Heart Failure Diagnosis - PowerPoint PPT Presentation

1 / 36
About This Presentation
Title:

Heart Failure Diagnosis

Description:

Investigations: Chest Radiography. ROC Curve BNP. 1 - Specificity ... (NYHA III-IV) randomised to medical therapy with or without cardiac resynchronisation ... – PowerPoint PPT presentation

Number of Views:295
Avg rating:3.0/5.0
Slides: 37
Provided by: jamil
Category:

less

Transcript and Presenter's Notes

Title: Heart Failure Diagnosis


1
Heart Failure Diagnosis Jamil Mayet, Consultant
CardiologistInternational Centre for
Circulatory HealthSt. Marys Hospital Imperial
College NHS Trust
London, January 16, 2008
2
Heart Failure The size of the problem
  • Common
  • Affects 1-2 of the population
  • Annual incidence is 0.5-1
  • Serious
  • Mortality is 40 by 12 months after new
    diagnosis, and 10 per year thereafter
  • Increasing
  • Due to ageing population and more effective
    treatment of acute myocardial infarction
  • Disabling
  • Symptoms have enormous impact on quality of life
    worse than many other chronic conditions
  • Expensive
  • Accounts for 1-2 of NHS budget, 5 of acute
    admissions, and 10 of bed occupancy

BMJ, 2002 Eur J Heart Failure, 1999 NICE, 2003
BHF, 2002 DOH 2003
3
Heart failure admissions are long
Average duration of hospital admission (days)
British Heart Foundation, 2002
4
The cost of heart failure in the UK is large and
is driven by inpatient care
Drugs 9
(11-13 visits per year)
Primary Care 17
Outpatient investigation 6
Outpatient care 8
Inpatient care 60
Total cost 600 million (1 of annual NHS
budget)
British Heart Foundation, 2002
5
(No Transcript)
6
Heart failure
  • Cardiac output that is insufficient to meet the
    needs of the body
  • Myocardial dysfunction
  • Ischaemic heart disease, Alcohol, Viral
    myocarditis
  • Peri-partum, Dilated Cardiomypathy
  • Volume overload
  • Aortic / Mitral Regurgitation
  • Obstruction
  • Aortic / Mitral Stenosis, Hypertrophic
    Cardiomyopahy
  • Diastolic dysfunction
  • Constriction
  • Mechanical problems
  • LV aneurysm
  • Rhythm disturbance
  • Atrial fibrillation
  • Metabolic
  • Thyrotoxicosis, Haemochromaotosis, Sarcoidosis
  • High output
  • Anaemia, shunts, thyrotoxicosis

7
Problems in heart failure management
  • Accurate diagnosis
  • Optimising drug therapy
  • Identification of patients who will benefit from
    toys (intervention)

8
Heart failure - diagnosis
  • European Society of Cardiology guidelines for
    diagnosis
  • Essential features
  • Symptoms of heart failure eg shortness of breath,
    ankle swelling
  • Objective evidence of cardiac dysfunction (at
    rest)
  • Non-essential featrures
  • Response to treatment directed at heart failure
    (in cases where diagnosis is in doubt)

9
Heart failure symptoms
  • SOBE
  • Orthopnoea, PND
  • Ankle swelling
  • Anorexia, weight loss
  • Cold peripheries
  • Tiredness

Heart failure signs
  • Tachycardia, hypotension
  • Raised JVP, S3
  • May be PSM of MR (or TR)
  • Basal crepitations
  • Ankle oedema

Not useful to divide into right and left heart
failure
10
Heart failure - diagnosis
  • Immobility
  • Heart failure
  • Venous thrombosis / obstruction / varicose veins
  • Hypoproteinaemia eg nephrotic syndrome, liver
    disease
  • Lymphatic obstruction

11
Heart failure - diagnosis
  • Common alternative causes of shortness of breath
  • COPD / Asthma
  • Chest infection
  • Pulmonary fibrosis
  • Myocardial ischaemia
  • Aortic stenosis
  • Obesity

12
Heart failure symptoms Classification
  • NYHA Classification of Heart Failure
  • Class 1 Asymptomatic
  • No limitation in physical activity despite the
    presence of heart disease
  • Class 2 Mild
  • Slight limitation in physical activity eg walking
    up several flights of steps. Almost normal
    lifestyle and employment
  • Class 3 Moderate
  • Marked limitation eg walking up 1 flight of
    steps symptoms walking on the flat. Interferes
    with work.
  • Class 4 Severe
  • Shortness of breath at rest or minimal exertion.
    Mostly housebound.

13
Investigations Electrocardiogram
Normal
Abnormal LBBB
If ECG normal very unlikely to be systolic
dysfunction
Previous MI, LBBB, Non-specific ST/T
abnormalities
14
Investigations Chest Radiography
15
Investigations Natriuretic peptides
Cut off point of 125 pg/ml for NTproBNP gives
97 NPV
Cut off point of 100 pg/ml for BNP gives 87 NPV
AUC 0.84 0.79-0.88
AUC 0.85 0.80 0.90
No test for heart failure has 100 negative
predictive value if clinical suspicion remains
high then further investigation should be
undertaken
Zaphiriou et al. Eur J Heart Failure 2005
16
Investigations Echocardiography
  • Confirms / refutes diagnosis of systolic
    dysfunction
  • Can exclude significant valvular disease
  • Can suggest ischaemic aetiology if regional wall
    motion abnormality

17
Investigations
  • Exercise ECG testing
  • Stress echocardiography
  • Nuclear imaging
  • Cardiac catheterisation
  • (Lung function testing)

18
Investigations Stress Testing
19
Investigations Angiography
20
Diagnosing ischaemic heart disease
  • 75 of white males in SOLVD were related to
    ischaemic heart disease
  • 50 of patients in Framingham had an ischaemic
    aetiology to their heart failure
  • Identification of patients who will benefit from
    revascularisation

21
Hibernating myocardium
  • Chronic LV dysfunction does not necessarily imply
    dead myocardium
  • Hibernating myocardium termed by Rahimtoola in
    1989
  • LV systolic function improved following coronary
    revascularisation

Rahimtoola. Am Heart J 1989117211-21
22
Coronary Revascularisation
23
Hibernating myocardium
24
Prediction of functional recovery following
revascularisation
Wijns et al. N Engl J Med 1998339173-81
25
Implications of viable myocardium
MV - revascularised
MV med Px
No MV med Px
No MV - revascularised
Senior et al. J Am Coll Cardiol 1999331848-54
26
Left Bundle Branch Block
  • Prolongation of the QRS complex is a specific
    indicator of decreased LV systolic function
  • LBBB with no structural heart disease associated
    with decreased LVEF
  • QRS duration broadens as LV function worsens

27
Dyssynchrony
  • Cardiac resynchronisation therapy (CRT) is an
    established treatment for patients with left
    bundle branch block (LBBB) and chronic severe
    heart failure.
  • CRT aims to improve symptoms by reducing
    ventricular dysynchrony.
  • The 12 lead ECG is commonly used to select
    patients suitable for CRT.
  • The QRS duration is used as a surrogate of
    ventricular activation time, from which
    dysynchrony is indirectly inferred.

28
Effects of Ventricular Dyssynchrony
  • Decrease in septal contribution to global EF
  • Uncoordinated ventricular contraction
  • early and late regions of LV activation
  • lateral wall contracts as septum relaxes (vice
    versa)
  • increase workload and LV stress
  • Abnormal LV filling - fusion of EA waves
  • Overlap between systole and diastole
  • Worsen mitral regurgitation

29
Defibrillators for heart failure
602 AM
605 AM
607 AM
611 AM
30
Implantable cardiac defibrillators
  • Selection for ICD often crucially depends on
    ejection fraction
  • MADIT 2
  • Previous MI
  • EFlt30
  • Mortality reduction of 28
  • SCD Heft
  • Ischaemic and non-ischaemic
  • EFlt35
  • Mortality reduction of 23

Assess for dysynchrony as well
31
NICE guidance on defibrillators
32
Heart Failure Diagnosis - Summary
  • Accurate diagnosis echo is the cornerstone
  • Investigate for coronary artery disease and
    viable myocardium
  • Will a pacemaker / defibrillator help
  • End of the bed assessment

33
Diastolic heart failure
  • Up to a third of patients have clinical heart
    failure with normal LV systolic function
  • Underlying pathophysiology relates to diastolic
    dysfunction
  • Commonest underlying pathologies
  • Normal ageing, Hypertension, Myocardial ischaemia

34
Left Ventricular Diastolic Dysfunction
35
Treatment of diastolic heart failure
  • Treat underlying cause eg ischaemia
  • Impaired relaxation
  • Theoretically rate-limiting agents effective
  • Beta-blockers, verapamil
  • Reduce HR and prolong diastole
  • Reduce myocardial oxygen demand
  • Lower BP and reduce LVH
  • Restriction
  • Drugs which reduce fibrosis and lower LA
    pressure theoretically should be effective
  • ACEI, AII blockers, Diuretics
  • If LA pressure lowered too much cardiac output
    significantly worsened
  • Can cause significant morbidity

36
CRT for heart failure CARE-HF
  • 813 patients (NYHA III-IV) randomised to medical
    therapy with or without cardiac resynchronisation
  • 37 reduction in primary endpoint, death or
    unplanned hospitalisation for cardiovascular
    event, 159 (39) CRT patients vs 224 (55)
    medical therapy Plt0.001
  • 36 reduction in secondary endpoint, death from
    any cause, 82 (20) CRT vs 120 (30) medical
    therapy P0.002

Cleland et al, NEJM, 2005
Write a Comment
User Comments (0)
About PowerShow.com