An update on heart failure for non cardiologists.

1. CONGESTIVE CARDIAC FAILURE – AN UPDATE ON MANAGEMENT Dr SYED RAZA Consultant Cardiologist MD,MRCP(UK),Dip. Card(UK),CCT(UK),FCCP(USA)

5. FAILING HEART

9. Heart Failure Admissions British Heart Foundation, 2002 Average duration of hospital admission (days)

10. Heart Failure Mortality

12. Prognostic Value of Haemoglobin Levels at Discharge in Older Patients Admitted With Heart Failure. 2 Syed Raza , 1 Nicolas Wisniacki, 2 Pam Aimson, 2 Chris Manning, 1 Alejandra Abramovsky, 1 Vinod Gowda, 1 Michael Lee, 2 Jason Pyatt. 1 Department of Medicine, University of Liverpool & 2 Department of Cardiology, Royal Liverpool and Broadgreen University Hospitals. United Kingdom.

14. Symptoms

16. I GIVE UP . I CAN’T TAKE IT ANY MORE !!

17. Acute Decompensated Heart Failure /Pulmonary Edema >Medical Emergency !

18. But

24. What is present in this extremity, common to right sided HF?

25. EMERGENCY MANAGEMENT (Pneumonic) U Upright Position N Nitrates L Lasix O Oxygen A Amiodorone > ACEI / ARB D Digoxin, Dobutamine M Morphine Sulfate E Extremities Down

26. Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations . – Initial diagnosis of heart failure. – Management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment, heart failure due to valve disease, or heart failure that can no longer be managed at home – Advice and care of women who are planning a pregnancy or are pregnant. Care of pregnant women should be shared between the cardiologist and obstetrician. Patients with previous MI Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks

28. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS) Vasoconstriction Oxidative Stress Cell Growth Proteinuria LV remodeling Angiotensinogen Angiotensin I Angiotensin II 3 .AT II receptor 1 .Renin 2 .Angiotensin Converting Enzyme 1.Direct Renin Inhibitor (Aliskiren) 2.ACEI 3.A2RB

35. Initial and Target Doses of beta-blockers for HF Medication Starting Dose Target Dosage Bisoprolol 1.25mg daily 10mg daily Carvedilol 3.125mg bid 25mg bid Metoprolol CR/XL 12.5-25mg daily 200mg daily

41. ENHANCED EXTERNAL COUNTERPULSATION (EECP)

42. Ultrafiltration

48. IMPLANTABLE CARDIAC DEFIBRILLATOR Device Shown: Combination Pacemaker & Defibrillator

50. Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β -Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8.5%

52. Left ventricular assist device

54. Newer Generation Artificial Hearts

55. ARTIFICIAL HEART

59. Worldwide Heart Transplants

60. Trends in Hospitalization for Heart Failure by Age Group 1979-2004 (CDC, 2006) 03/21/11

68. Recent Developments and Future Challenges of Integrated Care in Heart Failure in Europe and Northern America The International Network of Integrated Care, The Julius Center of the University Medical Center Utrecht and the University of Southern Denmark 11th International Conference on Integrated Care: 4.7. Paper session: IC for heart failure patients Pilot Study of Integrated home Care for Patients of Congestive Cardiac Failure: British District Hospital Experience – Dr Syed S.M. Raza et al., Dept. of Cardiology & Acute Medicine, Huddersfield and Calderdale Royal Hospitals NHS Trust, UK March 30 - April 1, 2011 in Odense, Denmark

69. REHABLITATION PROGRAMME