2. Programme
5-5.30 pm Registration
5.30 – 5.45 pm Welcome and Introduction
SESSION I
Chaired by Dr Fuad Saeed, BDF Hospital
Dr Taysir Garadah, AGU/Dr Sulaiman Al Habib
5.45 – 6.15 pm Heart Failure in the 21st century – An Overview
Speaker -Dr Syed Raza, Awali Hospital
6.15 – 6.45 pm Management of Acute Heart Failure
Dr Haitham Amin, BDF Hospital
6.45 – 7.15 pm Evidence based management of Chronic Heart Failure
Speaker: Dr Hussam Noor, BDF Hospital
7.15 – 7.25 pm Panel discussion
7.25- 7.40 pm Coffee break
3. SESSION II
Chaired by Dr Rashed Al Bannay, Salmaniya Hospital
Dr Sadananda Shivappa, BDF Hospital
7.40 – 8.10 pm Diastolic Heart Failure
Speaker : Dr Said Al Said, Salmaniya Hospital
8.10 – 8.40 pm Device Therapy in Heart Failure
Speaker: Dr Adel Khalifa, BDF Hospital
8.40 – 9.10 pm Cardio-renal Syndrome – Definition and Management.
Speaker: Dr Jafar Al- Said, Consultant Nephrology &Internal Med.
Bahrain Specialist Hospital
9.10 – 9.40 pm Integrated and End of Life Care in Heart Failure
Speaker: Dr Syed Raza, Awali Hospital
9.40 -9.50 pm Panel Discussion
9.50 pm Vote of thanks followed by dinner
6. OBJECTIVES
• Size of the problem
• Assessment and making the
diagnosis
• Therapy – Drug and Device
• Novel Therapy in heart failure
7. Case
• 76 years old male, chronic smoker, HPN,
Previous MI
• Presents to ER with acute SOB and chest
tightness of one hour duration.
• BP : 170/100 Chest -few wheeze CVS- no
murmur
• ECG- sinus tachycardia, Q waves in anterior
leads.
• CXR- ?Cardiomegaly, hyper inflated lungs,
increased broncho- vascular markings.
• Normal initial lab results
10. Further Careful Evaluation
• Orthopnoea, PND
• Cold peripheries, leg swelling, fine inspiratory
crackles at lung bases , JVP rise
• S3 Gallop
• BNP – markedly elevated
• ECHO- Dilated LV , severe LV systolic
dysfunction- EF 20%
11. • “The very essence of cardiovascular
practice is the early detection of
heart failure”
Sir Thomas Lewis, 1933
12. Epidemiology of Heart Failure
12
10
Heart Failure Patients in US
10
• Major public health problem
• 22 million cases world wide
8
(Millions)
• 550,000 new cases/year in US
6
4.7 • 4.7 million symptomatic
4 3.5 patients; estimated 10 million in
2037
2
0
1991 2000 2037*
*Rich M. J Am Geriatric Soc. 1997;45:968–974.
American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.
13. Facts on Heart Failure
One of the leading
causes of death.
• 35% will die within one
year of diagnosis.
50% of HF patients will
die 5 years after the
diagnosis.
01/29/13
14. • Less than 50% of patients with HF have
typical physical signs
• Less than 50% of patients being correctly
identified during the initial consultation.
• 50% readmission rate within 6 months
• It is estimated that in Europe total cost of HF
exceeds 50 billion Euro every year.
16. Heart Failure Admissions
Injuries and poisoning
Complications of pregnancy and childbirth
All GU system
All digestive system
All respiratory system
All nervous system
All cancer
Diabetes
Stroke
Heart failure
Acute MI
Angina
Coronary Heart Disease
All circulatory
All diagnoses
0 5 10 15 20 25 30
Average duration of hospital admission (days)
British Heart Foundation, 2002
20. Galectin-3
• New bio-marker for heart failure
• Galectin – 3 produced by macrophages sec. to
injury.
• High levels signify Increase fibrosis and
stiffening of heart muscle.
• Not specific for heart
21. BNP & NT-pro BNP
• Levels in pg/ml
•
• No HF Further evaluation HF
BNP < 100 100-400 > 400
NT-pro BNP <400 400-2000 >2000
22. ECHOCARDIOGRAM
• EF is the most important parameter most
physicians are interested in.
• Tells about the type of heart failure
• Etiology of heart failure
• Cost effective if well utilized
24. Left Ventricular Dysfunction
• Systolic: Impaired contractility/ejection
– Approximately two-thirds of heart failure patients have systolic
dysfunction1
• Diastolic: Impaired filling/relaxation
30%
(EF > 40 %)
(EF < 40%)
70%
Diastolic Dysfunction
Systolic Dysfunction
1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200
25. Advanced Imaging in Heart Failure
• Real Time and contrast enhanced 3-
Dimenstional Echocardiography
Nuclear Imaging : SESTAMIBI SPECT –
Myocardial Perfusion scan.
• Cardiac Magnetic Resonance (CMR) Imaging
26.
27. Cardiac MRI in Heart Failure
Ability to assess in a single setting
• Cardiac morphology,
• Function, flow, perfusion,
• Acute tissue injury, and fibrosis in a single
setting.
• Risk stratification
28. Referral and approach to care
NICE (UK) GUIDELINES
Refer patients to the specialist multidisciplinary
heart failure team in the following situation:
1.Initial diagnosis of heart failure.
2. Management of severe heart failure (NYHA
class IV), heart failure that does not respond to
treatment,
3. Patients with previous MI
4.heart failure due to valve disease.
5.Patient who is pregnant or planning a
pregnancy
30. ADVERSE PROGNOSTIC MARKERS
IN CHRONIC HEART FAILURE
• Old Age,
• Severity of heart failure (NYHA class)
• Left ventricular dysfunction,
• Diabetes Mellitus,
• Raised creatinine,
• Hyponatremia , Hypoalbuminaemia,Anaemia
• Presence of arrhythmia : AF / VT
31. Causes of Mortality in Heart
Failure
• Pump failure
• Arrhythmia
• Severe Anaemia
• Associated serious co-morbidities i.e. Renal
failure
32. Prognostic Value of Haemoglobin Levels at
Discharge in Older Patients Admitted With Heart
Failure.
2Syed Raza, 1Nicolas Wisniacki, 2Pam Aimson, 2Chris
Manning, 1Alejandra Abramovsky, 1Vinod Gowda, 1Michael
Lee, 2Jason Pyatt.
1Department of Medicine,
University of Liverpool & 2Department of Cardiology,
Royal Liverpool and Broadgreen University Hospitals.
United Kingdom.
33. Southey’s Tubes
In the 19th and early 20th centuries, heart failure associated with fluid
retention was treated with Southey's tubes, which were inserted into
edematous peripheries, allowing some drainage of fluid.
34. Heart Failure Management: The
Time Line
• 1920 Organo-mercurial diuretics
• 1970s and before- Bed rest and fluid
restriction
• 1980s- Diuretics and Digoxin
• 1990s- Nitrate, ACEI and ARB
• 2000s (early)- Aldosterone antagonist
• 2000s (late) – Device therapy ,Artificial heart
• 2010s- Gene and Stem Cell therapy.
36. EMERGENCY MANAGEMENT
(Mnemonic)
U Upright Position
N Nitrates
L Lasix
O Oxygen
A ACEI / ARB
D Digoxin, Dobutamine
M Morphine Sulfate
E Extremities Down
37. Use of CPAP /BiPAP
• Ample evidence
• CHF and Sleep Apnea/COPD often co-exist
• Bi PAP useful at later stage of acute heart
failure when patient starts to fatigue.
38. Acute Heart Failure
• In the setting of acute heart failure, new
inotropes such as cardiac myosin activators
and new vasodilators such as relaxin have
been developed
39. Rational for Medications
(Why does my doctor have me on so
many pills??)
• Improve Symptoms • Improve Survival
– Diuretics (water pills) – Betablockers
– digoxin – ACE-inhibitors
– Angiotensin receptor
blockers (ARB’s)
– Aldosterone antagonists
41. Newer Drugs
• Eplerenone (Inspra; EPHESUS 2003)
– Pts 6,642 asym LV dysfunction, DM, or after MI
– Dec CV mortality of 13%,
• Newer more selective inhibitor; fewer side effects
• Nesiritide (Natrecor) Recombinant form of
human BNP
• Causes venous and arterial vasodilation
– has been shown to improve dyspnea
– Shown to reduce 30 day mortality
42. Newer Drugs- contd.
• Ivabradine - Ifc current inhibitor in SA node
• SH IFc T study (6505 pts, 37 countries)
• Reduce hospitalization, mortality and improve
exercise tolerance.
• Add on therapy- chronic symptomatic systolic
heart failure (NYHA functional class II–IV) and
a heart rate ≥70 bpm.-ESC guideline May 2012
43. Drugs for systolic heart failure
• Direct Renin Inhibitors
• Neprilysin inhibitor
• Ryanodine receptor stabilizers,
SERCA activators
44. Diastolic Heart Failure
• no therapy has been demonstrated to
improve symptoms or outcomes
• Dicarbonyl-breaking compounds reverse
advanced glycation-induced cross-linking of
collagen reduce stiffness and improve the
compliance of aged and/or diabetic
myocardium
45. Some Practical Tips
• Diuretics : Intravenous for 48-72 hours in
acute decompensation, then change to oral
Beta blocker to be initiated when lungs are ‘Dry’
(“Start low and go slow” )
First dose of ACEI /ARB (small dose) usually at
night. Combination not recommended.
Calcium channel blocker - Limited evidence for
Amlodipine (PRAISE )
Do not forget prophylactic clexane to prevent
VTE
48. ULTRAFILTRATION
• Removal of isotonic fluid through an extra-
corporeal filter.
• Controlled and predictable even if urine
output is low i.e. Renal Failure
49. DEVICE THERAPY
• Unacceptably high morbidity and mortality
despite medical therapy.
• Device therapy in heart failure has shown to
improve symptoms as well as reduce mortality
and sudden death.
• Must be used in patients with good
indications
• Needs skills and resources
50. Biventricular Pacing
(CARDIAC RESYNCHRONISATION THEARPY)
• Abnormal ventricular conduction resulting in a
mechanical delay and dysynchronous
contraction
Overview of Device Therapy 50
51. Heart Failure and Sudden Cardiac
Death
– Usually caused by serious ventricular arrhythmia i.e. VT and VF
– SCD is one of the leading causes of death in the U.S. –
approximately 450,000 deaths a year
– Patients with heart failure are 6-9 times as likely to develop
sudden cardiac death as the general population
55. Heart Transplantation
• A good solution to the failing
heart– get a new heart
• Demand is high , limited donor hearts
• Approximately 2200 transplants are
performed yearly in the US
56.
57. Beyond Drug and Device Therapy!
• Cardiac rehabilitation programme
• Discharge planning
• Patient monitoring and follow up.
• Patient and family education
58. MULTI DISCIPLINARY APPROACH
(INTEGRATED CARE)
Purpose: To improve the
care delivered to heart
failure patients across
the continuum
01/29/13
59. In Summary….
• Heart failure is common and has high
mortality
• Timely and accurate assessment is the key to
management
• Drug therapy improves survival
• Newer device therapies are showing promise
for symptom relief and improve survival
• Transplants remain rare.
• Think beyond drug and device therapy.
Hinweis der Redaktion
Heart failure as mentioned is a growing public health problem and so Objectives of my talk would be to give you some facts and figures of heart failure. I would talk about how the patients of suspected HF are assessed in reaching an accurate diagnosis. I would touch upon very briefly on the drug, device and some novel therapy in HF.
In order to draw audience’s interest and attention, I usually prefer to break the subject with a case. This would be a typical case which we all see in our daily clinical practice.
As a physician it is our responsibility to differentiate a normal from a failing heart.
LV S3 (3 rd heart sound) gallop is most important and pathognomic sign for HF (specificity 99%). Low pitched sound best heard with a bell at cardiac apex . The ones in italics are major Framingham criteria for diagnosis of HF.
British Cardiologist
Some of the information we gathered was very interesting…..
Patients do not present with typical signs and symptoms of heart failure and so diagnosis is often missed. It incurs high cost on total health care budget.
The figure shows the average length of hospital admission by main diagnosis in NHS hospitals in England for 2000/01. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002.
There is a huge range of heart failure biomarkers but in practice only the following are more commonly used..
These markers are cardiac specific and some are non cardiac specific
Galectin 3 is a new bio marker. It is a marker for inflammation , fibrosis and ventricular remodelling
Bnp and NT –pro BNP are more commonly used biomarkers for HF.If levels are above.. Diagnosis of HF in conjuction with clinical diagnosis confirms the diagnosis. If the levels are between ….. , further evaluation is required i.e use of echocardiogram.
Echo is the most important diagnostic tool used in HF,It tells about the structure and funtion of the heart. Risk startify and provides guidance for use CRT ICD.
Commonest cause for HF is CAD (> 60%) , followed by HPN and Valvular heart ds.
Atleast 1/3 rd of patients have normal EF and they are classified as HF with preserved systolic function or diastolic heart failure.As previously seen, there are many causes of heart failure. Some diseases, however, tend to more adversely affect the heart’s systolic function (ventricular contraction/ejection), while others tend to more adversely affect diastolic function (ventricular filling/relaxation). This provides a useful way of classifying heart failure from a hemodynamic standpoint. Most patients who have systolic dysfunction also have a component of diastolic dysfunction.
All is not lost when one is diagnosed with HF and certainly HF is not a death sentence, however prognosis is poor in patients who are old…
Commonest cause for HF moratality is pump failure (70%). Commonest cause for sudden death is due to arrhthmia usually due to electrolyte imbalance.(hypokalemia more gdangerous than hyperlkalemia. HENCE renal function and electroltyes should be very closely monitored.
This is from one of our research where we looked at the prognostic markers of heart failure in the elderly population. We found anaemia as an independent predictor of mortality and hospital re-admission
For centuries blood letting and leeches were used to remove body fluid in patients of heart failure until 19 th and eraly 20 th century when southey’s tubes were introduced …
In early 20 th century injectable organomercurials were used for treating syphyllis. Medical student in Vienna noted that these patients passed a large amount of urine. For next 20 years used as a potent diuretic but replaced by carbonic anhydrase (metb acidosis) and later thiazide diuretics due to toxic side effects.
Acute heart failure is a medical emergency
Emergency management of acute HF has not changed for many years.Easy pneumonic to remember the management of acute heart failure.
Atleast 20 randomised con. Trials suggest that they improve survival. Increase intra thoracic pressurre/decrease pre and after load-improve LV systolic function as well as improve oxygenation. Decrease mortality. Pressure start 5cm H2O – max 10 cm H2O
Some of medications improve symptoms while others like... Improve survival
There is good evidence from some landmark trials in heart failure as … that the treatment reduces annual mortality significantly.
Newer drugs like eplerenone which is another aldosterone antagonsit reduces mortality. Nesiritide..
Ivabradine is a fairly new drug being used in the West for atleast few years and recently introduced in the middlke east market is a specific SA node blocker. It has recently been included in the ESC guideline for CHF treatnment in patients whose functional class is 2-4 and have a heart rate of more than 70. SHIFT trial used > 6000 patients and has shown mortality benefit in addition to reducing hospitalization and improving exercise tolerance.
Direct renin inhibitor (Aliskern) also used in HPN. Better tolerated compared to ACEI and ARB. Also used for HPN. The rest N R and S help in cardiac contractlity in some way or the other thereby improving LV systolic function.
Dicarbonyl breaking compounds help in reducing the stiffness and improving the compliance of LV myocardium.
Developed initially for Used for refractory angina but later started being used for HF Late 1990s. Hooked to ECG monitor and large pneumatic cuff are applied to legs/thighs and pelvis. Cuff inflation is synchronised to diastolic phase which compresses the veins to push blood upwards to allow cardiac and coronary filling in diastole. It also leads to formation of collaterals.
Patients often are admitted with fluid overload . Low urine output and renal failure adds to the problem further. It is with the use of devices like this that large amount of isotonic fluid using extracorporeal membrane can be removed.
There is a need for using device thearpy for selected patients since despite medical thearpy, morbidity and mortality due to HF remains unacceptably high.
Many patients with advanced systolic heart failure exhibit significant inter- or intraventricular conduction delays that disturb the synchronous beating of the left and right ventricles so that they pump less efficiently. This delayed ventricular activation and contraction is referred to as ventricular dysynchrony and is easily recognized by a wide QRS complex on an ECG. This IVCD (inter- or intraventricular conduction delay) typically has left bundle branch morphology.
Dr. (Name) says: Sudden Cardiac Arrest is as scary as it sounds. It means that your heart suddenly starts beating very fast and quivers instead of beating in a regular and organized way. No blood gets pumped, and you will die unless you get treatment within minutes. We’ll talk more about treatments in a moment. Unlike a heart attack, SCA is caused by an electrical problem in your heart. SCA can strike without warning, and there are no symptoms.
Click on animation. Dr. (Name) says: Some people with Class III and IV heart failure can benefit from a heart failure pacemaker that can help your heart beat more efficiently by coordinating or synchronizing the way the heart beats, so your heart pumps more efficiently. It works by automatically checking your heart function 24 hours a day. This type of heart device is also called cardiac resynchronization therapy or CRT. You may also hear the term biventricular pacing. All refer to the same kind of treatment. Treatment with a heart device may make you feel better. Although many people experience dramatic improvements in their quality of life and in their heart failure symptoms, results may vary. Not everyone responds to the treatment in the same way. It is also important to note that heart failure pacemakers do not cure heart failure--a heart failure pacemaker is part of an overall treatment plan. Describe heart failure pacemaker device: A heart failure pacemaker is about the size of a small pocket watch that contains a battery and computer circuitry to correct your heart rhythm and help your heart beat more efficiently. Small insulated wires called leads connect the device to the heart. We’re going to pass around a plastic replica of a Medtronic combination heart failure pacemaker and defibrillator pacemaker . Facilitators circulate and pass around replicas and collect them. Before I move on, I’d like to say a few words about Medtronic, the company helping us put on the seminar today. Medtronic was the first company to introduce a pacemaker in the United States. Physicians worldwide have prescribed heart failure pacemakers for more than 120,000 patients. Other people with heart failure are in danger of having heartbeats that are irregular and/or too fast. These irregular heart beats can cause you to feel short of breath and light headed. Such episodes may also be life threatening if not treated quickly. Some heart devices also contain a defibrillator in addition to the special kind of pacemaker. This combination device also sends out small electrical signals to restore your normal heart rhythm. If the small signals do not work, the device sends out a shock to reset your heart rhythm. This kind of device is also used to treat SCA.
Although the no of heart transplants have gone up worldwide, the figures are still low as about 2000 transplants per year in the USA. And the figures are even less in other countries including Europe. This is mainly due to limited donors.
Most modern and recent treatment is stem cell therapy where autologous or allogenic stem cells from bone marrow are harvested and injected intravenously or intracoronary/ encodcardia via catheter based treatment/
Must think beyond …. And this can be achieved using multidiciplinary team and adopting integrated care pathway.
Keeping that recommendation in mind, the HVHC HF Task force was created. It’s purpose was to…..
