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Heart Failure

Heart Failure. Claire B. Hunter, MD. Heart Failure is the inability of the heart to pump sufficient blood to the body tissue to meet ordinary metabolic demands. Heart Failure. 400,000 new cases annually 5 million Americans have congestive heart failure 200,000 deaths annually

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Heart Failure

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  1. Heart Failure Claire B. Hunter, MD

  2. Heart Failure is the inability of the heart to pump sufficient blood to the body tissue to meet ordinary metabolic demands.

  3. Heart Failure • 400,000 new cases annually • 5 million Americans have congestive heart failure • 200,000 deaths annually • Leading hospital dismissal diagnosis after age 65 • Cost over 20 billion dollars annually

  4. Heart Failure • Incidence 10/1000 over age 65 • Heart failure most common discharge group diagnosis • Direct and indirect costs $27.9 billion dollars in 2005 • $2.9 billion annually for drugs for treatment of heart failure

  5. Readmission after Hospitalization forHF Among Medicare Beneficiaries • 17,448 survivors of hospitalization for CHF • 7,596 re-hospitalized at least once in 6 months (44%) • 2,855 re-hospitalized at least twice in 6 months *16%) • Risk Factors: Age >75, Male, Admission in previous 6 months, Co-morbidities, LOS >7 days • Krumholtz et al. Arch of Internal Med 1997;157:99-104

  6. Factors Leading to the Increased Incidence of Heart Failure • Successful therapies for other cardiovascular diseases • Lytics: Decreased deaths due to Myocardial Infarction • Implantable Cardioverter Defibrillators: Decreased deaths due to arrhythmias • Statins: Decreased deaths due to Coronary Artery Disease • Advancing age of the population

  7. 6-year Mortality (Framingham) • 82% in men (29% sudden death) • 67% in women (13% sudden death)

  8. Some Factors Influencing the Progression of Heart Failure • History of Hypertension • Development of Left Ventricular Hypertrophy • Ischemia / Myocardial Infarction • Neurohormonal Activation

  9. CHF: Prognosis • Etiology • LV function • Therapy

  10. Heart Failure • Hypertension • Coronary artery disease

  11. Table 1 continued

  12. CHF: Etiologic Classification • Direct myocardial damage • Pressure/volume overload • LV filling restriction

  13. CHF due to direct myocardial damage • Ischemic cardiomyopathy: Extensive or multiple Mis with or without ventricular aneurysms • Nonischemic cardiomyopathy: The result of myocardial toxins (alcohol or adriamyacin)

  14. CHF due to pressure or volume overload • Pressure overload • Aortic stenosis • Hypertension • Coarctation of the aorta • Volume overload • Mitral regurgitation • Aortic regurgitation • Patent ductus arteriosus • Ventricular septal defect

  15. Conditions restricting ventricular filling • Mitral stenosis • Atrial myxoma (obstructing mitral or tricuspid orifice) • Pericardial restriction or constriction • Restrictive or infiltrative cardiomyopathy • Sarcoidosis • Amyloidosis • Hemochromatosis • Hypertrophic cardiomyopathy

  16. Diastolic Heart Failure • Resistance to filling one or both ventricles • Increased ventricular filling pressures • Congestive symptoms • Normal systolic function

  17. Diastolic Dysfunction • 40-50% of Heart Failure over age 70 • Most common cause • LV hypertrophy • Hypertensive heart disease

  18. Compensatory Factors in Congestive Heart Failure • Acute • Increased stroke volume due to passive cardiac muscle stretch (Frank-Starling mechanism) • Increased heart rate (cardiac output = stroke volume x heart rate) • Increased contractility (sympathetic tone and circulating catecholamines) • Chronic • Hypertrophy

  19. Symptoms of CHF related todeficiencies of cardiac performance CHF = Cardiac output +  Ventricular filling pressure Hypoperfusion  RA pressure  LA pressure Fatigue Dependant Breathlessness edema

  20. Major criteria for cardiac failure • Paroxysmal nocturnal dyspnea • Neck vein distention • Rales • Cardiomegaly • Acute pulmonary edema • S3 gallop • Increased venous pressure (>6 cm H2O • Hepatojugular reflux • Weight loss > 4.5 kg over 5 days in response to treatment

  21. Minor criteria for cardiac failure • Ankle edema • Night cough • Dyspnea on exertion • Hepatomegaly • Pleural effusion • Vital capacity reduced 1/3 from maximum • Tachycardia > 120 bpm • Weight loss > 4.5 kg over 5 days in response to treatment

  22. Norepinephrine Angiotensin II Aldosterone Endothelin Vasopressin Atrial + B type naturatic peptides Nitric oxide Prostacyclin Bradykenin Balancing Act Vasoconstrictors Vasodilators

  23. Evaluations ToolsEchocardiogram • To evaluate LV diastolic abnormalities • LV systolic function • Valvular abnormalities

  24. Evaluation cont’l Ischemia evaluation Dobutamine or Nuclear “Stress” not when wet

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