HeartHeart FailureFailureAn overviewAn overview

The Management of Heart Failure:The Management of Heart Failure: The Past, the Present, and the FutureThe Past, the Present, and the Future

Eugene Braunwald, MD

Volume 1, Issue 1; May, 2008

OBJECTIVESOBJECTIVES1.1.Disease BurdenDisease Burden

2.Heart Failure Therapy in 2.Heart Failure Therapy in the Past, Present and the Past, Present and Future.Future.

IS IT A PANDEMIC???IS IT A PANDEMIC???

Number 1 KillerNumber 1 Killer

5.7Million5.7MillionAmericansAmericans

Mortality has more thanMortality has more than

doubleddoubled since 1979since 1979

>65years>65years Leading cause of hospitalizationLeading cause of hospitalization

1-2%1-2%

of Health Care costof Health Care cost $ 39.2 Billion$ 39.2 Billion

55 years from diagnosis years from diagnosis

only only 50%50% alive alive

The PastThe Past

In 1950In 1950first edition of first edition of Harrison’s Principles of Internal MedicineHarrison’s Principles of Internal Medicine

DDecubitusecubitusDDietary sodium restrictionietary sodium restrictionDDigitalisigitalisDDiuretics (mercurial)iuretics (mercurial)Venesection and Venesection and MorphineMorphine

The Management of Heart Failure: The Past, the Present, and the FutureThe Management of Heart Failure: The Past, the Present, and the Future Eugene Eugene

Braunwald,MDBraunwald,MD Circulation: Heart Failure. 2008;1:58-62Circulation: Heart Failure. 2008;1:58-62

In 1970In 1970Sixth edition of Sixth edition of Harrison’s Principles of Internal MedicineHarrison’s Principles of Internal Medicine

Diuretics (Diuretics (Thiazide, Loop, Potassium sparingThiazide, Loop, Potassium sparing))β-adrenergic agonist β-adrenergic agonist Precipitating causePrecipitating cause

The Management of Heart Failure: The Past, the Present, and the Future Eugene Braunwald,MDThe Management of Heart Failure: The Past, the Present, and the Future Eugene Braunwald,MD

Circulation: Heart Failure. 2008;1:58-62Circulation: Heart Failure. 2008;1:58-62

The PresentThe Present

Level of EvidenceLEVEL OF EVIDENCE C ALEVEL OF EVIDENCE C A

ACE INHIBITORS or ARB

BETA BLOCKERS

DIURETICS

DIGOXIN

SPIRONOLACTONE

OPT: Optimal Pharmacologic TherapyOPT: Optimal Pharmacologic Therapy

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2001; 1-56.

ADJUNCT: HYDRALAZINE and NITRATESADJUNCT: HYDRALAZINE and NITRATES

Copyright ©2008 American Heart Association

Management of heart failure Management of heart failure over the past 40 yearsover the past 40 years

Katz, A. M. Circ Heart Fail 2008;1:63-71

Biventricular pacing therapy

INDICATIONS:

• Sinus rhythm, QRS interval >=120 ms

• LV systolic dysfunction LVEF (<=35%)

• Persistent, moderate to severe HF (NYHA III) despite optimal medical therapy.

(Strength of Evidence = A)

http://www.heartfailureguideline.org

2010 Comprehensive Heart Failure Practice Guideline

Cardiac Resynchronization Therapy

Prolongs Survival in Patients With Left Ventricular Dysfunction: A Meta-Analysis

McAlister FA. JAMA. 2007;297:2502.

Cardiac Resynchronization Therapy Prolongs Survival in Patients With Heart Failure (The CARE-HF Trial)

Percentage of Patients Free of Death from Any Cause or Unplanned Hospitalization for Major Cardiovascular Event

Percentage of Patients Free of Death from Any Cause

Cleland JG et al. N Engl J Med. 2005:352;1539.

ICD TherapyICD TherapyCLASS I INDICATIONS:CLASS I INDICATIONS:

1.1. Ischemic cardiomyopathy with LVEF Ischemic cardiomyopathy with LVEF

< 35%, at least 40 days post MI, NYHA class II < 35%, at least 40 days post MI, NYHA class II OR III. OR III. (Strength of Evidence = A)(Strength of Evidence = A)

2.2. Ischemic cardiomyopathy with LVEF < 30%, at Ischemic cardiomyopathy with LVEF < 30%, at least 40 days post MI, NYHA class I. least 40 days post MI, NYHA class I. (Strength of (Strength of Evidence = A)Evidence = A)

3.3. Non Ischemic cardiomyopathy with LVEF ≤ 35%, Non Ischemic cardiomyopathy with LVEF ≤ 35%, NYHA class II OR III. NYHA class II OR III. (Strength of Evidence = B)(Strength of Evidence = B)

The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

Left Ventricular Assist Devices Left Ventricular Assist Devices (LVAD)(LVAD)

The Jarvik-7The Jarvik-7

The Jarvik 2000

The World's First Artificial Heart

Indications• Bridge to Transplantation

• Bridge to Recovery

• Destination Therapy

Transcutaneous Ventricular Assist Transcutaneous Ventricular Assist DeviceDevice

Implantable Ventricular Assist Implantable Ventricular Assist DeviceDevice

Ventricular Assist DeviceVentricular Assist Devicein the marketin the market

HeartMate II®HeartMate II® Arrow LionHeartArrow LionHeart DeBakey LVADDeBakey LVAD

Thoratec CentriMag®Thoratec CentriMag® Thoratec PVAD™Thoratec PVAD™ Thoratec IVAD™Thoratec IVAD™ HeartMate® XVEHeartMate® XVE

Surgeries for heart failureSurgeries for heart failure

Coronary RevascularizationCoronary Revascularization

Valvular SurgeryValvular Surgery

Left Ventricular Reconstructive Left Ventricular Reconstructive Surgery (Dor Procedure)Surgery (Dor Procedure)

Batista ProcedureBatista Procedure

Cardiac TransplantCardiac Transplant

At Groote Schuur Hospital At Groote Schuur Hospital

On December 3On December 3rdrd 1967 1967

Mr. Louis Washkansky lived for 18 days Mr. Louis Washkansky lived for 18 days

Smithsonian‘s National Museum of American HistorySmithsonian‘s National Museum of American History

250,000 deaths per year250,000 deaths per year

Only 2000 donor hearts availableOnly 2000 donor hearts available

Never make predictionsNever make predictions

Genetic MutationsGenetic Mutations

Insertion/deletion polymorphism within the Insertion/deletion polymorphism within the ACE ACE genegene

Polymorphism ofPolymorphism of the adrenergic the adrenergic αα2c receptor and of 2c receptor and of thethe β1β1 adrenergic receptoradrenergic receptor

CELL BASED THERAPY

PREVENTIONPREVENTION

Thank youThank you