Heart Failure: Living with a

Hurting Heart
James T. DeVries, MD
Dartmouth-Hitchcock Medical
Center

Outline
Definitions and scope of problem
Diagnosing and classifying heart failure
Approach to management of CHF
Oral drug therapy (ACE-I, ARB, betablockers,
aldosterone blockade, digoxin)
Device therapy
Biventricular (BiV) pacers
Intracardiac defibrillators (ICDs)

Future directions and exciting

developments

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 8th Edition, 2001

Congestive Heart Failure

Symptoms:
Shortness of breath
Leg swelling (edema)
Breathing worsens with lying flat (orthopnea)
Fatigue

Anatomy 101

A normal heart pumps blood in a smooth and

synchronized way.

Heart Failure
Heart

A heart failure heart has a reduced ability to

pump blood.

Types of Heart Failure

Systolic (or squeezing) heart failure
Decreased pumping function of the heart, which
results in fluid back up in the lungs and heart failure

Diastolic (or relaxation) heart failure

Involves a thickened and stiff heart muscle
As a result, the heart does not fill with blood properly
This results in fluid backup in the lungs and heart
failure

Risk Factors for Heart Failure

Coronary artery
Diabetes
disease
Congenital heart defects
Hypertension (LVH)
Valvular heart disease Other:
Obesity
Alcoholism
Age
Infection (viral)
Smoking

High or low hematocrit level

Obstructive Sleep Apnea
CAD=coronary artery disease; LVH=left ventricular hypertrophy.

Epidemiology of Heart Failure

in the US
Heart Failure Patients in US
(Millions)

12

10

More deaths from heart failure

than from all forms of cancer
combined

550,000 new cases/year

10

4.7

4.7 million symptomatic

patients; estimated 10 million
in 2037

3.5

2
0
1991

2000

2037*

*Rich M. J Am Geriatric Soc. 1997;45:968974.

American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

Wow! Brazil is big."

George W. Bush, after being shown a
map of Brazil by Brazilian president Luiz
Inacio Lula da Silva, Brasilia, Brazil, Nov.
6, 2005

Classifying Heart Failure:

Terminology and Staging

A Key Indicator for Diagnosing Heart

Failure
Ejection Fraction (EF)
Ejection Fraction (EF) is the percentage of blood
that is pumped out of your heart during each
beat

Classification of HF: Comparison

Between ACC/AHA HF Stage and
NYHA Functional Class
ACC/AHA HF Stage1

NYHA Functional Class2

None

A At high risk for heart failure but without

structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
B Structural heart disease but without
symptoms of heart failure

C Structural heart disease with prior or

current symptoms of heart failure

D Refractory heart failure requiring

specialized interventions

Asymptomatic

II Symptomatic with moderate exertion

III Symptomatic with minimal exertion
IV Symptomatic at rest

Hunt SA et al. J Am Coll Cardiol. 2001;38:21012113.

New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890897.

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)

Pathophysiology

Pathologic Progression of CV Disease

Sudden
Death

Coronary artery
disease
Hypertension
Diabetes

Myocardial
injury

Pathologic
remodeling

Low ejection
fraction

Cardiomyopathy

Death

Pump
failure

Valvular disease

Neurohormonal
stimulation
Myocardial
toxicity

Adapted from Cohn JN. N Engl J Med. 1996;335:490498.

Symptoms:
Dyspnea
Fatigue
Edema

Chronic
heart
failure

Compensatory Mechanisms:

Renin-Angiotensin-Aldosterone System
Beta
Stimulation
CO
Na+

Renin + Angiotensinogen
Angiotensin I
ACE
Angiotensin II

Peripheral
Vasoconstriction

Kaliuresis
Aldosterone Secretion
Salt & Water Retention
Plasma Volume

Afterload
Cardiac Output

Heart Failure

Fibrosis

Preload
Cardiac Workload

Edema

Drug Therapy

Heart Failure Treatments:

Medication Types
Type
ACE inhibitor
(angiotensin-converting
enzyme)

What it
does
Expands blood vessels which
lowers blood pressure,
neurohormonal blockade

ARB (angiotensin
receptor blockers)

Similar to ACE inhibitor

lowers blood pressure

Betablocker

Reduces the action of stress

hormones and slows the heart
rate
Slows the heart rate and improves
the hearts pumping function (EF)

Digoxi
n
Diuretic
Aldosterone
blockade

Filters sodium and excess fluid from

the blood to reduce the hearts
workload
Blocks neurohormal activation and

Rational for Medications

(Why does my doctor have me on
so many pills??)
Improve Symptoms
Diuretics (water pills)
digoxin

Improve Survival

Betablockers
ACE-inhibitors
Aldosterone blockers
Angiotensin receptor
blockers (ARBs)

Lifestyle Changes
What

Why

Eat a low-sodium, lowfat diet

Sodium is bad for high blood

pressure, causes fluid retention

Lose weight

Extra weight can put a

strain on the heart

Stay physically active

Exercise can help reduce

stress and blood pressure

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

"During my service in the United States

Congress, I took the initiative in creating the
Internet"
Al Gore said when asked to cite
accomplishments that separate him from another
Democratic presidential hopeful, former Sen. Bill
Bradley of New Jersey, during an interview with
Wolf Blitzer on CNN on March 9, 1999.

Device Therapy:
Biventricular Pacing

Biventricular Pacing
Ventricular Dysynchrony
Abnormal ventricular conduction resulting
in a mechanical delay and dysynchronous
contraction

Overview of Device Therapy

25

BiV Pacing

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

Defibrillators (ICDs)

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

How does a defibrillator for

sudden cardiac death work?
Device
Shown:
Combination
Pacemaker
&
Defibrillator

Implantable Cardiac Defribrillators

EBM Therapies

Relative Risk
Reduction

Mortality
2 year

ACE-I

23%

27%

-Blockers

35%

12%

Aldosterone
Antagonists

30%

19%

ICD

31%

8.5%

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;

Other Therapies?
Transplant
Artificial hearts
New gadgets to help doctors manage
heart failure

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.

Worldwide Heart Transplants

Newer Generation Artificial Hearts

Future Tech

Intrathoracic Impedance for Heart

Failure

One of the Best Devices for

Monitoring Heart Failure

What have we learned?

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, ICDs

Transplants remain rare, but technology for

mechanical assist devices continues to improvestay tuned!