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Heart Failure: Living with a

Hurting HeartJames T. DeVries, MD

Dartmouth-Hitchcock Medical

enter


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!utline" De#initions and sco$e o# $ro%lem

" Diagnosing and classi#&ing heart #ailure" '$$roach to management o# HF

( !ral drug thera$& )'*-+, ', %eta%lockers,

aldosterone %lockade, digoin/( Device thera$&

" iventricular )iV/ $acers

" +ntracardiac de#i%rillators )+D0s/" Future directions and eciting

develo$ments


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ongestive Heart Failure

" Heart (or cardiac) failureis the state in

which the heart is una%le to $um$ %lood at a

rate commensurate with the re1uirements o#

the tissues or can do so onl& #rom high

$ressures

raunwald 2th*dition, 3445


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ongestive Heart Failure

" 6&m$toms:

( 6hortness o# %reath

( Leg swelling )edema/

( reathing worsens with l&ing #lat )ortho$nea/

( Fatigue


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'natom& 545


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A normal heart pumps blood in a smooth andA normal heart pumps blood in a smooth and

synchronized way.synchronized way.


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Heart FailureHeart Failure

HeartHeart

A heart failure heart has a reduced ability toA heart failure heart has a reduced ability to

pump blood.pump blood.


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T&$es o# Heart Failure

" 6&stolic )or s1uee7ing/ heart #ailure

( Decreased $um$ing #unction o# the heart, which

results in #luid %ack u$ in the lungs and heart #ailure

" Diastolic )or relaation/ heart #ailure

( +nvolves a thickened and sti## heart muscle

('s a result, the heart does not #ill with %lood $ro$erl&

( This results in #luid %acku$ in the lungs and heart

#ailure


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CAD=coronary artery disease; LVH=left ventricular hypertrophy.

isk Factors #or Heart Failure

" oronar& arter&

disease

" H&$ertension )LVH/

" Valvular heart disease

"'lcoholism

" +n#ection )viral/

" Dia%etes

" ongenital heart de#ects

" !ther:( !%esit&

( 'ge

( 6moking( High or low hematocrit level

( !%structive 6lee$ '$nea


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*$idemiolog& o# Heart Failurein the 86

" More deaths #rom heart #ailurethan #rom all #orms o# cancercom%ined

" 994,444 new cases&ear

" ;.< million s&m$tomatic$atients= estimated 54 millionin 34>>9:;@4(;@2.

Pat#olo$ic

re%odelin$

&o' eection

fraction eat#

!%+to%s,

s+neaFati$ue

-de%a

#ronic

#eartfailure

"/euro#or%onalsti%ulation

""ocardialtoicit

!udden

eat#

Pu%+failure

oronar arterdisease

H+ertension

ardio%o+at#

alular disease

"ocardial

inur

athologic rogression o# V Disease

iaetes


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om$ensator& Mechanisms:om$ensator& Mechanisms:enin-'ngiotensin-'ldosterone 6&stemenin-'ngiotensin-'ldosterone 6&stem

enin n$iotensino$en

n$iotensin

n$iotensin

Peri+#eralasoconstriction

fterload

ardiac ut+ut

Heart FailureHeart Failure

ardiac or:load

Preload

Plas%a olu%e

!alt ; ater etention

-de%a

ldosterone !ecretion

-


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Drug Thera$&


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Heart Failure Treatments:

Medication T&$es

ACE inhibitor(angiotensin-conertingenzyme!

A"# (angiotensinreceptor bloc$ers!

#eta-bloc$er

%igo&in

%iuretic

Aldosteronebloc$ade

'ype hat itdoesE&pands blood essels which

lowers blood pressure)neurohormonal bloc$ade

*imilar to ACE inhibitor+lowers blood pressure

"educes the action of stresshormones and slows the heartrate*lows the heart rate and improesthe heart,s pumping function (EF!

Filters sodium and e&cess uid fromthe blood to reduce the heart,swor$load

#loc$s neurohormal actiation and

ti l # M di ti


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ational #or Medications

)Ch& does m& doctor have me on

so man& $illsOO/" +m$rove 6&m$toms

( Diuretics )water $ills/

( digoin

" +m$rove 6urvival

( eta%lockers

('*-inhi%itors

('ldosterone %lockers

('ngiotensin rece$tor

%lockers )'0s/


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Li#est&le hanges

Eat a low-sodium) low-fat diet

ose weight

*tay physically actie

"educe or eliminate

alcohol and ca/eine

0uit *mo$ing

hat hy*odium is bad for high bloodpressure) causes uid retention

E&tra weight can put a

strain on the heart

E&ercise can help reducestress and blood pressure

Alcohol and ca/eine can wea$en

an already damaged heart

*mo$ing can damage blood esselsand ma$e the heart beat faster


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>urin$ % serice in t#e nited !tateson$ress? too: t#e initiatie in creatin$ t#enternet>

'l Gore said when asked to citeaccom$lishments that se$arate him #rom anotherDemocratic $residential ho$e#ul, #ormer 6en. ill

radle& o# ew Jerse&, during an interview withCol# lit7er on on March @, 5@@@.


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Device Thera$&:

iventricular acing


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!verview o# Device Thera$& 39

iventricular acingVentricular D&s&nchron&

" '%normal ventricular conduction resulting

in a mechanical dela& and d&s&nchronous

contraction


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iV acing


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ardiac es&nchroni7ation Thera$&


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ardiac es&nchroni7ation Thera$&

Ie& oints" ndications

( Moderate to severe HF who have #ailed o$timalmedical thera$&

( *FP>4Q

( *vidence o# electrical conduction dela&

" Timing o# e#erral +m$ortant( atients o#ten not on o$timal Medical

( atients re#erred too late- ot a ail !ut


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De#i%rillators )+D0s/


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Heart Failure and 6udden

ardiac Death

6udden ardiac Death )6D/( Kour heart suddenl& goes into a ver& #ast and chaotic

rh&thm and sto$s $um$ing %lood

( aused %& an BelectricalN $ro%lem in &our heart

( 6D is one o# the leading causes o# death in the 8.6. (a$$roimatel& ;94,444 deaths a &ear

( atients with heart #ailure are A-@ times as likel& to develo$sudden cardiac death as the general $o$ulation


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How does a de#i%rillator #or

sudden cardiac death workO

Device

Shown:

Combination1acema$er2%e3brillator


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+m$lanta%le ardiac De#ri%rillators

-=" @#era+ies elatie is:eduction

"ortalit2 ear

-A 3>Q 39Q 53Q

ldosteronenta$onists

>4Q 5@Q

>5Q 2.9Q


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Cho should onsider an +DO"

atients with weakend heart, ew KorkHeart 'ssociation )KH'/ lass ++ and +++

heart #ailure, and measured le#t ventricular

eection #raction )LV*F/ P >9Q

" atients who meet all current re1uirements

#or a cardiac res&nchroni7ation thera$&

)T/ device and have KH' lass +V

heart #ailure=


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!ther Thera$iesO

" Trans$lant

" 'rti#icial hearts

" ew BgadgetsN to hel$ doctors manageheart #ailure


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Heart Trans$lantation

" ' good solution to the #ailing heart( get a

new heart

" 8n#ortunatel& we are limited %& su$$l&, not

demand

" '$$roimatel& 3344 trans$lants are

$er#ormed &earl& in the 86, and this

num%er has %een sta%le #or the $ast 34

&ears.


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Corldwide Heart Trans$lants


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ewer Generation 'rti#icial Hearts


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Future Tech


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+ntrathoracic +m$edance #or Heart

Failure


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!ne o# the est Devices #or

Monitoring Heart Failure


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Chat have we learnedO


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+n 6ummar&R.

" Heart #ailure is common and has high mortalit&

" Drug thera$& im$roves survival

( eta%lockers, '*-+, aldosterone antagonists

" ewer device thera$ies are showing $romise #ors&m$tom relie# and im$roved survival

( iventricular $acing, +D0s

" Trans$lants remain rare, %ut technolog& #ormechanical assist devices continues to im$rove-

sta& tuned

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