Heart failure with perserved systolic function.

1. Heart Failure SyndromeHeart Failure Syndrome
withwith
Preserved Systolic FunctionPreserved Systolic Function
Dr. Asadullah SoomroDr. Asadullah Soomro
CardiologistCardiologist
King Fahad Hospital, HofufKing Fahad Hospital, Hofuf
Kingdom of Saudi ArabiaKingdom of Saudi Arabia
Email;hssbasadsoomro@gmail.comEmail;hssbasadsoomro@gmail.com

3. IntroductionIntroduction
Heart failure is an enormous and rapidlyHeart failure is an enormous and rapidly
growing public health problem all over thegrowing public health problem all over the
world and in Kingdom of Saudi Arabiaworld and in Kingdom of Saudi Arabia
indeed.indeed.
Recent estimates suggest that more thanRecent estimates suggest that more than
5 million patients carry this diagnosis in5 million patients carry this diagnosis in
USA alone 75% are older than 65 years.USA alone 75% are older than 65 years.
More than 550,000 new cases of CHF areMore than 550,000 new cases of CHF are
diagnosed each year.diagnosed each year.

4. It remain primary cause of death andIt remain primary cause of death and
disability despite advances in moderndisability despite advances in modern
treatment.treatment.
It is the most common cause of hospitalIt is the most common cause of hospital
admission and readmission indeed.admission and readmission indeed.
Over a period of 3-6 months, 20-50%Over a period of 3-6 months, 20-50%
patients are readmitted and the cost ofpatients are readmitted and the cost of
these hospitalization was $5.45 billionthese hospitalization was $5.45 billion
compared to $3.2 billion for cancer andcompared to $3.2 billion for cancer and
$3.2 billion for MI.$3.2 billion for MI.

5. Two-year mortality rate in patients withTwo-year mortality rate in patients with
newly diagnosed CHF is 35% and 6-yearnewly diagnosed CHF is 35% and 6-year
mortality is 67% in women and 82% inmortality is 67% in women and 82% in
men.men.

6. DefinitionDefinition
Heart failure is a progressive andHeart failure is a progressive and
debilitating clinical syndromedebilitating clinical syndrome
characterized by an inability of the heart tocharacterized by an inability of the heart to
deliver enough Odeliver enough O22 and nutrient to meet theand nutrient to meet the
body’s metabolic needs at normal fillingbody’s metabolic needs at normal filling
pressurepressure

7. To most physician, the typical image ofTo most physician, the typical image of
patients with heart failure is one of apatients with heart failure is one of a
“dilated/ischaemic cardiomyopathy” and“dilated/ischaemic cardiomyopathy” and
“low left ventricular ejection fraction”.“low left ventricular ejection fraction”.
This is certainly the case when one isThis is certainly the case when one is
considering the “end stage” or “refractoryconsidering the “end stage” or “refractory
heart failure”.heart failure”.

8. Patients with heart failure and preservedPatients with heart failure and preserved
systolic function are surprisingly commonsystolic function are surprisingly common
representing 20-50% of all patients withrepresenting 20-50% of all patients with
diagnosis of CHF, yet despite thediagnosis of CHF, yet despite the
frequency of this syndrome, we knowfrequency of this syndrome, we know
relatively little about regarding its morbidityrelatively little about regarding its morbidity
and mortality.and mortality.

9. Heart Failure ClassificationHeart Failure Classification
SystolicSystolic DiastolicDiastolic MixedMixed
60%60% 40%40% CADCAD
CAD esp. MICAD esp. MI Hypertension Amyloido-Hypertension Amyloido-
Dilated cardio- LVHDilated cardio- LVH sissis
myopathymyopathy AgeAge
1 year mortality Amyloidosis1 year mortality Amyloidosis
19%19% 1 year mortality1 year mortality
8%8%

10. Heart Failure ClassificationHeart Failure Classification
Acute heartAcute heart Chronic heart Acute onChronic heart Acute on
failurefailure failurefailure (most common)(most common) chronicchronic
- Acute MIAcute MI - Old infarction- Old infarction heart failureheart failure
- Mechanical - RHDMechanical - RHD
complications - CHDcomplications - CHD
- Arrhythmias - PericardialArrhythmias - Pericardial
- HTN- HTN

11. Heart failureHeart failure
with enlarged heart sizewith enlarged heart size
Chronic MR, ARChronic MR, AR
Old myocardial infarctionOld myocardial infarction
Chronic atrial fibrillationChronic atrial fibrillation
Cardiomyopathy (D)Cardiomyopathy (D)
Congenital heart defectsCongenital heart defects
Long standing severeLong standing severe
hypertensionhypertension
Heart failureHeart failure
with normal heart sizewith normal heart size
Mitral stenosisMitral stenosis
Acute infarction, shockAcute infarction, shock
Acute AR, MRAcute AR, MR
Infective endocarditisInfective endocarditis
Aortic stenosis or HCMAortic stenosis or HCM
with atrial fibrillationwith atrial fibrillation
Pericardial constrictionPericardial constriction

12. Heart FailureHeart Failure
Low ejection fractionLow ejection fraction Normal/high ejectionNormal/high ejection
fractionfraction
Normal EnlargedNormal Enlarged Normal EnlargedNormal Enlarged
heart size heartheart size heart heart size heartheart size heart
- Acute MI - Old MI - Aortic -ThyrotoxicosisAcute MI - Old MI - Aortic -Thyrotoxicosis
stenosis - MRstenosis - MR
-Myocarditis - Dilated CMP -Mitral - AR-Myocarditis - Dilated CMP -Mitral - AR
stenosis w/stenosis w/
atrial fibrillationatrial fibrillation
HCMHCM

13. King Fahad Hospital, HofufKing Fahad Hospital, Hofuf
Cardiac admission in month 1/1423Cardiac admission in month 1/1423
Total admissions = 140Total admissions = 140
Male 61% Female 39%Male 61% Female 39%
Heart failureHeart failure :: 70 (50%)70 (50%)
Myocardial infarctionMyocardial infarction :: 22 (15%)22 (15%)
AnginaAngina :: 1919
ArrhythmiasArrhythmias :: 1717
HypertensionHypertension :: 44
RHDRHD :: 77
CHDCHD :: 11

14. Heart Failure at KFHHHeart Failure at KFHH
Total = 70 (50%)Total = 70 (50%)
Male 48 (68%) Female 22 (31%)Male 48 (68%) Female 22 (31%)
≤≤ 45 yrs.45 yrs. 46-5946-59 ≥ 60 years≥ 60 years
99 2222 3939
(13%)(13%) (31%)(31%) (55%)(55%)

15. Heart Failure AuditHeart Failure Audit
at Dow Medical College & Civil Hospital, Karachiat Dow Medical College & Civil Hospital, Karachi
DemographyDemography
Total NumberTotal Number 372 patients372 patients
PeriodPeriod 15/07/1995 to 15/11/199715/07/1995 to 15/11/1997
MenMen 243 (65.3%)243 (65.3%)
WomenWomen 129 (34.6%)129 (34.6%)
≥≥ 50 years of age50 years of age 214 (57.5%)214 (57.5%)
< 50 years of age< 50 years of age 158 (42.4%)158 (42.4%)

16. Causes of Heart FailureCauses of Heart Failure
at Dow Medical College & Civil Hospital, Karachiat Dow Medical College & Civil Hospital, Karachi
CoronaryCoronary 164164
RheumaticRheumatic 8888
HypertensionHypertension 3131
CardiomyopathiesCardiomyopathies 1919
CongenitalCongenital 1515
PericardialPericardial 1212
MiscellaneousMiscellaneous 4343

17. CAD with Heart FailureCAD with Heart Failure
No. 164/372No. 164/372
Men: 131 (80%)Men: 131 (80%) Women: 33 (20%)Women: 33 (20%)
> 50 years: 108> 50 years: 108 > 50 years: 29> 50 years: 29
< 50 years: 23< 50 years: 23 < 50 years: 04< 50 years: 04

18. Classified in Four GroupsClassified in Four Groups
1.1. Old myocardial infarction with heartOld myocardial infarction with heart
failure. 92 (56%)failure. 92 (56%)
2.2. Acute myocardial infarction with heartAcute myocardial infarction with heart
failure. 29 (18%)failure. 29 (18%)
3.3. Unstable angina with heart failureUnstable angina with heart failure
(without old/acute MI). 21 (12.8%)(without old/acute MI). 21 (12.8%)
4.4. Primarily symptom of heart failure (noPrimarily symptom of heart failure (no
myocardial infarction and angina).myocardial infarction and angina).
22 (13%)22 (13%)

19. Rheumatic Heart Disease and Heart FailureRheumatic Heart Disease and Heart Failure
Men = 36Men = 36 Women = 52Women = 52
≤≤ 50 years = 72 (82%)50 years = 72 (82%)
< 50 years = 16 (18%)< 50 years = 16 (18%)
Isolated mitral stenosisIsolated mitral stenosis 43 (49%)43 (49%)
MS + MRMS + MR 15 (17%)15 (17%)
ARAR 07 (08%)07 (08%)
MRMR 04 (4.5%)04 (4.5%)
MS + ARMS + AR 04 (4.5%)04 (4.5%)
MR + ARMR + AR 04 (4.5%)04 (4.5%)
ASAS 02 (2%)02 (2%)
AS + ARAS + AR 01 (1%)01 (1%)
AS + MRAS + MR 01 (1%)01 (1%)
MixedMixed 07 (8%)07 (8%)

20. Heart Failure with Preserved Systolic FunctionHeart Failure with Preserved Systolic Function
Prevalence, Morbidity and MortalityPrevalence, Morbidity and Mortality
At least 30 different studies haveAt least 30 different studies have
examined the magnitude of this problem,examined the magnitude of this problem,
which vary tremendously with regard towhich vary tremendously with regard to
patient population.patient population.
Framingham criteria for CHF diagnosisFramingham criteria for CHF diagnosis
and normal LV systolic function defined asand normal LV systolic function defined as
EF >50% on echocardiogramEF >50% on echocardiogram

21. Median prevalence was 36% with rangeMedian prevalence was 36% with range
from 13-74%. There was no significantfrom 13-74%. There was no significant
difference in rate of readmission, 51% fordifference in rate of readmission, 51% for
low EF and 56% for preserved systoliclow EF and 56% for preserved systolic
function.function.
However mortality was 18% in low EF andHowever mortality was 18% in low EF and
9% for preserved systolic function.9% for preserved systolic function.

22. The first response to the findings ofThe first response to the findings of
normal or “preserved ejection fraction” isnormal or “preserved ejection fraction” is
to consider alternative diagnosis.to consider alternative diagnosis.
The main focus on systolic dysfunctionThe main focus on systolic dysfunction
(low EF%) has left many physicians(low EF%) has left many physicians
confused and uncomfortable in treatingconfused and uncomfortable in treating
the patient with CHF and preservedthe patient with CHF and preserved
systolic function.systolic function.
In recent years, however, there has beenIn recent years, however, there has been
a growing recognition of magnitude anda growing recognition of magnitude and
importance of this problem.importance of this problem.

23. Causes of CHF and PreservedCauses of CHF and Preserved
Systolic FunctionSystolic Function
1. Inaccurate diagnosis of CHF (e.g. COPD)1. Inaccurate diagnosis of CHF (e.g. COPD)
2. Inaccurate measurement of LV ejection fraction.2. Inaccurate measurement of LV ejection fraction.
3. LV systolic function overestimated by EF3. LV systolic function overestimated by EF
(e.g. mitral regurgitation)(e.g. mitral regurgitation)
4. Episodic LV systolic dysfunction with4. Episodic LV systolic dysfunction with
improvement at time of evaluation.improvement at time of evaluation.
e.g.: - Severe hypertensione.g.: - Severe hypertension
- Myocardial ischaemia- Myocardial ischaemia
- Tachy or bradyarrhythmias- Tachy or bradyarrhythmias
- Volume overload- Volume overload
- Infections, Drugs- Infections, Drugs

24. Patients with heart failure and preservedPatients with heart failure and preserved
systolic function are surprisingly commonsystolic function are surprisingly common
representing 20-50% of all patients withrepresenting 20-50% of all patients with
diagnosis of CHF, yet despite thediagnosis of CHF, yet despite the
frequency of this syndrome, we knowfrequency of this syndrome, we know
relatively little about regarding its morbidityrelatively little about regarding its morbidity
and mortality.and mortality.

25. 5. Pericardial diseases (constriction/5. Pericardial diseases (constriction/
tamponade)tamponade)
6. Obstruction to LV inflow6. Obstruction to LV inflow
- Mitral stenosis- Mitral stenosis
- Left atrial myxoma- Left atrial myxoma
7. Diastolic dysfunction7. Diastolic dysfunction
A. IschaemiaA. Ischaemia
HypertrophyHypertrophy HypertensionHypertension
HypertrophicHypertrophic
cardiomyopathycardiomyopathy
Aortic stenosisAortic stenosis

26. AgingAging
CardiomyopathiesCardiomyopathies
High output statesHigh output states InfectionInfection
ThyrotoxicosisThyrotoxicosis
overloadoverload AnaemiaAnaemia
Beri-beriBeri-beri
PressurePressure VolumeVolume AV shuntAV shunt
(ESRD)(ESRD)

27. B. Altered passive elastic propertiesB. Altered passive elastic properties
DiabetesDiabetes
Infiltrative myocardial diseasesInfiltrative myocardial diseases
(amyloidosis, sarcoidosis)(amyloidosis, sarcoidosis)
Storage myocardial diseasesStorage myocardial diseases
(haemochromatosis)(haemochromatosis)
Endomyocardial fibrosisEndomyocardial fibrosis
RadiationRadiation

28. Diastolic DysfunctionDiastolic Dysfunction
1907 – Henderson first describe1907 – Henderson first describe
importance of ventricular relaxation.importance of ventricular relaxation.
1960-1970s – recognized that altered1960-1970s – recognized that altered
diastolic properties of the left ventriculardiastolic properties of the left ventricular
filling pressures that result in clinicalfilling pressures that result in clinical
presentation of CHF despite the presencepresentation of CHF despite the presence
of normal systolic function.of normal systolic function.

29. DefinitionDefinition
There is no standard definition for diastolicThere is no standard definition for diastolic
dysfunction, however, it is characterizeddysfunction, however, it is characterized
by:by:
““Abnormally elevated ventricular fillingAbnormally elevated ventricular filling
pressures despite normal or modestlypressures despite normal or modestly
increased ventricular volume andincreased ventricular volume and
preserved systolic function”.preserved systolic function”.

30. Heart failure with normal systolicHeart failure with normal systolic
functionfunction
““Diastolic dysfunction is not the onlyDiastolic dysfunction is not the only
mechanism”.mechanism”.
There are several circumstances in whichThere are several circumstances in which
a patient present with apparent CHF anda patient present with apparent CHF and
normal systolic function but does notnormal systolic function but does not
actually have diastolic dysfunction indeed.actually have diastolic dysfunction indeed.

31. First and most obviously, the diagnosis of CHFFirst and most obviously, the diagnosis of CHF
may be erroneous. The findings of dyspnea,may be erroneous. The findings of dyspnea,
cough, tachycardia, pulmonary crackles andcough, tachycardia, pulmonary crackles and
peripheral edema are non specific for CHF andperipheral edema are non specific for CHF and
can occur in many non-cardiac conditions suchcan occur in many non-cardiac conditions such
as chronic obstructive pulmonary diseases oras chronic obstructive pulmonary diseases or
pulmonary fibrosis.pulmonary fibrosis.
Chest X-ray can be misleading in patients withChest X-ray can be misleading in patients with
acute respiratory distress syndrome oracute respiratory distress syndrome or
pulmonary infections.pulmonary infections.

32. Second, diagnosis of CHF with preservedSecond, diagnosis of CHF with preserved
systolic function is dependent on accuratesystolic function is dependent on accurate
measurement of ejection fraction, however, EFmeasurement of ejection fraction, however, EF
measurement can differ substantially by differentmeasurement can differ substantially by different
techniques and even same technique can varytechniques and even same technique can vary
widely (e.g. obese patients, ICU patients onwidely (e.g. obese patients, ICU patients on
ventilator).ventilator).
Third, the commonly used index of LV ejectionThird, the commonly used index of LV ejection
fraction may overestimate the true status of LVfraction may overestimate the true status of LV
systolic function particularly in setting of valvularsystolic function particularly in setting of valvular
regurgitation, e.g. patient with EF 45% withregurgitation, e.g. patient with EF 45% with
significant MR may have severe dysfunction.significant MR may have severe dysfunction.

33. Fourth, circumstance is episodic LVFourth, circumstance is episodic LV
systolic dysfunction that has improved atsystolic dysfunction that has improved at
the time of evaluation, e.g. myocardialthe time of evaluation, e.g. myocardial
ischaemia, severe hypertension can oftenischaemia, severe hypertension can often
quickly recover by medical treatment.quickly recover by medical treatment.
Myocarditis, tachycardia-relatedMyocarditis, tachycardia-related
cardiomyopathy, peripartum cardiomyo-cardiomyopathy, peripartum cardiomyo-
pathy and alcoholic cardiomyopathypathy and alcoholic cardiomyopathy
sometimes improve dramatically over asometimes improve dramatically over a
period of several weeks with resolution ofperiod of several weeks with resolution of
infection or conversion to sinus rhythm.infection or conversion to sinus rhythm.

34. Diagnosis of heart failure withDiagnosis of heart failure with
preserved systolic functionpreserved systolic function
““Can diastolic dysfunction be differentiated?”Can diastolic dysfunction be differentiated?”
A variety of clinical criteria have been used toA variety of clinical criteria have been used to
diagnose CHF (Framingham, Duke and Bostondiagnose CHF (Framingham, Duke and Boston
investigations) but non of these criteria is highlyinvestigations) but non of these criteria is highly
sensitive or specific.sensitive or specific.
““20% of patients with low ejection fraction did not20% of patients with low ejection fraction did not
have criteria for CHF and 51% of patients withhave criteria for CHF and 51% of patients with
criteria for CHF had a normal ejection fraction”.criteria for CHF had a normal ejection fraction”.

35. It is important to note that neither history,It is important to note that neither history,
physical examination or X-ray withphysical examination or X-ray with
enlarged heart are able to reliablyenlarged heart are able to reliably
determine whether a patient with CHF hasdetermine whether a patient with CHF has
normal or abnormal systolic function.normal or abnormal systolic function.

36. Diastolic Dysfunction AssessmentDiastolic Dysfunction Assessment
The specific diagnosis of diastolic dysfunctionThe specific diagnosis of diastolic dysfunction
require measurement of LV pressure andrequire measurement of LV pressure and
volume simultaneously during diastole tovolume simultaneously during diastole to
generate pressure-volume curves which cangenerate pressure-volume curves which can
only be done by cardiac catheterization. Thisonly be done by cardiac catheterization. This
approach is not only invasive but timeapproach is not only invasive but time
consuming indeed.consuming indeed.
As a result, indirect assessment such asAs a result, indirect assessment such as
echocardiography doppler to determine LV fillingechocardiography doppler to determine LV filling
velocity pattern at MV level and radionuclidevelocity pattern at MV level and radionuclide
angiography has provided an alternativeangiography has provided an alternative
approach for assessing diastolic dysfunction.approach for assessing diastolic dysfunction.

37. Unfortunately, none of these methods areUnfortunately, none of these methods are
specific for diagnosis of diastolicspecific for diagnosis of diastolic
dysfunction because:dysfunction because:
1. Doppler method measures only velocity1. Doppler method measures only velocity
and not volumetric flow.and not volumetric flow.
2. Doppler parameters can be altered2. Doppler parameters can be altered
dramatically by changes in heart ratedramatically by changes in heart rate
preload, afterload, valve regurgitationpreload, afterload, valve regurgitation andand
medications.medications.

38. Thus without a specific diagnostic tool, theThus without a specific diagnostic tool, the
diagnosis of CHF caused by diastolicdiagnosis of CHF caused by diastolic
dysfunction is difficult to determine withdysfunction is difficult to determine with
any degree of certainty.any degree of certainty.
Hence at present, diastolic dysfunctionHence at present, diastolic dysfunction
remains a diagnosis of exclusion.remains a diagnosis of exclusion.

39. Systolic vs Diastolic Heart FailureSystolic vs Diastolic Heart Failure
HistoryHistory SystolicSystolic DiastolicDiastolic
Coronary arteryCoronary artery
diseasedisease
++++++ ++++
HypertensionHypertension ++++ ++++++++
DiabetesDiabetes ++++ ++++
Valvular heartValvular heart
diseasedisease
++++++++ ++
Paroxysmal dyspneaParoxysmal dyspnea ++++ ++++++

40. Physical exam.Physical exam. SystolicSystolic DiastolicDiastolic
CardiomegalyCardiomegaly ++++++ ++
Soft heart soundsSoft heart sounds ++++++++ ++
S3 gallopS3 gallop ++++++ ++
S4 gallopS4 gallop ++ ++++++
HypertensionHypertension ++++ ++++++++
Mitral regurgitationMitral regurgitation ++++++ ++
RalesRales ++++ ++++
EdemaEdema ++++++ ++
Raised JVPRaised JVP ++++++ ++

41. X-ray ChestX-ray Chest SystolicSystolic DiastolicDiastolic
CardiomegalyCardiomegaly ++++++ ++
Pulmonary congestionPulmonary congestion ++++++ ++++++
Electrocardiogram andElectrocardiogram and
echocardiogramechocardiogram
Left ventricular hypertrophyLeft ventricular hypertrophy ++++ ++++++++
Q wavesQ waves ++++ ++
Low voltageLow voltage ++++++ --
Left ventricular hypertrophyLeft ventricular hypertrophy ++++ ++++++++
Left ventricular dilatationLeft ventricular dilatation ++++ --
Left atrial dilatationLeft atrial dilatation ++++ ++++
Reduced ejection fractionReduced ejection fraction ++++++++ --

42. Cardiac CatheterizationCardiac Catheterization
NormalNormal SystolicSystolic
DysfunctionDysfunction
DiastolicDiastolic
DysfunctionDysfunction
End diastolic volumeEnd diastolic volume
(ml/m(ml/m22
))
8080 135135 7070
End systolic volumeEnd systolic volume
(ml/m(ml/m22
))
4040 105105 3030
Stroke volume (ml/mStroke volume (ml/m22
)) 4040 3030 4040
Ejection fraction (%)Ejection fraction (%) 5050 2020 5656
End diastolic pressureEnd diastolic pressure
(mmHg)(mmHg)
1010 2525 2525
Mean diastolicMean diastolic
pressure (mmHg)pressure (mmHg)
55 -- 1818

43. Myocardial hypertrophy without failureMyocardial hypertrophy without failure
Diastolic complianceDiastolic compliance
LessLess MoreMore
Concentric hypertrophyConcentric hypertrophy Eccentric hypertrophyEccentric hypertrophy
Pressure overloadPressure overload Volume overloadVolume overload
- Aortic stenosis- Aortic stenosis - Mitral regurgitation- Mitral regurgitation
- Systemic HTN- Systemic HTN - Aortic regurgitation- Aortic regurgitation
- Hypertrophic CMP- Hypertrophic CMP
Preload
depen-
dent

44. Require high LVEDPRequire high LVEDP Increase in end diastolicIncrease in end diastolic
for normal fillingfor normal filling volume with relativelyvolume with relatively
diastolic pressure, oftendiastolic pressure, often
significantly myocardialsignificantly myocardial
dysfunctiondysfunction
Diastolic dysfunctionDiastolic dysfunction Normal stroke volumeNormal stroke volume
characterized bycharacterized by Normal end diastolicNormal end diastolic
volumevolume
Hence normal ejectionHence normal ejection
Fraction (50-75%)Fraction (50-75%)
Hypertrophy and delayed ventricular relaxation mayHypertrophy and delayed ventricular relaxation may
Limit time for diastolic filling and elevate filling pressure.Limit time for diastolic filling and elevate filling pressure.
Pulmonary congestionPulmonary congestion Pulmonary edemaPulmonary edema
Both are amplified by tachycardia + salt & water retentionBoth are amplified by tachycardia + salt & water retention

45. Compensated Heart FailureCompensated Heart Failure
It is a state in which the symptom of heartIt is a state in which the symptom of heart
failure are relieved and signs of pulmonaryfailure are relieved and signs of pulmonary
and peripheral congestion have beenand peripheral congestion have been
relieved by therapy, although the LVEDVrelieved by therapy, although the LVEDV
and LVEDP often elevated and ejectionand LVEDP often elevated and ejection
fraction remain reduced.fraction remain reduced.

46. Decompensated Heart FailureDecompensated Heart Failure
Sudden or progressive appearance of symptomsSudden or progressive appearance of symptoms
of heart failure and signs of pulmonary andof heart failure and signs of pulmonary and
peripheral congestion are usually due to:peripheral congestion are usually due to:
A. CVS factorsA. CVS factors
– Superimposed ischemia/infarctionSuperimposed ischemia/infarction
– Uncontrolled hypertensionUncontrolled hypertension
– Unrecognized primary valve diseaseUnrecognized primary valve disease
– Worsening secondary MRWorsening secondary MR
– New onset or uncontrolled atrial fibrillationNew onset or uncontrolled atrial fibrillation
– Excessive tachy, bradycardiaExcessive tachy, bradycardia
– Pulmonary embolismPulmonary embolism

47. B. Systemic factorsB. Systemic factors
– InappropriateInappropriate
medicationsmedications
– SuperimposedSuperimposed
infectionsinfections
– AnaemiaAnaemia
– UncontrolledUncontrolled
diabetesdiabetes
– Thyroid dysfunctionThyroid dysfunction
– Electrolyte imbalanceElectrolyte imbalance
– PregnancyPregnancy
C. Patient-relatedC. Patient-related
factorsfactors
– Medication non-Medication non-
compliancecompliance
– Dietary indiscretionDietary indiscretion
– AlcoholAlcohol
consumptionconsumption

48. Prevention of Heart FailurePrevention of Heart Failure
Primary and secondary prevention ofPrimary and secondary prevention of
coronary artery syndrome.coronary artery syndrome.
CAD being a major cause of heart failureCAD being a major cause of heart failure
demands risk factors modification.demands risk factors modification.
– Cigarette smokingCigarette smoking
– Control of blood pressureControl of blood pressure
– Control of diabetesControl of diabetes
– Lowering of hyperlipidemiaLowering of hyperlipidemia

49. Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Myocardial infarction is the most commonMyocardial infarction is the most common
cause of heart failure syndrome.cause of heart failure syndrome.
Requires:Requires:
1.1. Myocardial salvage (early thrombolysis).Myocardial salvage (early thrombolysis).
2.2. Prevention of another MI.Prevention of another MI.
3.3. Prevention, early recognition and timely.Prevention, early recognition and timely.
management of mechanical complication ofmanagement of mechanical complication of
MI.MI.
4.4. Active myocardial ischaemia: needs timelyActive myocardial ischaemia: needs timely
revascularization for enhancing L.V. function.revascularization for enhancing L.V. function.

50. Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Atrial fibrillation – early reversion and rateAtrial fibrillation – early reversion and rate
control is main objective.control is main objective.
Rheumatic heart disease: emphasisRheumatic heart disease: emphasis
should be given onshould be given on
– Mass education for prevention of R.F.Mass education for prevention of R.F.
– Prevention of recurrent attacks of R.F.Prevention of recurrent attacks of R.F.
– Control progression of disease.Control progression of disease.
– Timely correction of underlying defects.Timely correction of underlying defects.
– Prevention and effective treatment of infectivePrevention and effective treatment of infective
endocarditis.endocarditis.

51. Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Timely correction of congenital heartTimely correction of congenital heart
defects.defects.
Comprehensive search for systemicComprehensive search for systemic
disease responsible.disease responsible.
– ThyrotoxicosisThyrotoxicosis
– AnaemiaAnaemia
– Myocardial depressant drugsMyocardial depressant drugs
– AlcoholAlcohol
– NSAIDNSAID

52. Suggested Indications for CHFSuggested Indications for CHF
AdmissionAdmission
1.1. Symptomatic arrhythmias (syncope,Symptomatic arrhythmias (syncope,
presyncope, cardiac arrest)presyncope, cardiac arrest)
2.2. New myocardial infarction or ischaemiaNew myocardial infarction or ischaemia
3.3. Rapid onset of new symptoms of CHFRapid onset of new symptoms of CHF
4.4. Decompensation of CHFDecompensation of CHF

53. A. Need for immediate hospitalizationA. Need for immediate hospitalization
– Pulmonary edema or dyspnoea in sittingPulmonary edema or dyspnoea in sitting
positionposition
– Arterial desaturation < 90%Arterial desaturation < 90%
– Heart rate > 120/minHeart rate > 120/min
– Systolic BP < 75 mmHgSystolic BP < 75 mmHg
– Symptoms of mental hypoperfusionSymptoms of mental hypoperfusion

54. B. Need for urgent hospitalizationB. Need for urgent hospitalization
– Decompensation due to acutely worseningDecompensation due to acutely worsening
non cardiac conditions such as pulmonarynon cardiac conditions such as pulmonary
disease and worsening renal failure.disease and worsening renal failure.
– New development of liver congestion, tenseNew development of liver congestion, tense
ascites or anasarca.ascites or anasarca.
– New evidence of simultaneous congestionNew evidence of simultaneous congestion
and hypoperfusion.and hypoperfusion.
C. Consider hospitalizationC. Consider hospitalization
– Rapid fall in serum Na < 130 mEqRapid fall in serum Na < 130 mEq
– Rising s. creatinine > 2.5 mg/dlRising s. creatinine > 2.5 mg/dl
– Persistent symptoms at rest despire repeatedPersistent symptoms at rest despire repeated
OPD visits.OPD visits.

55. MortalityMortality
Most of the studies indicated that CHFMost of the studies indicated that CHF
with systolic dysfunction had a worsewith systolic dysfunction had a worse
prognosis than CHF caused by normalprognosis than CHF caused by normal
systolic function (19% vs 8.9% annualsystolic function (19% vs 8.9% annual
mortality).mortality).

56. TreatmentTreatment
Unfortunately, unlike the treatment of CHFUnfortunately, unlike the treatment of CHF
resulting from systolic dysfunction which isresulting from systolic dysfunction which is
based on evidence gathered in well designedbased on evidence gathered in well designed
clinical trials (ACE inhibitors, digoxin) there areclinical trials (ACE inhibitors, digoxin) there are
virtually no controlled studies of therapy forvirtually no controlled studies of therapy for
diastolic dysfunction.diastolic dysfunction.
As a result, treatment is directed at instigating orAs a result, treatment is directed at instigating or
reversing the presumed underlying orreversing the presumed underlying or
exacerbating conditions e.g., coronaryexacerbating conditions e.g., coronary
revascularization/PTCA or medical drugs forrevascularization/PTCA or medical drugs for
myocardial ischaemia may improve LV diastolicmyocardial ischaemia may improve LV diastolic
and systolic function.and systolic function.

57. Effective treatment of hypertension will causeEffective treatment of hypertension will cause
regression in LV hypertrophy which may improveregression in LV hypertrophy which may improve
myocardial compliance.myocardial compliance.
Tachyarrhythmias such as atrial fibrillation canTachyarrhythmias such as atrial fibrillation can
be converted to sinus rhythm bybe converted to sinus rhythm by
electrical/chemical cardioversion restoring theelectrical/chemical cardioversion restoring the
atrial contribution to ventricular filling.atrial contribution to ventricular filling.
Surgery and balloon dilatation have proven to beSurgery and balloon dilatation have proven to be
effective in treating valvular disease.effective in treating valvular disease.
Treatment of HCM with Verapamil has beenTreatment of HCM with Verapamil has been
mildly successful.mildly successful.

58. Hemochromatosis, thyrotoxicosis,Hemochromatosis, thyrotoxicosis,
anaemia and beri-beri are all treatableanaemia and beri-beri are all treatable
medical conditions.medical conditions.
Surgery can also strip the pericardium inSurgery can also strip the pericardium in
patients with pericardial constriction.patients with pericardial constriction.
Surgery by resecting left atrial myxoma isSurgery by resecting left atrial myxoma is
curable cause of CHF.curable cause of CHF.

59. Thus, the principal objectives of treatingThus, the principal objectives of treating
diastolic dysfunction are to:diastolic dysfunction are to:
– Aggressively control of hypertension.Aggressively control of hypertension.
– Recognize and timely treatment of significantRecognize and timely treatment of significant
myocardial ischaemia.myocardial ischaemia.
– Reduce symptoms related to fluid retentionReduce symptoms related to fluid retention
and elevated filling pressure.and elevated filling pressure.
Without data from clinical trials, drugWithout data from clinical trials, drug
therapy is essentially empiric and usuallytherapy is essentially empiric and usually
involved careful combination of agents.involved careful combination of agents.

60. e.g. Diuretic for fluid retention and nitrates fore.g. Diuretic for fluid retention and nitrates for
elevated ventricular filling pressures. Calciumelevated ventricular filling pressures. Calcium
antagonists to improve LV filling and relaxation.antagonists to improve LV filling and relaxation.
ββ-blockers are also attractive in slowing heart-blockers are also attractive in slowing heart
rate and improve diastolic filling. Digoxin cannotrate and improve diastolic filling. Digoxin cannot
be recommended routinely for patients withbe recommended routinely for patients with
preserved function. The empiric and paradoxicalpreserved function. The empiric and paradoxical
effects found with digoxin are poorly understoodeffects found with digoxin are poorly understood
and require further study. Which of these agentsand require further study. Which of these agents
beneficial in patients with diastolic dysfunction isbeneficial in patients with diastolic dysfunction is
perhaps the major challenge in clinicalperhaps the major challenge in clinical
management of CHF.management of CHF.

61. ConclusionConclusion
Heart failure is an epidemic with highHeart failure is an epidemic with high
morbidity and mortality. CAD ismorbidity and mortality. CAD is
commonest cause of heart failure withcommonest cause of heart failure with
systolic dysfunction.systolic dysfunction.
However, CHF with preserved systolicHowever, CHF with preserved systolic
function and diastolic dysfunction isfunction and diastolic dysfunction is
perhaps the next major challenge in theperhaps the next major challenge in the
clinical management of heart failure.clinical management of heart failure.

62. CHF is common and costly clinical entityCHF is common and costly clinical entity
with high rate of OPD and ER visits andwith high rate of OPD and ER visits and
longest hospital stay and is commonestlongest hospital stay and is commonest
cause of death indeed.cause of death indeed.
Prevention of CHF and frequentPrevention of CHF and frequent
decompensation is best achieved throughdecompensation is best achieved through
multidisciplinary approach like introductionmultidisciplinary approach like introduction
of “heart failure education” at communityof “heart failure education” at community
level.level.