Heart Failure Diagnosis

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Heart Failure Diagnosis Jamil Mayet, Consultant
CardiologistInternational Centre for
Circulatory HealthSt. Marys Hospital Imperial
College NHS Trust
London, January 16, 2008
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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
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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
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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

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Problems in heart failure management

• Accurate diagnosis
• Optimising drug therapy
• Identification of patients who will benefit from
  toys (intervention)

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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)

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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
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Heart failure - diagnosis

• Immobility
• Heart failure
• Venous thrombosis / obstruction / varicose veins
• Hypoproteinaemia eg nephrotic syndrome, liver
  disease
• Lymphatic obstruction

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Heart failure - diagnosis

• Common alternative causes of shortness of breath
• COPD / Asthma
• Chest infection
• Pulmonary fibrosis
• Myocardial ischaemia
• Aortic stenosis
• Obesity

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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.

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Investigations Electrocardiogram
Normal
Abnormal LBBB
If ECG normal very unlikely to be systolic
dysfunction
Previous MI, LBBB, Non-specific ST/T
abnormalities
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Investigations Chest Radiography
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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
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Investigations Echocardiography

• Confirms / refutes diagnosis of systolic
  dysfunction
• Can exclude significant valvular disease
• Can suggest ischaemic aetiology if regional wall
  motion abnormality

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Investigations

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

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Investigations Stress Testing
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Investigations Angiography
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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

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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
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Coronary Revascularisation
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Hibernating myocardium
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Prediction of functional recovery following
revascularisation
Wijns et al. N Engl J Med 1998339173-81
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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
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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

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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.

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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

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Defibrillators for heart failure
602 AM
605 AM
607 AM
611 AM
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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
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NICE guidance on defibrillators
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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

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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

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Left Ventricular Diastolic Dysfunction
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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

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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