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 to deficiencies 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 S 3 gallop Increased venous pressure (>6 cm H 2 O 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 arteriography Endomyocardial Biopsy

Aerobic capacity “6 minutes” walk MvO 2 uptake analysis

BNP as a Therapeutic

Actions of BNP Hemodynamic balanced vasodilation coronary arteries Neurohormonal decreases aldosterone decreases endothelin Renal increases diuresis increases natriuresis

Disease Management Telemonitoring Weekly educational mailings Medical claims declined by $1100 per patient in treatment group Claims increased $9600 in non-treatment group