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Congestive Heart Failure The Road to Recovery Philip D Houck M.D.

Congestive Heart Failure The Road to Recovery Philip D Houck M.D. This slide means this is a big expensive problem. 50% dead in 5 years as bad as Cancer. Don’t panic our new therapies are making recovery and a good life common. Common Causes of Heart Failure: Hypertension Diabetes

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Congestive Heart Failure The Road to Recovery Philip D Houck M.D.

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  1. Congestive Heart FailureThe Road to RecoveryPhilip D Houck M.D.

  2. This slide means this is a big expensive problem

  3. 50% dead in 5 years as bad as Cancer Don’t panic our new therapies are making recovery and a good life common

  4. Common Causes of Heart Failure: • Hypertension • Diabetes • Cholesterol trouble • Valvular heart disease - leaky or stenotic valves • Coronary or peripheral vascular disease • History or symptoms of sleep-disordered breathing – Too fat to breathe while asleep • Heart attacks • Idiopathic (too dumb to know why) • Many others

  5. Exposure to cardiotoxic agents • Current and past alcohol consumption • Smoking • Collagen vascular disease • Exposure to sexually transmitted diseases • Thyroid disorder • Pheochromocytoma • Obesity

  6. Diversion to coronary disease Heart attackscauseHeart Failure

  7. What is missing?

  8. Ackerman 77% trauma with CAD25 years of age

  9. Heart attack in the making

  10. Pizza Lecture

  11. How can we helpA Broken Heart ? • Nutrition “ Salt is your enemy “ • Exercise 1 hour per day • Stop Smoking • Medications including Statins • Devices $ • Fancy procedures $$$

  12. How does heart muscle work? • Preload • Afterload • Contractility Squeeze • Compliance Filling • Neuroendocrine • Geometry Synchronization • Properties of Blood Vessels

  13. How does heart muscle work? • Preload Water pill • Afterload Blood pressure pill • Contractility Digoxin • Compliance Spironolactone • Neuroendocrine Beta Blocker ACEI • Geometry Synchronization • Properties of Blood Vessels Medications Pacemakers Exercise

  14. Neuroendocrine

  15. Moderators of Cell death • Lipophilic Beta Blockers • Ace Inhibitors • Ace Blockers AT1 • Spironolactone • Statin’s • Lack of Stem cells

  16. Geometry

  17. ECG depicting cardiac resynchronization Cardiac Resynchronization Therapy • Cardiac resynchronization, in association with an optimized AV delay, improves hemodynamic performance by forcing the left ventricle to complete contraction and begin relaxation earlier, allowing an increase in ventricular filling time. • Coordinate activation of the ventricles and septum. ECG depicting IVCD Overview of Device Therapy

  18. Ventricular Dysynchrony

  19. Proposed Mechanisms of Cardiac Resynchronization • Improved Contraction Pattern • AV Interval Optimization Click to Start/Stop

  20. Proposed Mechanisms of Cardiac Resynchronization • AV Interval Optimization • Reduces mitral regurgitation1,2,3 • Increases diastolic filling time • Improves LV dP/dt Click to Start/Stop 1 Nishimura et al. J Am Coll Cardiol.1995; 25:281. 2 Walker et al. Europace 2000;I(suppl D): abstract 212/5. 3 Brecker et al.Lancet. 1992;340:1308.

  21. Electro-Myocardial Coupling • The variables that determine QRS duration are ventricular size and depolarization propagation velocity. • Propagation velocity has two components a circumferential (perpendicular) and axial (parallel). • The axial velocity must be faster since it has a greater distance to travel. The axial velocity parallel to conduction fibers has been experimentally shown to be higher than the circumferential velocity perpendicular to the conduction fibers. The larger the fiber the greater the velocity

  22. The Dilated Heart – Perpendicular Propagation velocity 96 cm/sec Axial Propagation velocity 84 cm/sec • The Normal Heart - Perpendicular Propagation velocity 106 cm/sec Axial Propagation velocity 125 cm/sec • Axial velocity is always faster than perpendicular velocity in normal heart • In dilated myopathy this is not true heart becomes sphereical

  23. Dilated cardiomyopathy with QRS widening is a slowing of axial electrical propagation velocity which causes the heart to remodel. The heart becomes larger and further increases the propagation times because the fibers become smaller from the stretch. • Explain Narrow complex dilated myopathy

  24. Systolic versus Diastolic Heart failure(Squeeze) (Filling) Normal Heart recovered

  25. Systolic versus Diastolic Heart failure(Squeeze) (Filling) Systolic dysfunction bad squeeze

  26. Systolic versus Diastolic Heart failure(Squeeze) (Filling) Diastolic dysfunction increased pressure to fill

  27. Determinants of Myocardial Performance • Preload - The stretch of the myocardium • How do we decrease Preload? GravitySit up, Stand up, Phlebotomy Venodilators NTG Natrecor Morphine Diurectics Lasix

  28. Determinants of Myocardial Performance • Afterload - The resistance to flow. The size of the arterioles.

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