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Chronic Heart Failure –An Update
T P Chua
Royal Surrey County Hospital, Guildford
St George’s Hospital, London
• Common (1-5% of population)
• High Mortality
• Disabling symptoms
• Expensive (30% require
hospitalisation/year)
• Recent Advances
Chronic Heart Failure – ClinicallyImportant
Chronic Heart Failure• Ventricular dysfunction with chronic
symptoms of breathlessness and/or fatigue and/or fluid retention
• Signs of pulmonary or peripheral congestion
• Systolic heart failure more common and better defined than diastolic heart failure
Eur Heart J 1995; 16: 741-751
Diastolic Heart Failure• Normal ejection fraction/systolic function• Normal or even small left ventricular
chamber volumes• Reduced active relaxation and increased
passive stiffness of LV• More than 75% of these patients have
hypertension and ~40% have left ventricular hypertrophy
Zile MR, et al. NEJM 2004; 350:
Sensitivity & Specificity of Symptoms
Dyspnoea
Orthopnoea
PND
Oedema
Sensitivity (%) Specificity (%)
66
21
33
23
52
81
76
80
Value of the ECG in Identifying Heart Failure
ECG Impaired LV Normal LV Total
Abnormal* 90 169 259
Normal 6 269 275
Total 96 438 534
*Abnormal ECG: AF, Previous MI, LVH, BBB, LAD
Davie AP, McMurray JJV, et al. BMJ 1996;312:222
Negative Predictive Value: 269/275: 98%
Sensitivity & Specificity of ECG,NT-proBNP and Hand-held Echo
Abnormal ECG
Raised NTproBNP
Abnormal ECG or raised NTproBNP
Sensitivity (%)Specificity (%)
80
96
76
78
88
72
94
NPV (%)
Abnormal ECG and raised NTproBNP
92 99.6
99
99.8
99.7
Hand-held Echo 93 97 99.3
EHJ 2006; 27: 193-200
Natriuretic PeptidesThree types present:-• ANP (atrial natriuretic peptide) first discovered;
primarily released by atria; potent vasodilator and natriuretic
• BNP (B-type natriuretic peptide); predominantly released by left ventricle in response to high filling pressures; also a vasodilator and natriuretic
• CNP (C-type natriuretic peptide); released by atria and ventricles; vasodilatory property only
B-type Natriuretic Peptide
Clinical Use of BNP in CHF• Diagnosis of CHF in patients with acute
dypsnoea