Heart Failure

Haissam A Haddad, MD, FRCPC, FACCProfessor of Medicine

University of Ottawa Heart Institute

Objectives

• -Classify the types of heart failure: systolic, diastolic, Left and right sided ‐heart failure.

• -Describe the compensatory mechanisms of heart failure taking into account: neurohormonal alterations, ventricular hypertrophy and remodeling.

• -Recognize the precipitating factors in heart failure.• -Describe the clinical presentation of heart failure including diagnostic

studies.• -Recognize the modalities of treatment of heart failure including: diuretics,

vasodilators, ionotropic drugs, B Blockers, and additional therapies.‐• -Describe measures to prevent heart failure and preserve left ventricular

function.• -Explain the sequella of ventricular dysfunction.• -Describe congestive heart faillure.• -Explain the physiological effects of congestive heart faillure

Heart Failure

• Heart failure is common, yet it is difficult to treat. It presents in many different circumstances in which therapy needs to be individualized.

• About 500.000 Canadian with Heart Failure “5 million Americans”

• HF remains one of the most common reasons for hospital admission, as well as one of the most costly cardiovascular disorders.

• Canada’s average annual in-hospital mortality rate is:– 9.5 deaths/100 hospitalized patients >65 years of age– 12.5 deaths/100 hospitalized patients >75 years of age

• HF patients have a poor prognosis, with an average 1-year mortality rate of 33%

Who Gets Heart Failure

• Affects men and women equally• Mortality risk between men and women is

similar

What is Heart Failure (HF)?

• Heart Failure is a complex syndrome in which abnormal heart function results in

Types of Heart Failure?

Left Heart Failure

– Involves the left ventricle (lower chamber) of the heart– Systolic failure

• The heart looses its ability to contract or pump blood into the circulation– Diastolic failure

• The heart looses its ability to relax because it becomes stiff• Heart cannot fill properly between each beat

Right Heart Failure

– Usually occurs as a result of left heart failure– The right ventricle pumps blood to the lungs for oxygen– Occasionally isolated right heart failure can occur due to lung disease or blood clots to

the lung (pulmonary embolism)

How fast does heart failure develop?

– Usually a chronic disease– The heart tries to compensate for the loss in pumping function by:

• Developing more muscle mass• Enlarging• Pumping faster

The Failing Heart

Myocyte hypertrophyMyocyte hypertrophy

Chamber dilationChamber dilation

Interstitial changesInterstitial changes

Normal Normal MyocyteMyocyte

HypertrophiedHypertrophiedMyocyteMyocyte

Less FibrosisLess Fibrosis

More FibrosisMore Fibrosis

Normal HeartNormal Heart Dilated HeartDilated Heart

RemodelingRemodelingin the failing heartin the failing heart

Causes of Left Ventricular Dysfunction

Metabolic

Drugs

Heavy metals

Infections

Connectivetissue diseases Neurologic

diseases

Inheriteddiseases

Otherdiseases

Pressure overload

Volume overload

Restrictivedisease

Primarycardiomyopathy

Coronary artery disease

RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)

Morbidity and mortalityArrhythmiasPump failure

Peripheral vasoconstrictionHemodynamic alterations

Heart failure symptoms

Remodeling and progressiveworsening of LV function

Initial fall in LV performance, wall stress

Activation of RAS and SNS

Fibrosis, apoptosis,hypertrophy, cellular/molecular alterations,

myotoxicity

FatigueActivity altered Chest congestionEdemaShortness of breath

Neurohormonal Activation in Neurohormonal Activation in Heart FailureHeart Failure

Symptoms of Heart Failure

NYHA CLASS

Noticeable limitations in ability to exercise or participate in mildly strenuous activities

Comfortable only at rest

No symptoms

Can perform ordinary activities without any limitations

Mild symptoms

Occasional swelling

Somewhat limited in ability to exercise or do other strenuous activities

No symptoms at rest

Unable to do any physical activity without discomfort

Symptoms at rest

Diagnosis of Heart Failure

Treatment of Heart Failure

Lifestyle Changes to prevent heart failure and preserve left ventricular function.

• Low-sodium, low-fat diet

• Lose weight

• Physically active

• Reduce or eliminate alcohol and caffeine

• Quit Smoking

What Why•Sodium is bad for high blood pressure

•Extra weight can put a strain on the heart

•Exercise can help reduce stress and blood pressure

•Alcohol and caffeine can weaken an already damaged heart

•Smoking can damage blood vessels and make the heart beat faster

Prevention of Heart Failure

• Coronary artery disease • Myocardial infarction• Hypertension• Diabetes• Valvular heart disease• Dilated or hypertrophic cardiomyopathy, myocarditis• Congenital heart disease• Severe lung disease

Drugs to Use With Caution in HF Patients

• Calcium channel blockers• Thiazolidinediones (glitazones)• Doxorubicin• NSAIDS, including Cox-2 inhibitors

Conclusions

• Management of HF begins with an accurate diagnosis

• Aggressive treatment of all known risk factors e.g., hypertension, diabetes, etc.

• Treatment requires rational combination drug therapy

• Care should be individualized for each patient based on:

• Symptoms• Clinical presentation• Disease severity• Underlying cause

• Patient and caregiver education should be tailored and repeated

• Mechanical interventions (e.g., revascularization and devices) should be available

• Collaboration is required among healthcare professionals

• Accessibility to primary, emergency and specialist care must be timely