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MORTALITY
50% of heart failure patients die
within 5 years from diagnosis.5
NEUROHUMORAL
IMBALANCE
The systemic responses in the renin–angiotensin–aldosterone and sympathetic nervous systems cause further
myocardial injury, and have detrimental effects on the blood vessels, and various organs, thereby creating a
pathophysiological ‘vicious cycle’. The natriuretic peptide system has a protective function, which can counterbalance
these detrimental effects.
Symptoms Signs
Typical More specific
Stage B Developed structural heart disease strongly Class II Slight limitation of physical activity. Comfortable
associated with development of HF, but at rest, but ordinary physical activity results in
without signs or symptoms HF symptoms
Stage C Symptomatic HF associated with underlying Class III Marked limitation of physical activity.
structural heart disease Comfortable at rest, but less than ordinary
activity results in HF symptoms
Stage D Advanced structural heart disease and Class IV Symptoms of HF present at rest. If any physical
marked symptoms of HF at rest, despite activity is undertaken, discomfort is increased
maximal medical therapy
environmental
determinants
LVH
Diastolic
Diastolic Heart Failure
Dysfunction
physical CVD risk factors Disturbed
activity ↓ & biomarkers Microcirculation
Systolic Systolic
Dysfunction Heart Failure
CAD / Infarktion
genetic determinants
Myocardial Remodeling
Stage A B C/D
*P<0.05 vs controls
HFpEF
stable angina & hypertension
hypertension
hypertension
hypertension
diabetes
hypertension
hypertension, very elderly
Outcomes of patients
with HFpEF as
Per 1000 patient years
Hypertension
hypertension
very elderly
Outcomes of patients
with HFpEF as
compared with those
in trials of other
Per 1000 patient years
cardiovascular
disease, with similar
ages, sex and
comorbidities profiles
HFpEF: heart failure with preserved ejection fraction, HFmEF : heart failure with mid-range ejection frection
Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200; McMurray et al. Eur Heart J 2012;33:1787–847;
Dickstein et al. Eur Heart J 2008;29:2388–442
21
Etiology
LV=left ventricular
McMurray. N Engl J Med 2010;362:228–38; Francis et al. Ann Intern Med 1984;101:370–7; Krum, Abraham. Lancet 2009;373:941–55
23
PATHOGENESIS OF HEART FAILURE
EVOLVING HEART FAILURE
25
CHRONIC HEART FAILURE : NEUROHORMONAL STATUS
DILATATION
CONSTRICTION
26
New York Heart Association (NYHA)
Heart Failure Symptom Classification
NYHA CLASS LEVEL of IMPAIRMENT
III
Exercise Limited by Dyspnea at Mild Work
Loads (ie. Short Distance Walking,
Climbing One Flight of Stairs)
IV Dyspnea at Rest or
With Very Little Exertion
27
ACC / AHA Classification of CHF
STAGE DESCRIPTION
A
High Risk For Hypertension, Diabetes Mellitus, CAD,
Developing Heart Family History of Cardiomyopathy
Failure
CONTRACTILITY
PRELOAD AFTERLOAD
STROKE
VOLUME
CARDIAC OUTPUT
Comorbidities in HF
Comorbidities impact prognosis in patients with HF1,2
Diabetes mellitus
Renal Anaemia
dysfunction Cachexia
Obesity
Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688
Section
Summary
• The global burden of HF is increasing in number and complexity, due to an aging patient population,
often with multiple comorbidities. Reducing readmissions can limit the burden for healthcare systems.
• There are many causes of HF that result in ventricular remodeling, reduction of the left ventricular
ejection fraction, and neurohumoral imbalance.
• Many of the symptoms of HF are non-specific. HF severity can be classified based on structure and
damage to heart (ACC/AHA) or based on symptoms or physical activity (NYHA). HF is a silently
progressive condition.
• HFrEF and HFpEF may present similarly within the clinical syndrome of HF. Half of patients have
HFpEF. Outcomes in HFpEF patients are worse than in similar patient populations with other
cardiovascular disease
• HF has a large impact on quality of life, including physical activities and psychological distress.
Comorbidities impact prognosis in patients with HF.
Activation of
RAS and ANS
Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688
Principles of diagnosis of HF
All diagnostic steps are equally important
• Stress echocardiography
Detailed workup in case • Invasive tests & hemodynamics
B of uncertainity
• Cardiac MRI
• Comorbidities
ECG normal and ECG abnormal or ECG abnormal or ECG normal and
NT-proBNP < 300pg/mL NT-proBNP > NT-proBNP > 125 NT-proBNP <
or 300pg/mLbb or pg/mLaa or 125pg/mL or
BNP < 100 pg/mL BNP > 100 pg/mL bb BNP > 35 pg/mL aa BNP < 35 pg/mL
HF unlikely cc
HF unlikely cc
Echocardiography
*In the acute setting, MR-proANP may also be used (cut-off point 120 pmol/L, i.e. <120 pmol/L = heart failure unlikely).
a.Exclusion cut-off points for natriuretic peptides are chosen to minimize the false-negative rate while reducing unnecessary referrals for echocardiography.
b.Other causes of elevated natriuretic peptide levels in the acute setting are an acute coronary syndrome, atrial or ventricular arrhythmias, pulmonary embolism, and severe chronic obstructive
pulmonary disease with elevated right heart pressures, renal failure, and sepsis. Other causes of an elevated natriuretic level in the non-acute setting are:
old age (>75 years), atrial arrhythmias, left ventricular hypertrophy, chronic obstructive pulmonary disease, and chronic kidney disease.
c. Treatment may reduce natriuretic peptide concentration, and natriuretic peptide concentrations may not be markedly elevated in patients with HF-PEF.
Normal or mildly reduced LV systolic function (LVEF >50% and LVEDVI <97 mL/m 2)
HFpEF
Paulus et al. Eur Heart J 2007;28:2539–50
Particular relevance of BNP
• diagnosis
• staging
• risk stratification
• monitor/titrate therapy
• admission/discharge decisions:
> rule out symptomatic LV dysfunction
Diagnosis of HF
• Adequate diagnosis of HF includes screening for cardiac dysfunction in
patients at risk, confirming the clinical suspicion with objective diagnostic
measures, and identifying the underlying phenotype and aetiology.
• The diagnosis of HFpEF is more difficult than the diagnosis of HFrEF because
it is largely one of exclusion.
Therapy
Therapy goals Therapy
Therapy goals Therapy
Therapy goals Therapy
goals goals goals Therapy goalsgoals
Treat All All
Treat hypertension
hypertension All measures
measures under
under All measures
measures under
under Stages
Stages A
A Appropriate
Appropriate measures
measures
Encourage Stage
Stage A and
and B
Encourage smoking
smoking cessation
cessation A B under
under Stages
Stages A,
A, B,
B, C
C
Development of symptoms of HF
Dietary salt restriction
Encourage
Drugs
Drugs Decision re: appropriate
Decision re: appropriate
Encourage regular
regular exercise
exercise ACEIs
ACEIs or
or ARBs
ARBs in
in appropriate
appropriate Drugs
Drugs for for routine
routine useuse level
level of
of care
care
Structural heart disease
Discourage
Discourage alcohol
alcohol intake, patients Diuretics
illicit drug use
intake, patients Diuretics for
for fluid
fluid retention
retention
illicit drug use β-blockers in appropriate ACEIs Options
Options
β-blockers in appropriate ACEIs
Control
Control metabolic
metabolic syndrome
syndrome patients
patients β-blockers
β-blockers Compassionate
Compassionate end-of-life
end-of-life
Drugs Devices care/hospice
care/hospice
Drugs Devices inin selected
selected patients
patients Drugs
Drugs in in selected
selected patients
patients
ACEIs
ACEIs or
or ARBs
ARBs inin appropriate
appropriate Implantable
Implantable defibrillators
defibrillators Aldosterone
Aldosterone antagonists Extraordinary
Extraordinary measures
measures
patients antagonists
patients for
for vascular
vascular disease
disease or
or ARBs Heart
Heart transplant
transplant
diabetes ARBs
diabetes Chronic
Digitalis
Digitalis Chronic inotropes
inotropes
Hydralazine/nitrates
Hydralazine/nitrates Permanent
Permanent mechanical
mechanical
Devices support
support
Devices inin selected
selected patients
patients
Biventricular Experimental
Experimental surgery
surgery or
Biventricular pacing
pacing or
Implantable
Implantable defibrillators
defibrillators drugs
drugs
CCBs YES NO
Beta-blockers NO YES
ACEIs NO YES
ARBs NO YES
MR antagonists NO YES
Ivabradine NO YES
Digoxin NO YES
H-ISDN NO YES
ARNIs PARAGON-HF study YES
ADD a beta-blocker
YES NO
LVEF ≤ 35% ?
YES NO
SR and HR ≥ 70
beats/min ? NO
No further specific treatment
Continue in disease-management
YES
programme
ADD ivabradine
YES NO
YES NO
YES
Consider digoxin and/or H-ISDN
If end stage, consider LVAD and/or transplantation
This study examined the individual and incremental clinical effectiveness of guideline-recommended therapies for patients with HF and reduced
LVEF.
ORs for 24-month mortality associated with the number of guideline-recommended therapies received at baseline.
Analysis includes all patients from the case-control population (N=4128). The number (%) of patients receiving each number of therapies at
baseline was as follows: 0 or 1, 238 (5.8%); 2, 712 (17.3%); 3, 1327 (32.2%); 4, 1123 (27.2%); and 5, 6, or 7, 728 (17.6%).
(-28% to -49%) (-54% to -71%) (-68% to -81%) (-75% to -86%) (-77% to -88%) (-72% to -87%)
P<0.0001 P<0.0001 P<0.0001 P=0.0038 P=0.1388 P=0.1208
Management
Management Adequate treatment of hypertension
of
ofunderlying
underlying Adequate treatment of myocardial ischaemia
disease
disease
McMurray et al. Eur Heart J 2012;33:1787–847
Components
• Optimized medical and device management
• Adequate patient education, with special emphasis on adherence and self-care
• Patient involvement in symptom monitoring and flexible diuretic use
• Follow-up after discharge
• Increased access to healthcare
• Facilitated access to care during episodes of decompensation
• Assessment of (and appropriate intervention in response to) an unexplained increase in
weight, nutritional status, functional status, quality of life, and laboratory findings
• Access to advanced treatment options
• Provision of psychosocial support to patients and family and/or caregivers McMurray et al. Eur Heart J 2012;33:1787–847
Summary: HF Guidelines
• ACE-inhibitors, beta-blockers and mineralocorticoid receptor antagonists
form the cornerstone of HF therapy, given their mortality benefit. Incremental
addition of treatments is recommended as HF progresses: Adding therapies
is adding life.
• The ESC guidelines also recommend regular aerobic exercise and enrolment
in care-management programmes.
Recommendations therapy for HF
stage B
Yance, SW, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol 2013;62:1495–539.
Yance, SW, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College
Yance, SW, et al. 2013 ACCF/AHA guideline for t
management of heart failure: executive summa
report of the American College of Cardiology
Foundation/American Heart Association Task Fo
on Practice Guidelines. J Am Coll Cardiol
2013;62:1495–539.
Yance, SW, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol 2013;62:1495–539.
Acute Heart Failure