1. Heart Failure: Living with a Hurting Heart

2. Congestive Heart Failure Heart (or cardiac) failure is the state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only from high pressures Braunwald 8 th Edition, 2001

3. Heart Failure Heart A heart failure heart has a reduced ability to pump blood.

4. CAD=coronary artery disease; LVH=left ventricular hypertrophy. Risk Factors for Heart Failure Coronary artery disease Hypertension (LVH) Valvular heart disease Alcoholism Infection (viral) Diabetes Congenital heart defects Other: –Obesity –Age –Smoking –High or low hematocrit level –Obstructive Sleep Apnea

5. Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class 1 Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897. ACC/AHA HF Stage 1 NYHA Functional Class 2 AAt high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) BStructural heart disease but without symptoms of heart failure CStructural heart disease with prior or current symptoms of heart failure DRefractory heart failure requiring specialized interventions I Asymptomatic II Symptomatic with moderate exertion IV Symptomatic at rest III Symptomatic with minimal exertion None

6. How Heart Failure Is Diagnosed Medical history is taken to reveal symptoms Physical exam is done Tests –Chest X-ray –Blood tests –Electrical tracing of heart (Electrocardiogram or “ECG”) –Ultrasound of heart (Echocardiogram or “Echo”) –X-ray of the inside of blood vessels (Angiogram)

7. Heart Failure Treatments: Medication Types ACE inhibitor (angiotensin-converting enzyme) ARB (angiotensin receptor blockers) Beta-blocker Digoxin Diuretic Aldosterone blockade Type What it does Expands blood vessels which lowers blood pressure, neurohormonal blockade Similar to ACE inhibitor—lowers blood pressure Reduces the action of stress hormones and slows the heart rate Slows the heart rate and improves the heart’s pumping function (EF) Filters sodium and excess fluid from the blood to reduce the heart’s workload Blocks neurohormal activation and controls volume

8. Device Therapy: Biventricular Pacing

9. Overview of Device Therapy9 Biventricular Pacing Ventricular Dysynchrony Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction

10. BiV Pacing

12. Cardiac Resynchronization Therapy Key Points Indications –Moderate to severe CHF who have failed optimal medical therapy –EF<30% –Evidence of electrical conduction delay Timing of Referral Important –Patients often not on optimal Medical Rx –Patients referred too late- Not a Bail Out

13. Defibrillators (ICD’s)

14. Heart Failure and Sudden Cardiac Death Sudden Cardiac Death (SCD) –Your heart suddenly goes into a very fast and chaotic rhythm and stops pumping blood –Caused by an “electrical” problem in your heart –SCD is one of the leading causes of death in the U.S. – approximately 450,000 deaths a year –Patients with heart failure are 6-9 times as likely to develop sudden cardiac death as the general population

15. How does a defibrillator for sudden cardiac death work? Device Shown: Combination Pacemaker & Defibrillator

16. Implantable Cardiac Defribrillators EBM TherapiesRelative Risk Reduction Mortality 2 year ACE-I 23% 27% Β-Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8.5%

17. Who should Consider an ICD? Patients with weakend heart, New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) < 35% Patients who meet all current requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure;

18. Other Therapies? Transplant Artificial hearts New “gadgets” to help doctors manage heart failure

19. Heart Transplantation A good solution to the failing heart– get a new heart Unfortunately we are limited by supply, not demand Approximately 2200 transplants are performed yearly in the US, and this number has been stable for the past 20 years.

20. Worldwide Heart Transplants

21. Newer Generation Artificial Hearts

22. Future Tech

23. Intrathoracic Impedance for Heart Failure

25. One of the Best Devices for Monitoring Heart Failure

26. What have we learned?

27. In Summary…. Heart failure is common and has high mortality Drug therapy improves survival –Betablockers, ACE-I, aldosterone antagonists Newer device therapies are showing promise for symptom relief and improved survival –Biventricular pacing, ICD’s Transplants remain rare, but technology for mechanical assist devices continues to improve- stay tuned!