation– Aortic regurgitation– Patent ductus arteriosus– Ventricular septal defect
Conditions restricting ventricular filling
• Mitral stenosis• Atrial myxoma (obstructing mitral or
tricuspid orifice)• Pericardial restriction or constriction• Restrictive or infiltrative cardiomyopathy
– Sarcoidosis– Amyloidosis– Hemochromatosis
• Hypertrophic cardiomyopathy
Diastolic Heart Failure
• Resistance to filling one or both ventricles
• Increased ventricular filling pressures
• Congestive symptoms
• Normal systolic function
Diastolic Dysfunction
• 40-50% of Heart Failure over age 70
• Most common cause– LV hypertrophy– Hypertensive heart disease
Compensatory Factors in Congestive Heart Failure
• Acute– Increased stroke volume due to passive cardiac
muscle stretch (Frank-Starling mechanism)– Increased heart rate (cardiac output = stroke
volume x heart rate)– Increased contractility (sympathetic tone and
circulating catecholamines)
• Chronic– Hypertrophy
Symptoms of CHF related todeficiencies of cardiac performance
CHF = Cardiac output + Ventricular filling
pressure
Hypoperfusion RA pressure LA pressure
Fatigue Dependant Breathlessness edema
Major criteria for cardiac failure
• Paroxysmal nocturnal dyspnea• Neck vein distention• Rales• Cardiomegaly• Acute pulmonary edema• S3 gallop• Increased venous pressure (>6 cm H2O• Hepatojugular reflux• Weight loss > 4.5 kg over 5 days in response to
treatment
Minor criteria for cardiac failure
• Ankle edema• Night cough• Dyspnea on exertion• Hepatomegaly• Pleural effusion• Vital capacity reduced 1/3 from maximum• Tachycardia > 120 bpm• Weight loss > 4.5 kg over 5 days in response to
treatment
Balancing Act
• Norepinephrine• Angiotensin II• Aldosterone• Endothelin• Vasopressin
• Atrial + B type naturatic peptides
• Nitric oxide• Prostacyclin• Bradykenin
Vasoconstrictors Vasodilators
Evaluations Tools
Echocardiogram
• To evaluate LV diastolic abnormalities
• LV systolic function
• Valvular abnormalities
Evaluation cont’l
Ischemia evaluation
Dobutamine
or Nuclear “Stress”
not when wet
Evaluation cont’d
Coronary arteriographyEndomyocardial Biopsy
Aerobic capacity
“6 minutes” walkMvO2 uptake analysis
BNP as a Therapeutic
Actions of BNP• Hemodynamic
balanced vasodilationcoronary arteries
• Neurohormonaldecreases aldosteronedecreases endothelin
• Renalincreases diuresisincreases natriuresis
Disease Management
• Telemonitoring
• Weekly educational mailings
• Medical claims declined by $1100 per patient in treatment group
• Claims increased $9600 in non-treatment group