4. Definition
• Heart Failure is a clinical syndrome including
circulatory congestion or inadequate tissue
perfusion, due to abnormal heart function and
associated neurohormonal abnormalities
5. Definition of Heart Failure (HF)
• HF is a clinical syndrome in which the patient have the
following features
– Symptoms typical of HF
• Breathlessness at rest or on exercise, fatigue,
tiredness, ankle swelling
– Signs typical of HF
• Tachycardia , tachypnoea, rales, pleural effusion,
raised venous pressure etc
– Objective evidence of structural or functional
abnormality of the heart at rest
• Cardiomegaly, S3,cardiac murmurs, abnormality on
echo, raised natriuretic peptides
6. Epidemiology of CHF
• ESC population: > 900 million in 51 countries
• Prevalence of HF : 15 million
• Prevalence of asymptomatic LV dysfunction: 15 million
• Estimated prevalence ~ 4 % of the population and increases with
age
– Ageing of the population
– Success of treatment of heart disease
– Hypertension
– Diabetes
– Success of treatment in pts with malignancies
– Obesitas
• Prognosis is poor: overall survival at 4 years is 50 %
• HF : 5 % of acute hospital admissions/ 10 % of pts in hospital
beds and ~ 2% of national expenditure on health
7. Prevalence of HF by Age and Gender
• HF afflicts 10 out of every 1,000 over age 65 in the U.S.
United States 1988-94
10
Percent of Population
Males
8
Females
6
4
2
0
20-24 25-34 35-44 45-54 55-64 65-74 75+
Source: NHANES III (1988-94), CDC/NCHS and the American Heart Association
8. Annual absolute mortality in the E.U. for different
pathologies
ovary cancer
bowel cancer
prostate cancer
breast cancer
colon/rectum cancer
lung cancer
all cancers combined
heart failure
myocardial infarction
sudden cardiac death
0 100000 200000 300000 400000 500000 600000 700000 800000
•( Murdoch RD et al. Importance of heart failure as a cause of death. Eur H J 1998;19 )
9. The mortality from heart failure is as bad as , or even worse
than, that of many common cancers
J. McMurray, H. Dargie, Chronic Heart Failure
10. Netherlands
• Prevalence: 250.000 pts
• Incidence : 20.000 pts annually
• 10 % of the population > 75 years
• Poor prognosis due to progression of HF and sudden cardiac
death
• 14 % of total hospital admissions for heart disease ( 8% of
all types of heart and vessel)
11. Prevalence of HF in relation to age
The Rotterdam Study
• 55-64 year: 0.9%
• 65-74 year: 4.0%
• 75-84 year: 9.7%
• >84 year: 17.4%
Bleumink GS et al. Quantifying the heart failure epidemic. The Rotterdam Study.
Eur. Heart J 2004:25:1614-19.
12. Life-time risk for HF
The Rotterdam Study
• 55 year: 30.2%
• 65 year: 30.3%
• 75 year: 28.7%
• 85 year: 23.1%
13. NYHA Class
Class I Class II Class III Class IV
Moderate
Asymptomatic Mild symptomatic Symptomatic
symptomatic
heart failure heart failure heart failure
heart failure
ejection fraction with ordinary at rest
with less than
(EF) <40% exertion
ordinary exertion
Advisory Council to Improve Outcomes Nationwide in Heart Failure. Consensus recommendations for the management of chronic
heart failure. Am J Cardiol. 1999;83(2A).
14. Ondanks maximale medicatie
100 10
Survival
Annual survival (%)
75
Hospitalizations / year
50 1
25
Hospitalization
0 .1
I II III IV
NYHA CLASS
•With the progress of the disease hospitalizations become frequent
15. NYHA II NYHA III
12%
26%
CHF
Other
SCD
24%
59% CHF
64% Other
15%
SCD
NYHA IV
33%
CHF
Other
SCD
56%
11% MERIT-HF studie. Lancet 1999;353:
2001-07
16. Incidence of intraventricular conduction disturbances
Gemiddelde HF 3-5
Severe Heart Failure class III/ IV
populatie 1,2
15%
IVCD
NCD
IVCD
30% NCD
70%
85%
1,2: Am H J 2002:; 143: 412-7/ Circ 2000; 102 ( 18 suppl II)
3-5: Am J Card 1993; 71: 720-6; Circ 1997; 95: 2660-7; Eur H J 2000;21:1246-
50
17.
18. Heart Failure Definition
A Complex Clinical Syndrome
in which the heart is incapable of
in which the heart is incapable of maintaining maintaining
a cardiac output adequate to
accommodate the metabolic requirements an adequate
venous return.
( E . Braunwald 1997)
19. Classification of HF
• To the onset:
– acute/ transient/ chronic
• Based on LV function:
– HF with low ejection fraction: Systolic Heart Failure
– HF with preserved ejection fraction: Diastolic Heart
Failure
• Clinical syndrome:
– Forward vs backward failure
20. Etiology of Heart Failure
What causes Heart Failure ?
Ischemic Heart Disease
Hypertension,
Idiopathic Cardiomyopathy,
Infections Injury to the heart
(viral myocarditis,Chagas’ disease),
Toxins
(alcohol,cytotoxic drugs),
Valvular Disease,
Prolonged Arrhythmias Loss of a critical quantity of
functioning myocardial cells
21.
22.
23. The progression of Heart Failure
Ho et al., Epidemiology of Congestive Heart Failure
24. The HF Syndrome
( Different Profiles)
Systolic and Diastolic Diastolic Dysfunction and
Dysfunction systolic function preserved
70% 30%
(EF > 40 %)
(EF > 40 %)
(EF < 40%)
1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200
30. Distribution of LVEF among women and men
enrolled in the Euro Heart Survey
Hogg K et al. JACC 2004;43:317-27
31. Kaplan-Meier Survival curves for Pts with Heart Failure and Preserved or
reduced Ejection Fraction
N Engl J Med 2006;355:260-9
32. Type hartfalen
• HF + low EF: systolic HF • HF + normal EF: diastolic
• Younger HF
• Males • Older
• Ischemic heart disease • Females
• Less comorbidity • Hypertension
• Cardiologist • More comorbidities
• Evidence based medicine • GP/ internal med
(RCT) • Treatment: ?
33.
34. Definition
• Heart Failure is a clinical syndrome including
circulatory congestion or inadequate tissue
perfusion, due to abnormal heart function and
associated neurohormonal abnormalities
35. Cardiac Output
• Cardiac output is the amount of blood that the ventricle ejects per
minute
Cardiac Output = HR x SV
4-8 liters / min 60-100 ml
41. Neuro Hormonal Activation Mechanism
Hormonal Systems
SNS RAAS
Vasopressin
Normal Cardiovascular Homeostasis
42. Pathophysiology of HF
Compensatory mechanisms and secondary damage
Tri
gg
er
i
60% njur
y
Compensatory
mechanisms
Ejection
Fraction
Secondary
damage
20%
Time
Asymptomatic Symptomatic
43. Compensatory Mechanisms:
Sympathetic Nervous System
Decreased MAP
↑Sympathetic Nervous System
↑Contractility Tachycardia Vasoconstriction
↑TPR
↑SV x ↑HR
46. Compensatory Mechanisms
Neurohormonal Activation
Many different hormone systems are involved in
maintaining normal cardiovascular homeostasis,
including:
• Sympathetic nervous system (SNS)
• Renin-angiotensin-aldosterone system (RAAS)
• Vasopressin (a.k.a. antidiuretic hormone, ADH)
47.
48.
49. Neurohormonal stimulation
• Actication of the Sympathetic nervous system:
• Tachycardia
• Increased Oxygen demand: ischaemia
• Fibrosis
• Increased cell death: apoptosis
• Vasoconstriction
• Activation of RAAS
• Activation of the Renin Angiotensin Aldosteron System
• Retention of Sodium and H2O
• Increased Aldosteron secretion
• Vasoconstriction
50. Left Ventricular Dysfunction
Volume Pressure Loss of Impaired
Overload Overload Myocardium Contractility
LV Dysfunction
EF < 40%
Cardiac End Systolic Volume
Output
End Diastolic Volume
Hypoperfusion
Pulmonary Congestion
51. Hemodynamic Basis for HF Symptoms
LVEDP
Left Atrial Pressure
Pulmonary Capillary Pressure
Pulmonary Congestion
56. Short- and Longterm results of
activation of the neurohormonal
system
• Retention of sodium and water: Increase of preload:
Congestion
• Vasoconstriction: increase of afterload
• SNS stimulation: increased oxygen expenditure
• Hypertrophy: cell death
57. - Combined 1-, 1- en 2-blockade at heart failure (1) -
CNS: sympathetic
activation
Cardiac sympathetic activitation Renal and peripheral
vascular& sympathetic
activitation
1- 2-receptoren 1-receptoren
receptoren
Hypertrophy and myocyte death, Vasoconstriction &Na+-
dilatation, ischaemia and retention
arrhythmia Packer (1998)
59. Angiotensine II and end organ damage
CVA
Atherosclerosis*
Vasoconstriction
Vasculaire hypertrophy Hypertension
Endothelial dysfunction MI
AII receptor
AT 1
LV hypertrophy
Fibrosis Heart fail Death
Remodeling
GFR
Proteinurie
Renal fail
Aldosteron release
Glomerulaire sclerosis
*
Rouleau J., data gepresenteerd tijdens WCC, Sydney 2002
69. Echocardiography
• Distinction between systolic versus diastolic dysfunction
– HFPEF: diastolic dysfunction
– Presence of signs & symptoms of HF
– Presence of normal or only mildly abnormal
LVEF≥45-50 %
– Evidence of abnormal LV relaxation or diastolic
stiffness
• Ejection fraction; RWM; valvular disease; filling status of
the ventricle
• TOE: inadequate TTE; complicated valvular pts;
endocarditis; CHD; suspection of thrombus in LAA in pts
with AF
75. Prediction of mortality and morbidity with a 6-minute
walk test in patients with LVD
12 10,23
p<0.02
10
Mortality % 7,88
8
6 4,19
2,99
4
2
0
level 1 level 2 level 3 level 4
n=176 n=241 n=215 n=201
Distance Walked, m, by
Performance Level
