Heart Failure A Disease for the InternistDr Chris DavidsonSussex Cardiac CentreBRIGHTON UK1EFIM Beziers 2007Heart Failure a typical case?nMedical Assessment Unitn78 year old womannHypertension ; type II DiabetesnAF 110/min, 180/80, JVP+, oedema+nCXR: cardiomegaly, pulmonary congestionnECG: AF, LBBBGiven iv Frusemide 80mg with a good diuresis and feels better today2EFIM Beziers 2007Heart Failure A Disease for the InternistnWho looks after patients with Heart Failure?nUse of Evidence-based TreatmentsnThe problem of Heart Failure with Preserved LV functionnCo-Morbidity in Heart FailurenHow do we prevent early relapse?3EFIM Beziers 2007EuroHeart Failure Survey11,327 diagnosis HF Mean age 71 years; 47% women GIM / geriatrics 55%, cardiology 45% CHD 66%, Valve disease 29%, DCM 5% HF principle reason for admission in 40% LVSD in 46%: male femaleEuropean Heart Journal (2003) 24, 442463 Registry of 46,786 consecutive admissions to general medicine and cardiology wards in 24 European countries over a 6 week period 2001-24EFIM Beziers 2007Heart Failure in France Cohen-Solal et al European Heart Journal (2000) 21, 7637695EFIM Beziers 2007HEART FAILUREHow Serious?6EFIM Beziers 2007Epidemiology of Heart Failure: Framingham StudyHypertensionHypertension76%76%79%79% CHDCHD46%46%27%27% RheumaticRheumatic2%2%3%3% OtherOther11%11%17%17%MORTALITYMORTALITY82%82%67%67% (6 Year)(6 Year)MALEMALEFEMALEFEMALEHo et al Circulation 1993;88:107-1157EFIM Beziers 2007MORE MALIGNANT THAN CANCER? Stewart S et al. Eur. J Heart Failure (2001) 3 315-322Reference: Stewart et al. Eur J Heart Failure 2001Five year Survival of Patients admitted to Hospital in Scotland 199128%28%8EFIM Beziers 2007HEART FAILUREWhat are the recommended treatments?9EFIM Beziers 2007HF Trial EvidencenACE inhibitorsnVasodilators: Hydrallazine/NitratenBeta-BlockersnSpironolactonenAngiotensin Receptor BlockersnExercise TrainingnBiventricular Pacing / DefibrillatorsnCardiac Transplantation10EFIM Beziers 2007Mortality Benefit of Treatments in Heart Failure6mo 3.5yr 6mo 1.3yr 1yr 2yr11EFIM Beziers 2007Euro Heart Failure Survey: Use of ACEI and BB12EFIM Beziers 2007Guidelines for the Treatment of Heart FailurenAmerican Heart Ass. / American College of Cardiologyq Chronic Heart Failure 2005 J Am Coll Cardiol 2005; 46:1116-43 nEuropean Society of CardiologyqChronic Heart Failure 2005 EHJ 2005;26:1115-1140 nEuropean Society of Cardiology qAcute Heart Failure 2005 EHJ 2005;26:384-416 ALL THERAPEUTIC GUIDELINES RELATE TO SYSTOLIC DYSFUNCTION13EFIM Beziers 2007Heart Failure a typical case?nMedical Assessment Unitn78 year old womannHT ; type II DiabetesnSR 110/min, 180/80, JVP+, oedema+nCXR: cardiomegaly, pulmonary congestionnECG: AF, LBBBGiven iv Frusemide 80mg with a good diuresis and feels better todayEchocardiography : LVH, Ejection Fraction 48%14EFIM Beziers 2007HEART FAILURESystolic vs. Diastolic Dysfunction15EFIM Beziers 2007EuroHeart Failure Study: Preserved vs Impaired LV Function (EF menq4 years olderqHypertension more commonEuropean Heart Journal (2004) 25, 1214122016EFIM Beziers 2007Adjusted Survival Curves for Patients with Heart Failure with Reduced or Preserved Ejection Fraction over the Year after the First Hospital AdmissionBhatia R et al. N Engl J Med 2006;355:260-26917EFIM Beziers 2007PATHO-PHYSIOLOGY OF HEART FAILURECardiac OutputCardiac OutputBloodBlood PressurePressureVasoVaso- - ConstrictionConstrictionNa+ retentionNa+ retentionNEURO-ENDOCRINE ACTIVATIONRENAL PERFUSIONRenin/Angiotensin Sympathetic sys. ANP / BNP18EFIM Beziers 2007HEART FAILURE: Diastolic DysfunctionHow should we treat these patients?19EFIM Beziers 2007CHARM ProgrammeLancet. 2003; 362: 759-766. n=3025LVEF 40% ACE inhibitor treated/not treatedCHARM AddedCHARM Preserved3 component trials comparing candesartan to placeboCHARM Alternativen=2028 LVEF 40% ACE inhibitor intolerantn=2548LVEF 40% ACE inhibitor treatedPrimary outcome: CV death or CHF hosp20EFIM Beziers 2007CHARM-Preserved: Primary outcome CV death or CHF hospitalisation0123years3.50102030 PlaceboCandesartan51525HR 0.89 (95% CI 0.77-1.03), p=0.118 Adjusted HR 0.86, p=0.051%366 (24.3%) 333 (22.0%)RRR=11%Lancet. 2003;362:759-766. 21EFIM Beziers 2007Heart Failure A Disease for the InternistnWho looks after patients with Heart Failure?nUse of Evidence-based TreatmentsnThe problem of Heart Failure with Preserved LV functionnCo-Morbidity in Heart FailurenHow do we prevent early relapse?22EFIM Beziers 2007Co-Morbidity in Heart Failure Survey of 122,630 patients in US Healthcare SystemBraunstein et al JACC 2003 42; 122639% overall had 5 or more co- morbidities; Only 4% had HF alone23EFIM Beziers 2007Co-Morbidity in Heart Failure (2)nAnaemiaqKosiborod M, Smith GL, Radford MJ, Foody JM, Krumholz HM. The prognostic importance of anaemia in patients with heart failure. Am J Med 2003;114:1129.nChronic InflammationqElevated circulatin