Definition of HF

A pathophysiological state in which the

heart is unable to pump blood at a rate
sufficient to meet the metabolic needs of
the body

HF is a chronic condition
Congestive heart failure (CHF) is common
terminology, but HF is preferred, as not all
patients present with congestion

-An Increasing Public Health

Burden-

2001 CCS Consensus Guideline update. Can J Cardiol 2001;17(Suppl E);5E-24E.

General Pharmacological Treatment Strategies in HF

Asymptomatic

Mild/Mod

Severe

Refractory

Digoxin
Spironolactone
Angiotensin II Receptor Blocker
-Blocker
Angiotensin Converting Enzyme Inhibitor
No added
salt

2 gm Na
HF clinics
follow-up

Customized
lifestyle program

Treatment Objectives
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms

(Cost)

Treatment

Selected patients

Prevention. Control of risk factors

Life style
All Treat etiologic cause / aggravating factors
Drug therapy
Personal care. Team work
Revascularization if ischemia causes HF
ICD (Implantable Cardiac Defibrillator)
Ventricular resyncronization
Ventricular assist devices
Heart transplant
Artificial heart
Neoangiogenesis, Gene therapy

Precipitating Causes of HF

Therapies of Demonstrated Benefit

Across the Cardiovascular
Continuum
Post-MI
Mild-Mod Severe
ACC A

CAD

Post-MI LV Dysfunction

HF

HF

HTN
DM
HPL
Genetics

ACE
Inhibitor

HOPE
(ramipril)

TIBBS
Beta-Blocker (bisoprolo
l)

ARB
Aldosterone
Antagonist
Diuretics

HOPE
(ramipril)
BHAT/Norwegian
(propranolol/timol
ol)
(metoprolol)

AIRE/SAVE
(ramipril/captopril)
CAPRICORN
(carvedilol)
VALIANT
valsartan
EPHESUS
(eplerenone)

SOLVD /CONSENSUS
(enalapril)
MERIT/US CARV
(Toprol carvedilol)

COPERNICUS
(carvedilol)

ELITE II
CHARM
Losartan=Captopril Candesartan
Val-HFT
(Valsartan)

RALES
(spironolactone

Treatment Strategies

Complications of HF
Arrhythmias: AF; V Tach, VF, Brady arrhythmias
Thromboembolism: Stroke; DVT, PE, VTE
Gastrointestinal: Hepatic congestion and hepatic
dysfunction; malabsorption
Musculoskeletal: Muscle wasting
Respiratory: Pulmonary congestion; respiratory
muscle weakness; pulmonary hypertension (rare)
BMJ Vol . 320, 22 Jan 2000

Prognosis of Heart Failure

The prognosis of Heart failure is poor
Mortality from CHF after 5 years - 32 years
follow up in the Framingham study

62% in Men; 42% in Women

Mortality rate >> Ca Breast, Prostate, Colon

Survival better with NEF HF
Disability extreme recurrent hospital adm.
HF quality of life is much worse
HF is an expensive condition
Trends: increasing incidence & prevalence

of

Predisposing Factors Ventricular Arrhythmias

Recurrent or continued coronary ischemia
Recurrent myocardial infarction
Hypokalemia and Hyperkalemia
Hypomagnesaemia
Psychotropic drugsfor example, TCA
Digoxin toxicity
Anti arrhythmic drugs (cardio-depressant inotropism
and pro arrhythmic)
BMJ Vol . 320, 22 Jan 2000

Conclusion
CHF is common
CHF is deadly
CHF is costly
CHF is preventable
effective strategies exist to deal with
CHF but are greatly underutilized