???? Clinical Aspect of Congestive Heart Failure

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????Clinical Aspect of Congestive Heart Failure
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The Epidemiology of Congestive Heart Failure in
the United States
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Prognosis Related to Severity of Heart Failure
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Left Ventricle
Right Ventricle
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• Left vs. Right heart failure
• Forward vs. Backward heart failure
• Systolic vs. Diastolic heart failure
• Low vs. High cardiac output heart failure
• Chronic vs. Acute heart failure

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Causes of Left Heart Failure
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Causes of Right Heart Failure

• Consequence of Left Heart Failure
• Right Ventricular Infarction
• Pulmonary Hypertension Disease
• Congenital Heart Disease
• Infective Endocarditis

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Causes of Low Cardiac Output Heart Failure

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• ??Preload ??
• ??Afterload ??

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Causes of High Cardiac Output Heart Failure

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• Vit B1 ?? (Beri Beri disease)
• AV fistula / shunt

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Common Causes of Chronic Heart Failure
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Common Causes of Acute Heart Failure

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New York Heart Association Classification, 1964
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Normal vs. Enlarged Heart Failure Diastolic vs.
Systolic Heart Failure
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Congestive Heart Failure with Left Ventricular
Hypertrophy
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Congestive Heart Failure with Bi-ventricular
Dilatation and Bilateral Pleural Effusion
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Aims of Treatment for CHF
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??????? - Systolic CHF

• To improve
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• ??Afterload ??

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??????? - Diastolic CHF

• To improve
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• ??Afterload ??

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Non-pharmacological Treatment of CHF
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• ACEI
• ????? Normal cardiac size or Rapid heart rate

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Neuro-Hormonal Activation in CHF
Renin-Angiotensin System ( Angiotensin II )
Autonomic System ( Norepinephrine )
Hypertrophy, Apoptosis, Remodelling, Fibrosis,
Ischemia, Arrhythmia
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ACE inhibitors in heart failure

• Approximately 7,000 patients evaluated in
  placebo-controlled clinical trials
• Consistent improvement in cardiac function,
  symptoms and clinical status
• Decrease in all-cause mortality by 20-25
  (plt0.001)
• Decrease in combined risk of death and
  hospitalisation by 20-25 (plt0.001)

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Class I
Class IV
Class II Class III
SOLVD Prevention (enalapril)
CONSENSUS (enalapril)
SOLVD Treatment (enalapril) V-HeFT II (enalapril)
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ACE inhibitors in heart failure

• Consensus recommendations
• All patients with heart failure (NYHA Fc I-IV)
  due to left ventricular systolic dysfunction
  should receive an ACE inhibitor unless they have
  a contraindication to its use or cannot tolerate
  treatment with the drug

US Consensus Recommendations (1996)
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Adrenergic activation
CNS sympathetic outflow
Cardiac sympathetic activity
Sympathetic activity to kidneys blood vessels
b1 receptors
b2 receptors
a1 receptors
Myocyte hypertrophy death, dilatation,
ischaemia arrhythmia's
Vasoconstriction Sodium retention
Adapted from M Packer
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Antiadrenergic therapy by ? blockade
Sympathetic activation
b1 receptors
a1 receptors
b2 receptors
Bisoprolol Metoprolol
Propranolol
Carvedilol
CARDIOTOXICITY
Adapted from M Packer
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Comprehensive Adrenergic Blockade
b blockade
a1 blockade
Cardiac output
Renal blood flow
Worsening heart failure
a1 blockade
Sodium retention
Adapted from M Packer
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US Carvedilol Study
Survival
1.0 0.9 0.8 0.7 0.6 0.5
Carvedilol (n696)
? blockers in heart failure - all-cause
mortality
Placebo (n398)
Risk reduction 65
plt0.001
Days
0
50
100
150
200
250
300
350
400
Packer et al (1996)
Mortality
Survival
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MERIT-HF
CIBIS-II
1.00.80.6 0
Placebo
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Bisoprolol
Metoprolol CR/XL
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Risk reduction 34
Placebo
Risk reduction 34
5
p0.0062
plt0.0001
0
0
3
6
9
12
15
18
21
0 200 400
600 800
Months of follow-up
The MERIT-HF Study Group (1999)
Lancet (1999)
Time after inclusion (days)
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? blockers in heart failure

• Over 13,000 patients evaluated in
  placebo-controlled clinical trials
• Consistent improvement in cardiac function,
  symptoms and clinical status
• Decrease in all-cause mortality by 3035
  (plt0.0001) (up to 65 with carvedilol)
• Decrease in combined risk of death and
  hospitalisation by 2530 (plt0.0001)

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Class I
Class IV
Class II Class III
CAPRICORN (carvedilol) ?
COPERNICUS (carvedilol)
US Carvedilol (carvedilol)CIBIS II
(bisoprolol)MERIT-HF (metoprolol)
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? blockers in heart failure

• Consensus recommendations
• All patients with stable class II or III heart
  failure due to left ventricular systolic
  dysfunction should receive a ? blocker (in
  addition to an ACE inhibitor) unless they have a
  contraindication to its use or cannot tolerate
  treatment with the drug
• Why are the recommendations more restrictive
  than for ACE inhibitors despite the available
  evidence?

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• ???????ACEI
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• ??? - Cardiomegaly Atrial fibrillation
• ???????? Normal cardiac size or Rapid heart
  rate
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Thank you for your attention