1. Strategies for Heart Failure Prevention
Stuart J Smith MD
Heart Failure Program
St Mary’s Regional Cardiac Centre

2. Outline Know your enemy Epidemiology of Heart Failure – the Basics
Pathophysiology / Stages of Heart Failure
Implications for Prevention
Prevention of HF in CHD
Prevention of HF in asymptomatic LV dysfunction
Prevention of HF targeting BP

3. Epidemiology of Heart Failure AHA Heart & Stroke Statistical Update (2009)
Prevalence in US : 5.7 million , males > females
Race adjusted prevalence
Caucasian : 3.1 % male , 1.8% for women
Blacks : 4.2 % male , 4.2% for women
Incidence in US
670,000 new cases /year with 1 % / year after 65
Leading cause of hospitalization for age ≥ 65
1.1 million in 2006 vs 0.4 million in 1980
Total US cost for HF ( 2009) : $37.2 billion

4. Prevalence of Heart Failure by Age
Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2005–2008).
Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2005–2008). Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute.
AHA Heart Disease and Stroke Statistics 2012 Update
Copyright © American Heart Association

5. Lifetime Risk for HF by Sex and Age Framingham Heart Study
A person aged 40 or over has a lifetime risk of heart failure of one in five, which is doubled if they have high blood pressure.
Donald Lloyd-Jones Circ 106 : 3068 (2002)

6. Hospital Discharge for HF
Hospital discharges for heart failure by sex United States: –2009
Hospital discharges for heart failure by sex (United States: 1979–2009). Note: Hospital discharges include people discharged alive, dead, and status unknown. Source: National Hospital Discharge Survey/National Center for Health Statistics and National Heart, Lung, and Blood Institute.
AHA Heart Disease and Stroke Statistics 2012 Update
Copyright © American Heart Association

7. Trends in Incidence of HF Olmstead County , 1979 - 2000
Table 1. Temporal Trends in the Age-Adjusted Incidence of Heart Failure
Roger, V. L. et al. JAMA 2004;292:
Copyright restrictions may apply.

8. Incidence and Prevalence of HF in Medicare Patients , 1994- 2003
Year
Prevalence /1000
1994
89.9
1996
104.4
1998
114.9
2000
119.9
2002
121
Lesley Curtis et al; Arch Intern Med 2008

9. Risk Factors and PARS for HF Olmstead County, 1979-1999
Prevalence
Odds Ratio (95%CI)
PAR (95% CI)
CAD
27%
(2.26 – 4.19)
( )
Hypertension
67%
(1.40 – 2.25)
( )
Obesity
24%
(1.84 – 3.50)
( )
Diabetes
19%
( 2.14 – 4.44)
( )

12. Prevalence and Prognosis of HF Stages, Olmstead County
Ammar et al. Circulation 2007;115:

13. Is the HF Epidemic a Consequence of Our Successes or our Failures ?
Improved survival after MI   incidence
Improved survival in patients with HF leading to  prevalence
Failures
Failure to control HTN
Failure to prevent progression from MI to HF
Neither
Immutable consequence of an aging population

14. Primordial and Primary Prevention of Heart Failure
Prevention in all patients
Prevention in patients with asymptomatic LV systolic dysfunction ( ASLVD)
Prevention in patients with hypertension (HTN)
Prevention in patients with CAD
Prevention in patients with diabetes

15. Dietary and Lifestyle Factors
Major Risk Factors for HF all linked
( CAD , HTN ,Diabetes , Obesity , Renal Disease)
All of these predisposing factors can be prevented or mitigated by diet and physical activity
Eg  dietary sodium ,  vegetables /fruits,  fat , less saturated fats , weight maintenance , weight loss

16. Role of Screening for Asymptomatic Systolic LV Dysfunction ( ASLVD )
Not recommended as a “routine”
All AHA Stage A patients should be questioned about signs & symptoms of HF routinely.
Recommendation for echo screening for selected patient groups at “high risk”
Eg Patients with hx of previous MI ( especially anterior) ; patients who received cardiotoxic interventions ; patients with strong family hx of HF in absence of other factors ( LBBB on ECG)
The future ?? – BNP may be a “cost effective” means for  yield

17. HTN and Asymptomatic Systolic LV Dysfunction (ASLVD)
Community Based Studies
Prevalence of ASLVD varies from 2- 5%
Among those with ASLVD , the prevalence of HTN varies from 23% - 73% ……. Similar to prevalence of MI.
Progression from ASLVD to HF can be prevented …….
Wang et al . Ann Intern Med 2003

18. SHEP Trial : Cardiovascular Disease Endpoints
- 13%
- 25%
-36%
- 32%
- 54%
JAMA 265: 3255 ( 1991)

19. ALLHAT N = 42,488 HTN , Age  55 PLUS  1 other CVS risk factor :
Previous MI /stroke ;revascularization , Type II DM , low HDL , LVH , smoking
Excluded recent event , CHF or EF < 35% , Crt > 185
Untreated BP / mmHG
Treated ( 1 or 2 meds) BP <160/100 mmHg
Randomized to Cholthalidone vs Amolodipine vs Lisinopril vs Doxazocin [ 1.7 : 1 : 1 : 1 ]
Enrolled 19941998 ; follow-up to 03 /2002
Primary Endpoint : CAD death or non fatal MI

20. ALLHAT – Doxazosin Arm 3.3 years of follow-up Relative Risk for:
All Cardiovascular Events 1.25 ( P< 0.001)
For Stroke ( P = 0.04)
For Heart Failure ( P < 0.001)

22. Hypertension in the Very Elderly Trial (HYVET ) Design
International multicentre trial
Patients ≥ 80 years with HBP
SBP 160 – 199 mmHg
SBP after standing 2 minutes ≥ 140 mmHg
Randomized to Indapamide 1.5 mg OD vs Placebo
Target BP < 150 / 80 mmHg
Can receive Perindopril 2 – 4 mg OD vs placebo
Primary Endpoint: Fatal or non-fatal stroke
Secondary Endpoints : mortality , CVD death,cardiac death, stroke death , fatal / non-fatal CHF
NEJM 358: 1887 (2008)

23. HYVET – Heart Failure Subset Results
64% RRR
NNT = 52 over 2 years
NEJM 358: 1887 (2008)

24. Choosing an Antihypertensive Agent
Most important goal – get the BP down.
More then likely will require ≥ 2 meds
For patients who are at particular risk for symptomatic HF  DIURETICS
For patients with cardiovascular disease or significant CV risk factors  DIURETIC ( ALLHAT) or ACEi (HOPE)
For patients with LVH  OPTIMAL TREATMENT ??? Can consider ACEi or ARB or diuretic
All other patients : path to HF leads thru HTN /LVH and /or MI  INDIVIDUALIZE

25. Prevention of HF in Patients with Cardiovascular Disease
Prevention of ongoing ischemic damage
Risk factor modification ( smoking cessation , lipid-lowering , BP lowering , weight loss , optimization of diabetic management )
“Plaque Stabilization” with statin , ACEi , β-Blockers
Revascularization ( where practical AND possible)
Prevention / “reversal” of LV remodeling

26. ACEi Trials of Primary Prevention
Entry
Drug
HF Result
SAVE
Post MI , Asymptomatic
Captopril
HF Hospitalization by  22%
SOLVD - P
Asymptomatic LVSD
Enalapril
HF  by 37%
TRACE
Post MI , EF <35%
Trandolapril
HF  by 29%
HOPE
Hi Risk for CAD
Ramipril
HF  by 23%

27. SOLVD Prevention Trial Death or Development of CHF
Risk Reduction 29%
p<0.001
Death or Development of CHF  by 29%
Development of CHF  by 37%
CHF hospitalizations  by 44%
N Engl J Med 1992;327:685-91

28. PEACE Trial
Tested addition of ACEi (trandolapril) to usual therapy in stable cardiovascular patients with normal or mildly reduced LVEF plus other risk factors well controlled .
Primary Endpoint : CVD death , MI or need for revascularization - no additional benefit ( p = NS)
Secondary Endpoints:
HF Hospitalization or death : 25% RR ; 3.7% vs 2.8% (p =0.02)
HF Hospitalization: 23% RR ; 3.2% vs 2.5% ( p = 0.05 )
HF Death : 41% RR ; 0.6% vs 0.4% ; p = 0.11

29. Prevention of HF in Patients with Diabetes Mellitus
Diabetes + cardiovascular disease at VERY HIGH RISK for development of heart failure
Diabetes in itself at HIGH RISK for HF development over the longterm.
Must focus on multiple risk factors
BP control critical : ACEi , ARB , Diuretics
Some evidence for glycemic control and  HF eg HF 29% at 1 year post MI in diabetics with tight glycemic control

30. Conclusions / Implications
Development of HF still portends a grim prognosis
HF prevalence epidemic likely to continue
Caused mostly by aging , uncontrolled HTN
Apparent contribution from improved survival with HF
? Contributions from MI survival per se
Effective therapies exist but are under-utilized
Especially for Primary Prevention of HF in HTN
Maximal medical therapy to prevent HF in patients with CV disease / post myocardial infarction also critical

31. Key Targets for Preventing HF
Prevention can be very successful
Weight maintenance , diet and physical activity
Control HTN and prevent LVH
ACEi , CCB , ARB , Thiazides
Prevent progression of ASLVD
Prevent CAD and MI ( 10 and 20 prevention )
In setting of CVS disease or diabetes mellitus, intensive risk-factor modification is warranted.