1. Chronic Heart Failure – An Update T P Chua Royal Surrey County Hospital, Guildford St George’s Hospital, London

2. Common (1-5% of population) High Mortality Disabling symptoms Expensive (30% require hospitalisation/year) Recent Advances Chronic Heart Failure – Clinically Important

3. 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

4. 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:

5. Sensitivity & Specificity of Symptoms Dyspnoea Orthopnoea PND Oedema Sensitivity (%)Specificity (%) 66 21 33 23 52 81 76 80

6. Value of the ECG in Identifying Heart Failure ECGImpaired LVNormal LVTotal Abnormal*90 169 259 Normal6 269 275 Total96 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%

7. 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 Echo9397 99.3 EHJ 2006; 27: 193-200

8. Natriuretic Peptides Three 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

9. B-type Natriuretic Peptide

10. Clinical Use of BNP in CHF Diagnosis of CHF in patients with acute dypsnoea