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Heart Failure
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Overview

HF is a complex clinical
Abnormality of cardiac
syndrome that results
structure or function
from any structural/
leading to failure of heart
functional impairment of
to deliver O2 required for
ventricular filling/ blood
metabolizing tissues1
ejection

HF with reduced EF
Cardinal manifestation:
(HFrEF) & preserved EF
dyspnea & fatigue
(HFpEF)2

1. McMurray JJV, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012.
AB

European Journal of Heart Failure. 2012; 14: P 803-869.


2. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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Epidemiology

Incidence increases 5.1 million persons


with age (20/1,000 in the US have
at age 65-69 yo to clinically manifest
>80/1,000 >85 yo) HF

Absolute mortality
rates for HF remain Incidence in USA is
approximately 50% approximately 2-
within 5 years of 5/1,000 per year
diagnosis1

Both risk factors &


cardiac
Men > Women2
abnormalities are
associated with HF1
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
2. Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart ailure. Nat Rev. Cardiol. 2011; 8; P 30-41.
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Risk Factors

Hypertension
• Especially elevated diastolic pressure (isolated hypertension)
• The incidence of HF is greater with higher levels of blood
pressure, older age & longer duration of hypertension
Diabetes mellitus
• Obesity & insulin resistance are important risk factors

Metabolic syndrome
• Abdominal adiposity, hypertriglyceridemia, low high-density
lipoprotein, hypertension, and fasting hyperglycemia
• Prevalence of metabolic syndrome at age < 20 exceeds 20%
and 40% at age > 40

Atherosclerotic disease
• Coronary, cerebral, or peripheral blood vessels1
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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Cardiac Structural Abnormalities &
Other Causes of HF
Dilated cardiomyopathies
•Ventricular dilation & depressed myocardial contractility

Familial cardiomyopathies

Endocrine & metabolic causes of cardiomyopathy


•Obesity, DM, thyroid disease, acromegaly and GH deficiency

Toxic cardiomyopathy
•Alcohol, cocaine, cancer therapies (anthracycline)

Tachycardia-induced cardiomyopathy

Myocarditis & cardiomyopathies due to inflammation

Inflammation-induced cardiomyopathy
•Hypersensitivity myocarditis, rheumatological/ connective tissue disorders  myocardial fibrosis

Other cardiomyopathies & causes


•Peripartum cardiomyopathy (last trimester of pregnancy or the early puerperium)
•Cardiomyopathy caused by iron overload (increased deposition of iron in the heart and)
•Amyloidosis
•Cardiac sarcoidosis
•Stress (Takotsubo) cardiomyopathy (acute reversible LV dysfunction in the absence of significant
CAD, triggered by acute emotional or physical stress)
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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History & Physical Examination

History
Potential etiology, duration of illness, severity &
trigger of dyspnea & fatigue, presence of chest
pain, development of peripheral edema or
ascites, diet & medication

Physical
Examination BMI or evidence of weight loss, blood pressure
(pulse pressure may reflect cardiac output), JVP
(congestion), extra heart sounds & murmurs (S3
is associated with adverse prognosis in HFrEF;
murmurs – valvular disease), right ventricular
heave (pulmonary hypertension), hepatomegaly,
ascites, peripheral edema, temperature of lower
extremities (inadequate cardiac output)
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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Classification
Classification EF (%) Description

Heart failure with ≤40 Also referred to as systolic HF. Efficacious


reduced ejection therapies have been identified to date.
fraction (HFrEF)
Heart failure with ≥50 Also referred to as diastolic HF. Several different
preserved ejection criteria have been used to further define HFpEF.
fraction (HFpEF) The diagnosis of HFpEF is challenging because it
is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF.
To date, efficacious therapies have not been
identified.
HFpEF, borderline 41-49 These patients fall into a borderline or intermediate
group. Their characteristics, treatment patterns,
and outcomes appear similar to those of
patients with HFpEF
HFpEF, improved > 40 Subset of patients with HFpEF previously had
HFrEF. These patients with improvement or
recovery in EF may be clinically distinct from
those with persistently preserved or reduced
EF. Further research is needed to better
characterize these patients.
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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Diagnosis
Diagnosis of HFrEF

1. Symptoms typical of HF

2. Signs typical of HF

3. Reduced LVEF

Diagnosis of HFpEF

1. Symptoms of typical of HF

2. Signs typical of HF

3. Normal or only mildly reduced LVEF & LV not dilated

4. Relevant structural heart disease (LV hypertrophy/ LA enlargement)


and/ or diastolic dysfunction

Symptoms: breathlessness, ankle swelling, and fatigue

Signs: elevated JVP, pulmonary crackles, displaced apex


beat
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1. McMurray JJV, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European
Journal of Heart Failure. 2012; 14; P 803-869
9 Diagnosis
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AB

1. McMurray JJV, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European
Journal of Heart Failure. 2012; 14; P 803-869
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Stages of Heart Failure
ACCF/ AHA Stages of HF NYHA Functional Classification
A At high risk for HF but None
without structural heart
disease or symptoms of HF
B Structural heart disease but I No limitation of physical activity
without signs or symptoms
of HF
C Structural heart disease with
prior or current symptoms
II Slight limitation of physical activity,
of HF
comfortable at rest, but ordinary
physical activity results in symptoms of
HF
III Marked limitation of physical
activity. Comfortable at rest, but less
than ordinary activity causes
symptoms of HF.
D Refractory HF requiring IV Unable to carry on any physical
specialized interventions activity, without symptoms of HF, or
symptoms of HF at rest.
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1. Yancy CW, et al. 2013 ACCF/AHA Heart Failure Guideline. Circulation. 2013;128:000–000.
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Prognosis

 Prognosis is based on control of hypertension,


hyperglicemia, and BMI (obesity or cachexia)

 Age, aetiology, NYHA class, EF, key co-morbidities


(renal dysfunction, diabetes, anaemia,
hyperuricaemia), and plasma natriuretic peptide
concentration1
AAB

1. McMurray JJV, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European
Journal of Heart Failure. 2012; 14; P 803-869
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Conclusion

 Abnormality of cardiac structure or function leading


to failure of heart to deliver O2 required for
metabolizing tissues

 Risk factors & cardiac abnormalities will result in


heart failure

 Classified as Heart failure with reduced ejection


fraction (HFrEF) & Heart failure with preserved
ejection fraction (HFpEF)

 Management of HF depends on its stage,


comorbidities and complications
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THANK YOU
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