1. Congestive Heart Failure Stephen Gottlieb, MD Professor of Medicine Director, Cardiomyopathy and Pulmonary Hypertension University of Maryland

2. What is Congestive Heart Failure?  Ejection Fraction  NYHA (New York Heart Association Class)  Cardiac Index  Pulmonary Capillary Wedge Pressure  Cardiopulmonary exercise test (CPEX)  BNP  None of the above

3. Congestive Heart Failure is a Clinical Diagnosis!  Called heart failure, chronic heart failure, CHF, HF  It is not equivalent to cardiomyopathy  Often defined as inability to maintain adequate cardiac output (CO) at normal filling pressures, either at rest, with exercise or both - resulting in symptoms and / or signs.  All of the previous factors help the clinician decide if the patient has CHF

4. Causes of Heart Failure  Ischemic heart disease – Myocardial infarction – Ischemic heart disease  Non-ischemic cardiomyopathy – Alcohol – Hypertension – Thyroid disease – Amyloid – HIV – Myocarditis – Idiopathic  Diastolic dysfunction – Normal ejection fraction heart failure

5. Symptoms  Shortness of breath (dyspnea)  Fatigue, Weakness  Orthopnea (dyspnea lying flat)  Paroxysmal nocturnal dyspnea (episodes of waking from sleep by dyspnea)  Cough, chest discomfort

6. Signs  Pulmonary – Rales, CXR abnormalities (may disappear with chronicity)  Fluid overload – Edema, hepatomegaly, ascites, increased jugular venous distention

7. Diagnosis  Clinical – Does the patient have typical symptoms? ­ Shortness of breath with exertion ­ Orthopnea, PND ­ Fluid overload ­ Known cardiac disease – Is it cardiac or pulmonary – If cardiac, what is the cause?

8. ? Dilated Cardiomyopathy: Diverse etiologies, Common pathology

9. Ejection Fraction  What is it? – The % of blood coming out of the heart with each beat  Advantages – Objective – Tells if there has been myocardial damage – Prognostic  Disadvantages – Doesn’t reflect physiology – Doesn’t tell you about physical limitations of patient

10. No Systolic (Diastolic?) Dysfunction  Normal cardiac function  Elderly  Hypertension  Infiltrative (Restrictive Cardiomyopathy) – Amyloid – Hemachromatosis  Hypertrophic (HCM) – With Obstruction = HOCM

11. NYHA (New York Heart Association Class)  What is it? – A subjective indication of physical status – I - no limitations – II – dyspnea on moderate exertion – III – dyspnea on minimal exertion – IV – dyspnea at rest  Stages – A - Risk for CHF; B – LF dysfunction without symptoms; C- Symptoms of CHF; D – Advanced CHF  Advantages – Assesses physical limitation  Disadvantages – Subjective – Affected by depression, deconditioning, psychological status

12. Predictors of Depression (BDI) VariableSlope Estimate SEt statistic P-value Age-0.150.015-10<0.0001 6 minute walk dist.-0.00800.0020-4.1<0.0001 Peak RER-4.01.6-2.40.015 NYHA class (II vs. III/IV) 2.90.407.3<0.0001 Sex-0.830.41-2.00.041 From Gottlieb et al, HF-ACTION data, 2008

13. Hemodynamics  What is it? – A catheter measures cardiac function  Advantages – Objective, shows cardiac function  Disadvantages – Poorly related to symptoms – A one time measurement – PCWP reflects fluid status Cardiac Index (CI) Pulmonary capillary wedge pressure (PCWP)

14. Cardiopulmonary Exercise Test (CPEX)  What is it? – Can measure work-load, peak oxygen consumption  Advantages – Objectively measures functional status  Disadvantages – Affected by deconditioning – Affected by lung disease

15. BNP  What is it? – Blood test of peptide released by heart when distended

16. We Know: BNP Levels Higher in Patients with Cardiogenic Dyspnea Maisel, A. et al. JACC, 2001; 37 N=139N=14N=97

17. From Richards et al. J Am Coll Cardiol 2006;47:52 We Know: BNP and NT-proBNP is Prognostic in CHF Below Median Above Median

18. BNP  Advantages – Objective – Reflects cardiac pressure  Disadvantages – Can change with fluid status – Affected by Obesity, Intensive Care, Renal Disease, Chronicity of CHF, Pulmonary disease, Age

19. Conclusion

20. Conclusions  Heart failure is common, the cause of many hospitalizations (the most for Medicare) and disability  There are many different types of heart failure with many causes  It can be very difficult to determine if someone has heart failure  Our tests all tell different information