1. 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

2. 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

3. 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 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%

4. 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):

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

6. 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)

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. Diagnosis of Heart Failure

14. Treatment of Heart Failure

15. 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

16. 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

17. 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.

18. 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