Ischemic Heart Failure with out Myocardial infarction and without symptoms of angina.

1. HEART FAILURE
SYNDROMES
World
HEART
FAILURE WORLD
Chronic non ischemic advanced Heart Failure
Big ( elephant heart ) expired after two years with recurrent readmissions.
Acute de-novo ischemic type 1 malignant HF . expired during index
admission ( small tiger heart )
Chronic ischemic ( type 11) advanced HF ,expired after > 100 HF readmissions ,refractory ascites
and this is his infected umblical hernia
RCA of Ischemic HF ( type 1V ) expired after CABG
Malignant HF ,33 male Inf STEMI RV extension ,complicated by VSR expired . 30 yr F Cong VSD with HF right heart thrombus
died of pulm embolism
HF with Left main occlusion and polymorph VT(
shown on right., after PCI living with chronic HF
Ischemic HF type 1V with angina Typical ST elevation in
Avr & V1 total ST score > 18mm Left main 3VD CAD ,did
early CABG
50 Yr F presented with de novo HF .this is her LA
myxoma after surgery
Elephant in heart, huge myxoma
Asadullah Khan Soomro KAMC Makkah;
hssbasadsoomro@gmail.com

2. Introduction
Heart Failure is not a disease itself but a complex and costly life
threatening syndrome with multiple etiologies & precipitants.
At present ,approximately 60 million worldwide are living with
heart failure.
83 % of HF patients are hospitalized due to an acute HF episode at least
once, and nearly half (43%) are hospitalized at least four times.
Every year, there are approximately one million hospitalizations due to
HF in the US and Europe, and on average, a HF patient remains in
hospital for 5 to 10 days. Due to this, heart failure presents a major and
growing health-economic burden that currently costs the world
economy $108 billion every year

3. Cont,
The out look for such patients is poor, with survival rates worse
than many cancers.
Furthermore ,heart failure has tremendous impact on patients,
families, caregivers and healthcare system indeed, and is
predicted to increase dramatically over the next decades to
come.
Heart failure is a major public health problem with high
morbidity and mortality.
Ischemic heart failure is commonest cause of heart failure all
over the world and in kingdom of Saudi Arabia indeed
,however despite being common has never been classified
appropriately.

4. Ischemic Heart failure
syndromes

5. SOOMRO,S , CLASSIFICATION OF
ISCHEMIC HEART FAILURE SYNDROMES
ISCHEMIC
HEART FAILURE
WITH MYOCARDIAL
INFARCTION.
4
3
ISCHEMIC
HEART FAILURE
WITHOUT MYOCARDIAL
INFARCTION.
Subjective & objective evidence of healed
( Old ) myocardial infarction, complicated by
first time or recurrent heart failure &
hospitalization.
2
Subjective & objective evidence of
acute myocardial infarction,
complicated by heart failure during
index hospitalization.
1
Primary symptoms of heart failure,
without symptoms of angina and
myocardial infarction ( Neither objective
evidence of MI ).
Concomitant symptoms of angina and
heart failure, without subjective or
objective evidence of myocardial
infarction.
( Type 1 to type 1V )

6. Type 1V
“ Orphan Ischemic heart failure
Syndromes”
“ Occlusion versus Stenosis”
“ Myth or reality”

7. Ischemic Type 1V Heart failure syndromes
( Without MI & angina)
Athero-thrombotic CAD is commonest cause of heart failure syndromes
and is present in 2/3 of patients with heart failure and low ejection
fraction.
No controlled trials have addressed the issue of weather the coronary
revascularization can improve clinical outcome in patients with
heart failure without angina.
However observational studies have shown that revascularization can
favorably affect LV function in some patients with
impaired yet viable myocardium.

8. Ischemic Type 1V Heart failure syndromes
( Without MI & angina)
It is not clear how such patients should be identified because the
sensitivity and specificity of abnormal imaging test have not been
validated in patients with heart failure without angina.
Additional studies are needed to determine weather the possibility of
myocardial ischemia or viability should be evaluated routinely to
assess the contribution of CAD in patients with HF and systolic
dysfunction, who do not have angina
2004 HF Guide line recommends revascularization in patients with
significant left main and in patients who have large area of
non infarcted but hypoperfused and hypocontractile
myocardium on non invasive testing.

9. Ischemic Type 1V Heart failure syndromes
( Without MI & angina)
How should cardiac physician
evaluate patients with heart
failure, and LV systolic
dysfunction ,who do not have
chest pain and ,who do not have
history of CAD indeed ??

10. Ischemic Type 1V Heart failure syndromes
( Without MI & angina)
In younger patients without risk factors it is
reasonable to exclude presence of congenital
coronary anomalies.
In older patients ,however efforts to detect the
presence of CAD may not be worthwhile , because
revascularization has not been shown to
improve clinical outcomes in patients with heart
failure without angina .

11. Ischemic Type 1V Heart failure syndromes
( Without MI & angina)
Nevertheless , the observation that
revascularization might have a favorable effect on
LV function, has led some experts to suggest that
CAD should be excluded whenever possible ,
especially in patients with DM , HTN, smokers and
in those associated with silent myocardial ischemia.
Only CAG can reliably demonstrate or exclude presence
of significant CAD with good or bad targets of
revascularization.

12. Why Ischemic Type 1V Heart failure syndromes
are neglected.
1) Very Elderly patients with low ejection fraction are not studied to
rule out CAD as cause of heart failure .
2) Similarly elderly hypertensive patients with perserved systolic
function are usually neglected indeed .Therefore CAD as a cause of
heart failure is overlooked.
3) Heart failure with global systolic dysfunction and LBBB despite
having athero-thrombotic risk factors are also neglected as dilated
/ Ischemic cardiomyopathy and are presumed not suitable
for coronary angiography, or delayed , and hence do not
benefit from late revascularization.

13. Cont,
4) Elderly DM,HTN & CKD ,COPD with MR & TR
associated with paroxysmal or permanent atrial
fibrillation , and low ejection fraction are
denied coronary angiography to rule out CAD as
cause of heart failure until present with acute
STEMI.
5) Adults with Corrected congenital heart defects , with
residual sequele ,baseline abnormal EKG and ventricular
dysfunction especially those associated metabolic
syndrome , are also overlooked to rule out CAD as a
etiology or precipitant of heart failure.

14. Cont,
6) Last not the least although rare but yet we see some
patients with long standing risk factors , who are presented
with malignant cardiac dysrrhythmias and first
time symptoms of heart failure , with severe
transient LV systolic dysfunction
,resuscitated successfully from cardiac arrest,
with out EKG evidence of myocardial
infarction .
They are also neglected or delayed to rule out significant
CAD with otherwise viable and good targets of
revascularization.

15. Ischemic Type 1V Heart failure syndromes
History , EKG and Echocardiogram ,found evidence of CAD in 42% men
and 25% women predicting HF.
However careful history in patients with high probability of
CAD may help in diagnosis of type 1V ischemic heart
failure in many patients.
More recent studies using different techniques have found higher
prevalence of type 1V ischemic heart failure syndromes .
Average 61% ( 68% in men & 38% in women) in
east Finland.

16. Ischemic Type 1V Heart failure syndromes
In 1995 while working at Dow Medical college &
civil hospital Karachi Pakistan, I first time
discovered this tiny group of ischemic heart
failure patients, who were presumed as dilated /
ischemic cardiomyopathy but without objective
evidence of CAD.
They had severe LV systolic dysfunction with recurrent
HF hospitalizations. ( dual reason ischemia as etiology of HF &
precipitant of ADCHF without angina , EKG changes and troponin )

17. Ischemic Type 1V Heart failure syndromes
To establish HF etiology ,and with a view to
assess if they have suitable revascularization
targets, we did coronary angiogram in few such
high risk patients.
We found in them small caliber ,multi vessel severe
diffuse ,multiple lesions ,( as an ischemic etiology
and precipitant of decompensation indeed).
Considered unsuitable for revascularization ,
therefore stopped further testing .

18. Ischemic Type 1V Heart failure syndromes
Based on above coronary morphological features and
diverse clinical manifestations , I first time in 1995
classified ischemic heart failure in four
groups.
I presented a first paper on heart failure audit in Dow
medical golden jubilee and centenary scientific
congress held on 28th December 1996 and in
cardiology congress organized by Pakistan cardiac society ,
but was categorically neglected by most of the physicians.

19. Ischemic Type 1V Heart failure syndromes
After coming to Kingdom of Saudi Arabia in 2002 ,
continued interest in ischemic heart failure syndromes,
after joining prince sultan cardiac center in Al -
Ahsa in 2007 ,after around 15 year ,again I
discovered few patients with ischemic type 1V
heart failure syndromes with same coronary
morphological features.
Following is one of the good example to share in this
regard.

20. THANK YOU
Living Longer, Living Well