Haissam A Haddad, MD, FRCPC, FACC University of Ottawa Heart Institute Heart Failure Haissam A Haddad, MD, FRCPC, FACC Professor of Medicine University of Ottawa Heart Institute

Objectives -Classify the types of heart failure: systolic, diastolic, Left and right‐sided heart failure. -Describe the compensatory mechanisms of heart failure taking into account: neurohormonal alterations, ventricular hypertrophy and remodeling. -Recognize the precipitating factors in heart failure. -Describe the clinical presentation of heart failure including diagnostic studies. -Recognize the modalities of treatment of heart failure including: diuretics, vasodilators, ionotropic drugs, B ‐Blockers, and additional therapies. -Describe measures to prevent heart failure and preserve left ventricular function. -Explain the sequella of ventricular dysfunction. -Describe congestive heart faillure. -Explain the physiological effects of congestive heart faillure

Heart Failure Heart failure is common, yet it is difficult to treat. It presents in many different circumstances in which therapy needs to be individualized. About 500.000 Canadian with Heart Failure “5 million Americans” HF remains one of the most common reasons for hospital admission, as well as one of the most costly cardiovascular disorders. Canada’s average annual in-hospital mortality rate is: 9.5 deaths/100 hospitalized patients >65 years of age 12.5 deaths/100 hospitalized patients >75 years of age HF patients have a poor prognosis, with an average 1-year mortality rate of 33%

Affects men and women equally Who Gets Heart Failure Affects men and women equally Mortality risk between men and women is similar Dr. (Name) says: It may be interesting for you to know a little bit about the similarities and difference between men and women with heart failure. First, women are almost as likely as men to develop heart failure. There are many similarities in the disease between men and women. However, there are also some differences. Source: Vaccarino V, Chen YT, Wang Y, et al. Sex differences in the clinical care and outcomes of congestive heart failure in the elderly. Am Heart J. 1999; 138(5):835-842.

What is Heart Failure (HF)? Heart Failure is a complex syndrome in which abnormal heart function results in

Types of Heart Failure? Left Heart Failure Right Heart Failure Involves the left ventricle (lower chamber) of the heart Systolic failure The heart looses its ability to contract or pump blood into the circulation Diastolic failure The heart looses its ability to relax because it becomes stiff Heart cannot fill properly between each beat Right Heart Failure Usually occurs as a result of left heart failure The right ventricle pumps blood to the lungs for oxygen Occasionally isolated right heart failure can occur due to lung disease or blood clots to the lung (pulmonary embolism)

How fast does heart failure develop? Usually a chronic disease The heart tries to compensate for the loss in pumping function by: Developing more muscle mass Enlarging Pumping faster

Remodeling in the failing heart Myocyte hypertrophy Chamber dilation Interstitial changes Remodeling in the failing heart Less Fibrosis Normal Myocyte Hypertrophied Myocyte More Fibrosis Normal Heart Dilated Heart

Causes of Left Ventricular Dysfunction Coronary artery disease Volume overload Pressure overload Metabolic Connective tissue diseases Neurologic diseases Primary cardiomyopathy Heavy metals Many conditions can lead to HF. More than 2/3 of patients with HF have underlying CAD (MI, silent ischemia, chronic ischemia). Identifying the underlying cause of HF can be difficult. Our strategy as clinicians should be to manage the risk factors and treat the conditions before HF becomes established. HF is progressive despite the cause. Inherited diseases Other diseases Restrictive disease Drugs Infections

Neurohormonal Activation in Heart Failure Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Initial fall in LV performance,  wall stress Activation of RAS and SNS Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity Remodeling and progressive worsening of LV function Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Morbidity and mortality Arrhythmias Pump failure Fatigue Activity altered Chest congestion Edema Shortness of breath RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Symptoms of Heart Failure Shortness of breath Chronic lack of energy Cough with frothy sputum Swelling of the feet and legs Difficulty sleeping due to breathing problems Swollen or tender abdomen with loss of appetite Increased urination at night Confusion and/or impaired memory Dr. (Name) says: During heart failure, fluid can build up in your lungs, legs, feet, and other parts of your body. That’s why the term congestive heart failure is sometimes used to describe the disease. Because the heart isn’t pumping efficiently, you might feel tired and can’t do the things you want to do. Speak to reason(s) fluid builds up when a person has heart failure. Review the symptoms on the graphic one by one. Explain which symptoms you will usually experience first and which ones appear later in the course of the disease. Your symptoms will help your doctor classify the severity of your heart failure and monitor the effects of treatment. Are there any questions? Now that we have gone over the basics of heart failure, I’ll tell you a bit about how it’s diagnosed.

NYHA CLASS No symptoms Can perform ordinary activities without any limitations Mild symptoms Occasional swelling Somewhat limited in ability to exercise or do other strenuous activities No symptoms at rest Noticeable limitations in ability to exercise or participate in mildly strenuous activities Comfortable only at rest Unable to do any physical activity without discomfort Symptoms at rest Review symptoms of all Classes of heart failure – NYHA description and practical examples.

Diagnosis of Heart Failure

Treatment of Heart Failure

Lifestyle Changes to prevent heart failure and preserve left ventricular function. What Why Low-sodium, low-fat diet Sodium is bad for high blood pressure Lose weight Extra weight can put a strain on the heart Physically active Exercise can help reduce stress and blood pressure Lifestyle changes involved in managing heart failure: Discuss diet and exercise in some detail: Staying active does not mean training as if you were going to run a marathon: but can simply mean regular walks. You can start slowly and build up under the direction of your doctor. Can reduce sodium in your diet by focusing on eating fresh meats, fruits, and vegetables; reading labels: asking questions when you eat out; and getting a low-sodium cookbook. Lifestyle changes are things you can do to influence how your feel. It may seem difficult to accomplish these things, but they are an essential part of treating heart failure. There are many resources to help you get started in incorporating these changes into your life. List any. Also, ask your friends and family for support. Reduce or eliminate alcohol and caffeine Alcohol and caffeine can weaken an already damaged heart Quit Smoking Smoking can damage blood vessels and make the heart beat faster

Prevention of Heart Failure Coronary artery disease Myocardial infarction Hypertension Diabetes Valvular heart disease Dilated or hypertrophic cardiomyopathy, myocarditis Congenital heart disease Severe lung disease

Drugs to Use With Caution in HF Patients Calcium channel blockers Thiazolidinediones (glitazones) Doxorubicin NSAIDS, including Cox-2 inhibitors Reference: 1. Arnold JMO, Liu P et al. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006:diagnosis and management. Can J Cardiol 2006;22(1):23-45.

Conclusions Management of HF begins with an accurate diagnosis Aggressive treatment of all known risk factors e.g., hypertension, diabetes, etc. Treatment requires rational combination drug therapy Care should be individualized for each patient based on: Symptoms Clinical presentation Disease severity Underlying cause Patient and caregiver education should be tailored and repeated Mechanical interventions (e.g., revascularization and devices) should be available Collaboration is required among healthcare professionals Accessibility to primary, emergency and specialist care must be timely