1. HEART FAILURE Prevalence increasing in our ageing population Incidence doubles with each decade between 40 and 80 At any age more common in men than women One of the commonest causes of hospital admission

2. Heart Failure 1.A cardiac disorder that prohibits delivery of sufficient output to meet the perfusion requirements of metabolizing tissues 2. A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic and hormonal responses

3. Causes of heart failure Coronary artery disease Hypertension Cardiomyopathy Valvular heart disease Other causes

4. Heart failure: aggravating factors Cardiac arrhythmias (esp AF) Hypertension Anaemia Chest infection

5. Sympatho-adrenal activation Renin-angiotensin activation Redistribution of venous flow Salt and water retention Ventricular dilatation  Inotropic state  Myocardial mass  Contractile Function Compensatory Physiology in Heart failure

6. Heart failure: symptoms and signs SymptomsSigns  cardiac outputfatiguecool skin (peripheral hypoperfusion)peripheral cyanosis Fluid retentiondyspnoeabasal crackles (congestion)oedema  JVP ankle swelling, ascites  sympathetic activity-tachycardia sweating Other findings-S3, alternating pulse

7. S3 Heart failure: S3, alternating pulse

8. Heart failure: ECG (never normal) Inferior Q waves Anterior T wave + ectopics Left bundle branch block

9. Heart failure: CXR Pulmonary congestion Pulmonary oedema

10. Heart failure: m-mode echo Cardiomyopathy: global LV dysfunction Coronary heart disease: regional LV dysfunction S3

11. Heart failure: 2D echo LV LA RA RV 4 chamber view Long axis view

12. Heart failure: brain natriuretic peptide (BNP) Secreted by myocardial cells in response to raised left atrial pressure Promote natriuresis, vasodilatation Inhibit ADH and aldosterone release Levels >50pg/ml indicate heart disease as cause of dyspnoea and fluid retention

13. Heart failure: Complications Intravascular thrombosis – pulmonary embolism – systemic embolism Infection – chest infection – ulcerated cellulitic legs Functional valvular dysfunction – MR, TR Multi-organ failure – renal failure – liver failure Cardiac Arrhythmias – AF – VT VF Sudden death

14. Heart failure: non-drug treatment Severely oedematous patient – bed rest – nurse in head up position – oxygen therapy – aspiration of large pleural effusions – salt restriction Ambulant patient – no added salt – regular walking exercise

15. Heart failure: treat aggravating factors Atrial fibrillation – rate control + warfarin – DC cardioversion Hypertension – ACE-Is + beta blockers + diuretics Anaemia – haematinics – erythropoetin (?) – blood transfusion (?) Chest infection – physiotherapy – antibiotics

16. Sympatho-adrenal activation Renin-angiotensin activation Redistribution of venous flow Salt and water retention Ventricular dilatation  Inotropic state  Myocardial mass  Contractile Function Treatment of Heart failure Beta-blockers ACE-Is, ARBs Spironolactone

17. Beta-blockers Carvedilol in the COPERNICUS trial Circulation 2002 ACE-Inhibitors Meta-analysis of all randomized trials Lancet 2000 Spironolactone RALES trial NEJM 1999 ARBs Losartan in ELITE II Lancet 2000 Treatment of Heart failure: Evidence base ACE-I Placebo Losartan Captopril

18. Heart failure: treatment Fluid retention – diuretics Symptoms and prognosis in systolic heart failure Drugs – ACE-Is (all grades of heart failure) – ARBs (if ACE-Is cannot be tolerated) – beta-blockers (all grades of heart failure) – spironolactone (NYHA grade III and IV only) Devices – Cardiac resynchronization therapy (CRT)

19. Heart failure: treatment of complications Atrial fibrillation – cardioversion (often not possible) – rate control (beta-blockers ± digoxin) – warfarin Ventricular arrhythmias – implantable defibrillator

20. Canadian Implantable Defibrillator Study Circulation 2004

21. Heart Transplantation Indications: resistant ccf without: – major organ failure – major co-morbidity – psychological disability – severe pulmonary hypertension Procedure – orthotopic transplant Prognosis – 80% 1 year survival

22. Prognosis of Heart Failure

23. The End