Title: Heart Failure Diagnosis
1Heart Failure Diagnosis Jamil Mayet, Consultant
CardiologistInternational Centre for
Circulatory HealthSt. Marys Hospital Imperial
College NHS Trust
London, January 16, 2008
2Heart 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
3Heart failure admissions are long
Average duration of hospital admission (days)
British Heart Foundation, 2002
4The 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)
6Heart 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
7Problems in heart failure management
- Accurate diagnosis
- Optimising drug therapy
- Identification of patients who will benefit from
toys (intervention)
8Heart 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)
9Heart 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
10Heart failure - diagnosis
- Immobility
- Heart failure
- Venous thrombosis / obstruction / varicose veins
- Hypoproteinaemia eg nephrotic syndrome, liver
disease - Lymphatic obstruction
11Heart failure - diagnosis
- Common alternative causes of shortness of breath
- COPD / Asthma
- Chest infection
- Pulmonary fibrosis
- Myocardial ischaemia
- Aortic stenosis
- Obesity
12Heart 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.
13Investigations Electrocardiogram
Normal
Abnormal LBBB
If ECG normal very unlikely to be systolic
dysfunction
Previous MI, LBBB, Non-specific ST/T
abnormalities
14Investigations Chest Radiography
15Investigations 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
16Investigations Echocardiography
- Confirms / refutes diagnosis of systolic
dysfunction - Can exclude significant valvular disease
- Can suggest ischaemic aetiology if regional wall
motion abnormality
17Investigations
- Exercise ECG testing
- Stress echocardiography
- Nuclear imaging
- Cardiac catheterisation
- (Lung function testing)
18Investigations Stress Testing
19Investigations Angiography
20Diagnosing 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
21Hibernating 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
22Coronary Revascularisation
23Hibernating myocardium
24Prediction of functional recovery following
revascularisation
Wijns et al. N Engl J Med 1998339173-81
25Implications of viable myocardium
MV - revascularised
MV med Px
No MV med Px
No MV - revascularised
Senior et al. J Am Coll Cardiol 1999331848-54
26Left 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
27Dyssynchrony
- 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.
28Effects 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
29Defibrillators for heart failure
602 AM
605 AM
607 AM
611 AM
30Implantable 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
31NICE guidance on defibrillators
32Heart 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
33Diastolic 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
34Left Ventricular Diastolic Dysfunction
35Treatment 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
36CRT 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