Transcript Heart Failure - Northwestern Memorial Hospital

The Heart and Heart Failure
in the Year 2013
Jonathan D. Rich, MD
Associate Director, Mechanical Circulatory Support Program
Bluhm Cardiovascular Institute
Assistant Professor of Medicine
Northwestern University Feinberg School of Medicine
Outline
Basics of the heart and the cardiovascular system
Define the term “heart disease”
Heart disease risk factors and prevention
Heart Failure as a major consequence of heart
disease
Treatment of heart failure in 2013
Q and A
•Since 1900, heart disease has been the No. 1
killer in the United States every year but 1918
•Nearly 2,600 Americans die of heart disease
each day, an average of 1 death every 33 seconds
•Almost 150,000 Americans killed by heart
disease each year are under age 65
The Heart Basics
A muscle about the size of your
fist
Weighs approximately one pound
Is located behind and slightly to
the left of the breastbone
Pumps about 5 liters of blood
every minute
Major Function of the Heart
•Pump blood through the lungs to refresh the blood
with oxygen and remove carbon dioxide
•The oxygenated blood is pumped to the body to
provide oxygen and nutrients and to remove waste
products
•The coronary arteries are the blood vessels that
supply blood and oxygen to the heart
What exactly is heart disease?
Any disease that affects the heart
Because coronary artery disease is so common,
many people use the term “heart disease”
synonymously with “coronary artery disease”
Coronary Artery Disease
Coronary artery disease is one of the most common
causes of heart disease.
Fatty deposits build up in blood vessel walls causing
narrowings, called atherosclerosis.
Over time, this can lead to a complete blockage of the
coronary artery and a “heart attack”.
Heart Disease Risk Factors
High cholesterol
High blood pressure
Diabetes
Smoking
Obesity
Lack of physical activity
Genetics
Heart Disease Risk Factors
Uncontrollable
•Sex
•Race
•Age
•Genetics
Heart Disease Risk Factors
Uncontrollable
Controllable
•Sex
•High cholesterol
•Race
•High blood pressure
•Age
•Diabetes
•Genetics
•Smoking
•Physical activity
•Obesity
•Stress and anger
•Get regular medical checkups.
•Control your blood pressure.
•Check your cholesterol.
•Don’t smoke.
•Maintain a healthy weight
•Avoid diabetes
•Exercise regularly.
•Manage stress.
•Choose your parents wisely!
Heart Failure: Incidence and Prevalence
• Approximately 5,000,000 Americans currently suffer from heart
failure
• Approximately 500,000 new cases of heart failure are diagnosed
each year
• Among those with heart failure, approximately 250,000 have
“advanced” or Stage D heart failure
• Nearly 1,000,000 hospital discharges per year for heart failure
and the most frequent cause of hospitalization in the elderly
• Given the burden of heart failure, emphasis on aggressive,
guidelines-based medical heart failure therapy is critical.
1 World Health Statistics, World Health Organization, 1995.
2 American Heart Association, 2002 Heart and Stroke Statistical Update.
Heart Failure
What is Heart Failure?
• A. The heart is not pumping/squeezing as well as it should
(aka systolic heart failure)
• B. The heart is not relaxing as well as it should
(aka diastolic heart failure)
• Usually, the heart has been weakened by an underlying
condition(s)
– Blocked coronary arteries/heart attack
– High blood pressure
– Heart valve abnormalities
– Viral infection
– Other/unknown
Heart Failure
Heart failure can involve the left or right side of the
heart (or both sides)
In the majority of cases, the left side is affected first
Heart failure occurs when either side of the heart
cannot keep up with the demands placed on it to
provide sufficient blood flow to the body
Heart Failure
How quickly does heart failure develop?
• It depends
– Often a chronic disease with a slow, insidious onset
– Other times can develop rapidly (i.e. after a large heart
attack or an acute viral infection).
• The heart tries to compensate for the loss in
pumping function by:
– Developing more muscle mass
– Enlarging itself
– Pumping faster
Natural History of HF
100%
Survival (%)
Progression
Mechanism of Death
Sudden death 40%
Worsened HF 40%
Other
20%
Annual Mortality
0%
<5%
Asymptomatic
10%
Mild
20%–30%
Moderate
30%–80%
Severe
LV Dysfunction and Symptoms
Disease Progression of HF
ACC/AHA Stages
D
C
B
A
Refractory
End-Stage HF:
Marked symptoms
at rest despite maximal
medical therapy
Symptomatic HF: Known structural
heart disease, shortness of breath and
fatigue, reduced exercise tolerance
Asymptomatic LVD: Previous MI, LV systolic
dysfunction, asymptomatic valvular disease
High Risk: Hypertension, coronary artery disease, diabetes,
family history of cardiomyopathy
Yancy CW, Strong M. Prim Care Spec Ed. 2002;6:15
Heart Failure Treatment Objectives
First Objective: Improve survival
Second Objective: Improve quality of life
–
–
–
–
Reduce symptoms
Improve exercise capacity
Reduce hospitalizations
Slow the progression of the disease
The more common forms of heart failure often cannot be
cured, but they can be effectively treated
Disease Progression of HF
ACC/AHA Stages
D
C
B
A
Refractory
End-Stage HF:
Marked symptoms
at rest despite maximal
medical therapy
Symptomatic HF: Known structural
heart disease, shortness of breath and
fatigue, reduced exercise tolerance
Asymptomatic LVD: Previous MI, LV systolic
dysfunction, asymptomatic valvular disease
High Risk: Hypertension, coronary artery disease, diabetes,
family history of cardiomyopathy
Yancy CW, Strong M. Prim Care Spec Ed. 2002;6:15
Progression of HF Therapy
PLUS inotropes,
transplant, ventricular
assist device
PLUS ACE inhibitors, beta blockers,
diuretics, digoxin, aldosterone receptor
antagonists, dietary salt restriction
PLUS ACE inhibitors, ARB, beta blockers, and
aldosterone receptor antagonists in
appropriate populations
Treat hypertension and lipids, smoking cessation,
exercise, limit alcohol, ACE inhibitors in appropriate
populations
Yancy CW, Strong M. Prim Care Spec Ed. 2002;6:15
Heart Failure
Medications: The Cornerstone of HF Therapy
• Beta Blockers
• Ace Inhibitors
• Aldosterone antagonists
• Diuretics
• Digoxin
• Others
Heart Failure
Device Therapy
-Defibrillator (ICD)
-Biventricular Pacemaker
-Combined ICD and BIV pacemaker
Surgery and/other Procedures
– Angioplasty
– Coronary artery bypass surgery
– Valve replacement
Surgical
Percutaneous
Heart Failure: Advanced Treatment Options
 Heart transplantation
 Left ventricular assist devices (LVAD)
A: Bridge to transplantation
B: “Destination therapy”
The Right Time for Advanced Heart Failure Therapy
“Perfect Window”
Operative
Risk
Too early
Clinical severity
of heart failure
Too late
End-organ dysfunction
Death
HEART TRANSPLANTS
Kaplan-Meier Survival
(Transplants: January 1982 - June 2010)
100
Half-life = 10 years
Conditional half-life = 13 years
Survival (%)
75
50
N = 96,273
N at risk at 25 years = 112
25
0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Years
ISHLT
2012
J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095
Survival is based on adult and
pediatric transplant recipients
NUMBER OF HEART TRANSPLANTS
REPORTED BY YEAR
4500
3500
3000
2500
2000
4003
3136
1500
4364 4429 4396 4263
4199
3363
3864
3581
3433 3390 3283
3226
3065 3185 3205
2713
2159
1000
1182
500
0
4171 4203
665
189 318
19
8
19 2
8
19 3
8
19 4
8
19 5
8
19 6
87
19
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
9
19 6
9
19 7
9
19 8
99
20
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
06
Number of Transplants
4000
ISHLT
J Heart Lung Transplant 2008;27: 937-983 2008
NOTE: This figure includes only the heart transplants that are
reported to the ISHLT Transplant Registry. As such, this
should not be construed as evidence that the number of
hearts transplanted worldwide has declined in recent years.
Heart Transplantation
Rise of the Machines
INTERMACS
First Generation VADs
First Generation VADs
HeartMate Vented
Electric (VE) LVAS
1995
1997
HeartMate Implantable
Pneumatic (IP) LVAS
Second Generation VADs
First Generation Pulsatile LVAD
Second Generation Continuous flow LVAD
Continuous flow LVADs
N Engl J Med 2007;357:885-96
Continuous Flow LVADs
3rd Generation Continuous Flow LVADs
Next Generation Continuous Flow LVADs