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