Chronic heart failure

Yusra Pintaningrum
I. Introduction
Chronic Heart Failure
“How big is the problem?”

Complex clinical syndrome  Highmorbidity, mortality,

with increasing prevalence hospitalization, and
substantial economic burden
Incidence: 10 per 1000
population > 65 years of Death rate: 50% within 5 years
age

Causes:
Diagnostic difficulty
>> CAD (HFREF),
hypertension (HF-PEF)

CAD: coronary arterial disease; HF-REF: Heart failure with reduced ejection fraction;
HF-PEF: Heart failure with preserved ejection fraction
SIGN (2007); Haga et al, 2012; Tierney, 2012; Roger et al (2012)
 ……………..Introduction
Heart Failure Future
Projected Growth of Heart Failure Prevalence
(North America: 2000-2030)

10
Prevalence (in millions

0
2000 2010 2020 2030
Year

“It is estimated that by 2030, an additional 3 million people will

have heart failure, a 25.0% increase in prevalence from 2010”
Roger et al ., 2012
 II. Definition
Chronic Heart Failure – A Syndrome
“ Chronic heart failure (CHF) is a complex clinical
syndrome that can result from any structural or functional
cardiac or non-cardiac disorder that impairs the ability of
the heart to respond to physiological demands for
increased cardiac output”
SIGN (2007)

“HF is defined, clinically, as a syndrome in which patients

have typical symptoms (e.g. breathlessness, ankle
swelling, and fatigue) and signs (e.g. elevated jugular
venous pressure, pulmonary crackles, and displaced apex
beat) resulting from an abnormality of cardiac structure or
function”
McMurray, et al (2012)
 Terminology Related to
Left Ventricular Ejection Fraction

HF with HF with
Reduced LVEF Preserved LVEF

• "HF with a Dilated Left • "HF with a Non-Dilated LV"

Ventricle“ • Signs and symptoms typical
• Signs and symptoms typical • LVEF: Normal or  mildly
• LVEF  • Relevant structural heart
disease and/or diastolic
dysfunction

HF-REF: Heart failure with reduced ejection fraction; HF-PEF: Heart failure with preserved ejection fraction; LVEF: left
ventricular ejection fraction
Lindenfeld, et al ., 2010; McMurray et al., 2012
 Clinical Classifications
New York Heart Association-Functional Classification

Class IV:
Symptoms
at rest and severe
limitations in functional
activity
Class III:
Marked limitation due to symptoms
with less than ordinary activity
Class II:
Symptoms with normal activity
Class I:
No abnormal symptoms with activity
Ho, 1993.
 ACC/AHA Stages of Heart Failure
At Risk for Heart Failure Heart Failure
STAGE A STAGE B STAGE C STAGE D
At high risk for Structural heart Structural heart Refractory HF
HF but without disease but without disease with prior or requiring
structural heart signs or symptoms current symptoms of specialized
disease or of HF HF interventions
symptoms of HF

eg; Patients with: eg; Patients with:

Who have marked
-Hypertension eg; Patients with: symptoms at rest
eg; Patients with:

symptoms of HF at
despite maximal

symptoms of HF
-Atherosclerosis
Development of -Known structural
Heart disease

disease medical therapy

Refractory
-Previous MI
Structural

-Diabetes heart disease (eg; those who are

-LV remodelling

rest
-Obesity and recurrently
including LVH & -Shortness of
-Metabolic syndrome hospitalized or can
low EF breath & fatigue,
or not be solely
-Asymptomatic reduced exercise
Patients: discharged from
valvular disease tolerance
-Using cardiotoxins the hospital
-With FHx CM without specialized
interventions)

Hunt, S.A. et al., 2009

 III. Pathophysiology
Heart failure is a progressive disease following an
“index event.”

60% Compensatory
mechanisms
Ejection Fraction

Secondary
damage

20%
Time (years)
Asymptomatic Symptomatic
Schwinger , 2010
…………Pathophysiology
Myocardial contractility 

Organ perfusion 

Compensatory mechanisms

Renin, Angiotensin II,

Sympathicus Vasopressin Aldosterone

Myocardial β-
Adrenoceptor- Vasoconstriction PVR 
stimulation Na+-H2O-Retention Volume 

Desensitization of
myocardial
adenylatcyclase 
Schwinger, 2010
IV. Diagnosis of Chronic Heart Failure

CHF

History Physical Diagnostic

taking examination tests

SIGN (2007); McMurray, et al (2012)

Framingham system for diagnosis of heart failure
Major Criteria Minor Criteria
Paroxysmal nocturnal dyspnea Nocturnal cough
Weight loss of 4-5 kg in 5 days in response Dyspnea on ordinary exertion
to treatment
Neck vein distention A decrease in vital capasity by one third the
maximal value recorded
Rales Pleural effusion
Acute pulmonary edema Tachycardia (rate of 120 bpm)
Hepatojugular reflux Hepatomegaly
S3 gallop Bilateral ankle edema
Central venous pressure > 16 cm water
Circulation time of 25 sec
Radiographic cardiomegaly
Pulmonary edema, visceral congestion, or
cardiomegaly at autopsy

The diagnosis of heart failure requires that either 2 major criteria or 1

major and 2 minor criteria be present concurrently Ho, K.K., 1993
 Recommendations for The Diagnostic Investigations
Recommendation Class Level
Investigations to consider in all patients

Transthoracic echocardiography : evaluate cardiac structure and function, assist in I C

planning and monitoring of treatment, and obtain prognostic information.
A 12-lead ECG: determine heart rhythm, heart rate, QRS morphology, and QRS duration, I C
and to detect other relevant abnormalities
Blood chemistry: assist in planning and monitoring of treatment, and obtain prognostic I C
information.
A complete blood count: detect anaemia, obtain prognostic information. I C

Natriuretic peptide (BNP, NT-proBNP, or MR-proANP):exclude alternative causes of IIa C

dyspnoea, obtain prognostic information
A chest radiograph (X-ray): detect/exclude certain types of lung disease, identify pulmonary IIa C
congestion/oedema
Investigations to consider in selected patients

CMR: evaluate cardiac structure and function (echocardiography: inconclusive/incomplete I C

Coronary angiography: coronary revascularization, evaluate the coronary anatomy. I C

Myocardial perfusion/ischaemia imaging (echocardiography, CMR, SPECT, or PET) IIa C

Left and right heart catheterization I C

Exercise testing IIa C

McMurray et al., 2012

 Algorithm for The Diagnosis of Chronic Heart Failure
Suspected heart failure

Acute onset Non-acute onset

ECG ECG
Chest x-ray Possibly chest x-ray

Echocardiography BNP/NT-pro BNP BNP/NT-pro BNP Echocardiography

ECG normal and NT- ECG abnormal or NT- ECG abnormal or NT- ECG abnormal or NT-
proBNP<300 pg/mL or proBNP >300 pg/mL or proBNP >125 pg/mL or proBNP <125 pg/mL
BNP < 100pg/mL BNP >100pg/mL BNP > 35pg/mL or BNP <35pg/mL

Heart failure unlikely Heart failure unlikely

Echocardiography

If heart failure confirmed, determine

aetiology and start appropriate treatment McMurray et al., 2012
 V. MANAGEMENT FOR CHF
It’s time to tackle heart failure
 Management Outline CHF

Estimate Choose
Identify
prognosis appropriate
Establish Determine Assess precipitating
and management
Diagnosis Etiology of severity of and
anticipate and monitor
CHF CHF symptoms exacerbating
complica- progress
factor
tion CHF
 MANAGEMENT FOR CHF
G Relieve symptoms and sign

Prevent hospitality
O admission

A Slow disease progress

L Improve survival rate

Reduction mortality and

S hospital admision rate

Mant, 2011; McMurray et al., 2012

 Nonpharmacologic Management
and Health Care Maintenance
in Patients with Chronic Heart Failure
Recommendation
Educating patient and family

Dietary sodium restriction (2-3 g daily) (< 2 g daily: in moderate to severe HF) (SOE: C)

Restriction of daily fluid intake to < 2 liters is recommended in patients with severe hyponatremia
(serum sodium < 130 mEq/L) & all patients demonstrating fluid retention that is difficult to control
(SOE:C)
Nutritional management : ensure adequate intake of the recommended daily value of essential
nutrients (SOE:C)
Continuous positive airway pressure to improve daily functional capacity and quality of life is
recommended in patients with HF and obstructive sleep apnea (SOE: B)
Stress reduction with nonpharmacologic techniques (SOE: C)

Stop smoking and to limit alcohol consumption to ≤ 2 standard drinks per day in men or ≤ 1
standard drink per day in women (SOE: B)
Pneumococcal vaccine and annual influenza vaccination are recommended in all patients with HF in
the absence of known contraindications (SOE: B)
Reguler aerobic exercise (goal :30 minutes of moderate-high intensity/exercise, 3-5 days per week
with warm up and cool down exercises ) (SOE:IA)
Multidisciplinary-care management programme (SOE: IA)

Lindenfeld, et al . , 2010; Lainsack et al., 2011; Piepoli et al., 2011; McMurray, et al., 2012
Pharmacological treatments :
potentially all patients with symptomatic (NYHA functional
class II–IV) systolic HF
Recommendation Class Level Key evidence (trials)
ACE inhibitor: in addition to a beta-blocker, for I A Cooperative North Scandinavian
all patients with an EF ≤40% to risk of HF Enalapril Survival Study
hospitalization and premature death (CONSENSUS) and Studies of Left
Ventricular Dysfunction (SOLVD)
Beta-blocker: in addition to an ACE inhibitor (or I A Cardiac Insufficiency Bisoprolol
ARB if ACE inhibitor not tolerated), for all patients Study II (CIBISII), Carvedilol
with an EF ≤40% to risk of HF hospitalization Prospective Randomized Cumulative
and premature death Survival (COPERNICUS), and
Metoprolol CR/XL Randomised
Intervention Trial in congestive Heart
Failure (MERIT-HF)
MRA:all patients with persisting symptoms I A The Randomized Aldactone
(NYHA class II–IV) and an EF 35%, despite Evaluation Study (RALES)
treatment with an ACE inhibitor (or an ARB if an
ACE inhibitor is not tolerated) and a beta-
blocker, to risk of HF hospitalization and
premature death

ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; EF : ejection fraction; HF: heart failure; MRA :
mineralocorticoid receptor antagonist

McMurray, et al. Eur Heart J 2012

 Diuretics to relieve symptoms/signs of congestion
+
ACE inhibitor (or ARB if not tolerated) (LOE: IA)

ADD a beta-blocker (LOE: IA)

Still NYHA class II–IV?

+ -
ADD a MR antagonist (LOE: IA)

Still NYHA class II–IV? Treatment options for

+ -
LVEF < 35%?
patients with chronic
+
- symptomatic systolic
heart failure
Sinus rhythm and HR >70 beats/min?
+ - (NYHA fc. class II–IV).
ADD ivabradinee McMurray et al., 2012;

Still NYHA class II–IV and LVEF < 35%?

+ -
QRS duration >120 ms?
+ -
Consider Consider ICD
CRT-P/CRT-D

Still NYHA class II–IV?

No further specific treatmentc
-
+ Continue in disease-
Consider digoxin and/or H- management programme
ISDN If end stage, consider
LVAD and/or transplantation
Stages in the Development of Heart Failure/Recommended Therapy by Stage
STAGE A STAGE B STAGE C STAGE D
At high risk for HF but
Structural heart disease but Structural heart disease with Refractory HF requiring
without structural heart
without signs or symptoms of specialized interventions
disease or symptoms of prior or current symptoms of
HF
HF HF

eg; Patients with:

-Hypertension eg; Patients with:
eg; Patients with: eg; Patients with: -Who have marked symptoms at
-Atherosclerosis disease
-Previous MI -Known structural heart rest despite maximal medical
-Diabetes
-LV remodelling including disease and therapy (eg; those who are
-Obesity
LVH & low EF -Shortness of breath & recurrently hospitalized or can
-Metabolic syndrome or
-Asymptomatic valvular fatigue, reduced not be solely discharged from the
Patients: Structural Development Refractory
disease of symptoms of exercise tolerance hospital without specialized
-Using cardiotoxins Heart symptoms of
disease HF HF at rest interventions
-With FHx CM

THERAPY GOALS
THERAPY GOALS -All measures under Stage A THERAPY GOALS
-Treat hypertension &B -Appropriate measures
-Encourage smoking THERAPY GOALS -Dietary salt restriction
-All measures under under Stage A, B,C
cessation DRUGS FOR ROUTINE -Decision re: appropriate
-Treat lipid disorders Stage A USE
DRUGS level of care
-Encourage regular -Diuretics for fluid retention OPTIONS
exercise -ACEI or ARB in -ACEI
appropriate patients -Compassionate end-of-life
-Discourage alcohol -Beta-blockers care hospice
intake, illicit drug use (see text) DRUGS IN SELECTED
-Beta-blockers in -Extraordinary measures:
-Control metabolic PATIENTS -Heart transplant
syndromes appropriate patients -aldosterone antagonist
(see text) -Chronic inotropes
DRUGS -ARBs -Permanent mechanical
- ACEI or ARB in -Digitalis support
appropriate patients -Hydralazine nitrates -Experimental surgery
(see text) for DRUGS IN SELECTED or drugs
vascular disease or PATIENTS
diabetes -Biventricular pacing 20
-Implantable defibrillators
 NICE
recommendation for
treatment of heart
Reduce progression failure

Mant J et al. Ann Intern Med 2011; 155,:252-259

Non Surgical Device Treatment of Heart Failure
with Reduced Ejection Fraction (HF-REF)

• Implantable cardioverter-
defibrillator (ICD)

• Cardiac resynchronization
therapy (CRT)
Non Surgical Device Treatment of HF-REF
1. Implantable cardioverter-defibrillator (ICD)

• Symptomatic HF (NYHA class II–III) and

EF < 35% despite ≥3 months of
treatment with optimal pharmacological
therapy (expected to survive for >1 year
Primary with good functional status)
prevention 
• Ischaemic aetiology & >40 days after
acute myocardial infarction (LOE: IA)
• Non-ischaemic aetiology (LOE: IB)

Ventricular arrhytmia causing

haemodynamic instability
Secondary (expected to survive for >1 year
prevention with good functional status)
(LOE: IA)

McMurray, et al. Eur Heart J 2012;DOI:10.1093/eurheartj/ehs104

2. Cardiac resynchronization therapy (CRT)
Recommendations  patients in sinus rhythm with NYHA functional class III and ambulatory
class IV HF & a persistently reduced EF, despite optimal pharmacological therapy

Recommendations Class Level

LBBB QRS morphology I A

CRT-P/CRT-D : patients in sinus rhythm with a QRS duration of ≥120 ms, LBBB QRS
morphology, and an EF ≤35% (are expected to survive with good functional status for >1 year)
Non-LBBB QRS morphology IIa A
CRT-P/CRT-D : patients in sinus rhythm with a QRS duration of ≥150 ms, irrespective of QRS
morphology, and an EF ≤35% (are expected to survive with good functional status for >1 year),

Recommendations  patients in sinus rhythm with NYHA functional class II HF and a persistently
reduced EF despite optimal pharmacological therapy

Recommendations Class Level

LBBB QRS morphology I A

CRT, preferably CRT-D: patients in sinus rhythm with a QRS duration of ≥130 ms, LBBB QRS
morphology, and an EF ≤30% (are expected to survive for >1 year with good functional status)
Non-LBBB QRS morphology IIa A
CRT, preferably CRT-D: patients in sinus rhythm with a QRS duration of ≥150 ms, irrespective
of QRS morphology, and an EF ≤30%, who are expected to survive for >1 year with good
functional status,

  risk of HF hospitalization and the risk of premature death

McMurray, et al. Eur Heart J 2012;DOI:10.1093/eurheartj/ehs104
 Surgical Approaches to Heart Failure
• It is recommended that the decision to undertake
surgical intervention for severe HF be made in light
of functional status and prognosis based on severity
of underlying HF & co-morbid conditions

• Procedures should be done at centers with

demonstrable expertise, multidisciplinary medical
and surgical teams experienced in the selection,
care, and perioperative and long-term management
of high risk patients with severe HF
Strength of Evidence = C

Lindenfeld, et al . J Card Fail 2010;16:475-539; McMurray, et al. Eur Heart J 2012;DOI:10.1093/eurheartj/ehs104

 Surgical Approaches to Heart Failure
Recommendation Class level
Myocardial - Angina and significant left main stenosis, who are otherwise suitable I C
revascularization for surgery and expected to survive >1 year with good functional
(CABG) status, to  the risk of premature death
- Angina and two- or three-vessel coronary disease, including a left I B
anterior descending stenosis, who are otherwise suitable for surgery
and expected to survive >1 year with good functional status, to  the
risk of hospitalization and premature death from cardiovascular
causes
- PCI may be considered as an alternative to CABG in the above IIb C
categories of patients unsuitable for surgery

Ventricular - Restoring a more physiological LV volume and shape

reconstruction - Uncertain and not shown to be of benefit in STICH  not
recommended for routine use
Valvular surgery -Aortic valve repair or replacement is recommended in all symptomatic
patients with severe AR dan EF<50%
- Isolated mitral valve repair or replacement for severe mitral
regurgitation secondary to ventricular dilatation in the presence of C
severe LV systolic dysfunction is not generally recommended
Heart transplantation End-stage heart failure with severe symptoms, a poor prognosis, and
no remaining alternative treatment options
Mechanical circulatory Patients awaiting heart transplantation who have become refractory to B
support all means of medical circulatory support should be considered for a
mechanical support device as a bridge to transplant
CABG: coronary artery bypass graft; EF: ejection fraction; HF:heart failure; LV: left ventricular; PCI: percutaneous coronary
intervention
Lindenfeld, et al . J Card Fail 2010;16:475-539; McMurray, et al. Eur Heart J 2012;DOI:10.1093/eurheartj/ehs104
Chronic heart failure is a common,
complex syndrome with poor prognosis

Diagnosis and the optimum approach of

CHF remains a challenge

Optimization of medical treatment with

holistic management and multidisciplinary
care approach for people with CHF
improves quality of live, reduce
hospitalisation rates and prolongs survival
THANKYOU