1. Heart Failure (HF) : Overview Common underlying heart diseases or causes of HF 1.Valvular HD-Rheumatic etiology 2.Cardiomyopathy – Dilated type 3.Ischemic HD – Postmyocardial infarction

2. Epidemological Data of HF in USA -7.5 millions Americans have history of myocardial infarction, 34% develope disable HF over 6 years -500,000 patients were diagnosed as new HF cases every year -Major cause of HF is postmyocardial infarction cases

3. Death in Postmyocardial infarction 1.Cardiac sudden death-fatal ventricular arrhythmia (HR 4-6) 2.Progressive LV remodeling and failure to Pump failure

4. Current managements of HF A.Diuretics Inotropes and digitalis Symptomatic relief but No mortality benefit

5. B. Evidences of improved morbidity (hemodynamic) and mortality B.1 Drugs : ACEI Beta Blockers : Carvedilol Metoprolol, Bisoprolol Aldosterone antagonist (RALES study, FC III-IV): spironodactone

6. B.2 Devices : ICD Cardiac resynchronised therapy (CRT) – Biventricular pacings (COMPANION study) C. Heart transplant : LVAD bridge to transplant

7. Future Directions or New Paradigm in Management HF 1.Loop diuretic (Lasix) caused myocardial fibrosis (Lopez et all : JACC 2004; 43:2028- 35) Looking for new (type) diuretic 2. Beta Blockers : What type, How and When to start Carvedilol, metoprolol, Bisoprolol

8. 3. The best order of initiating therapy : ACEI-first VS Beta blocker-first Bata blocker-first is superior (CIBIS-III, Sliwa et all : JACC 2004;44:1825-30) 4. New selective aldosterone receptor antagonist From Spironolactone to Eplerenone (EPHESUS study)

9. 5. LVAD bridge to recovery (Sir Magdi Yacoub) LVAD LV rest to reverse remodeling of LV (with Digoxin, ACEI, Beta blocker, Spironolactone) Residual myocardial atrophy Physilogic myocardial hypertrophy (by Beta agonist, Clenbuterol) Recovered LV function Removed LVAD Pilot study : 19 LVAD patients, 11 improved LV function and had LVAD removed

10. 6. Cell (Stem Cell) Transplantation Aims : - Growing of new cardiac myocytes on scar tissue - Stimulating angiogenesis to viable and ischemic myocardium