New toy in town, non dilated non ischemic Cardiomyopathy with severe LV systolic dysfunction . Potentially reversible heart failure.

1. Reversible Etiology
Reversible Heart Failure ,is it different ??
Dr Asadullah Khan Soomro & Dr Burai Adlan
Department of Adult Cardiology
King Abdullah Medical City Holy Makkah
Email; hssbasadsoomro@gmail.com
Non Dilated ,non ischemic
Heart Failure Syndromes
With Severe Systolic Dysfunction
“ Benign or Malignant”

2. Non Dilated ,Non Ischemic
De-Novo Heart Failure ,Severe LV Systolic
Dysfunction, moderate MR severe pulm hypertension
.
Journey of simple acute De-Novo
Heart Failure syndromes
Admitted 30.12 2019,discharged
2.1.2020, three post discharge HF face
to face visits.
Two HF Virtual Clinic review 23.6.20 and 19.8.20.
Later regular HF review .Last visit 6.4.2021.
IstPost discharge Heart Failure clinic Visit on 28.1.2021, Stopped Coversyl and after 36 hours wash out
switched to sacubitril 50 mg bid,
2nd Visit 11.2.2021 Clinically compensated, Vitally stable, Labs OK Sacubitril Titrated to 100 mg bid
3rd visit 10.3.20 No ER visit, No readmission, Vitally stable ,Labs OK sacubitril titrated to200 bid.
First HF
hospitalization
ER Visit Post discharge HF clinic
Transitional care
Vulnerable phase to visit
ER and readmission
BNP Level
6.2.20, 759
8.3.20, 1105
19.8.20, 179
20.10.20, 47
HB%, 14.3, Trop 0.070, HB A1C 8.4
Creat 1.0, Na 139, K,4.3 T bil,0.7
AST 15, ALT 26,Cholest 128,TG 80
LDL 75, HDL 37 ,Uric acid 9.3
Here we are at Get with the Guide Line standard
( AHA) Achieved sacubitril dose titration goal with
in 5-6 weeks . We wish could have even started
early before discharge from hospital.

3. Non Dilated ,Non Ischemic
De-Novo Heart Failure ,Severe LV Systolic
Dysfunction, moderate MR severe pulm hypertension
62 year male DM,HTN non smoker admitted first time at local
hospital in December 2019 with H/O symptoms of heart failure
FC 111 1V for two weeks
Diagnosed to had De-Novo heart failure with severe LV
systolic dysfunction EF 20-25%.No major organ dysfunction
After stablization shifted to our hospital on 30.12.2019 for CAG
to rule out CAD.
Echo revealed Non dilated LV with severe global systolic
dysfunction, & moderate MR

4. Non Dilated ,Non Ischemic
De-Novo Heart Failure ,Severe LV Systolic
Dysfunction, moderate MR severe pulm hypertension
Did CAG and coronaries were essentially normal, evaluated by MRP
and was considered for CRTD after cardiac MRI.
Seen by pulmonology colleague and there was no apparent cause of
severe pulmonary hypertension, may be related to heart failure.
Discharged on 3rd day on Perindopril, Bisoprolol, Spironolactone
,Furosemide, Nitrates ,Statins and ASA .
Follow up after two weaks at HF clinic /MRP 3 months.
Post discharge he was seen in screening clinic on 28.1.20
( First HF Review ).
Subsequently he was seen face to face until sacubitril full dose
titration, stopped Nitrates and furosemide ,Followed twice Virtually
,& Refilled 200 mg sacubitril .

5. Non Dilated ,Non Ischemic
De-Novo Heart Failure ,Severe LV Systolic
Dysfunction, moderate MR severe pulm hypertension
During COVID phase could not turn up for CMRI, neither got opportunity
to repeat echo after 6 months of sacubitril full dose ( standard
practice) .
BNP came down from 1105 to 47 , He maintained dry weight to 75 Kg,
Echo was repeated after one year of sacubitril 200 mg , His EF improved
from 20-25% to 50-55%, MR reduced to mild pulmonary
hypertension stablized RSVP reduced from > 60 to 35.
Last seen on 6.4.21 ,sacubitril changed to candesarten 16 mg
Will see him back after 4 months.
During this one & half year journey on ARNI, 0% Visit to ER,0% Non HF
and HF readmission, Improved quality of life .Fasted whole month of
Ramdan with prayers in Masjid.
( Be Ever green)

6. Non Dilated non Ischemic
Heart Failure
Improved EF ( 15 month Post ARNI )
.
30.12.2019 before ARNI
The left ventricle is grossly normal size.
EF= 20-25 %
There is moderate to severe global hypokinesis of
the left ventricle.
The right ventricle is mild to moderately dilated.
The right ventricular systolic function is mildly
reduced.
There is moderate mitral regurgitation. (vena
contracta = 0.4 cm) No Aortic Valve stenosis No
aortic regurgitation is present. There is moderate
to severe tricuspid regurgitation.
Right ventricular systolic pressure is elevated at
>60mmHg. (assuming RAP =15 mmHg)
There is no pericardial effusion.
4.4.2021 After ARNI
Left ventricular systolic function is low normal.
EF= 50-55 %
There is borderline global hypokinesis of the left
ventricle.
Left ventricular diastolic dysfunction grade II.
The right ventricle is normal in size and function.
The left atrium is mildly dilated.
There is mild mitral regurgitation.
Right ventricular systolic pressure is elevated at 30-
40mmHg.
There has been an improvement of the global LV
systolic function since the last echo 2019.

7. Soomro’s Classification of Heart Failure
Syndromes
.
Acute De-Novo
Heart Failure syndromes
Chronic Heart Failure
Syndromes
Chronic
Compensated
Stage C Acute
Decompensation
of Chronic HF
Stage C
Chronic
Advanced HF
Syndromes
Stage D
Acute
De-Novo
Simple Acute
De-Novo
Complex
Acute
De-Novo
Malignant
“Benign or Malignant ?”
We have following 6 common heart failure syndromes , always classify your patients
80 to 90% job is clinical . Use your wisdom before decisions.

8. Heart Failure clinic Dispose Criteria
“ Dispose to where ,if greens are rising“
Low risk HF patient ,can be discharged if established co-ordinated follow
up at community heart failure services are available at primary /
secondary care HF Clinics attended by combination of nurses and
experienced physicians. Minimum of at least two of the following patient
characteristics should be present to justify discharge from HF clinic.
1) Stable NYHA class 1 or 11 for 6-12 months.
2) Using optimal devices and pharmacological therapies.
3) Stable adherence to optimal HF therapy.
4) No hospitalization for > one year.
5) LVEF > 35% ( Consisitently shown if > 1 recent EF measurement).
6) Reversible causes of heart failure controlled.
7) Follow up by physician interested in management of HF.
8) Establish a new permanent KAMC Virtual Heart failure clinic

9. Alternatives after disposal
from HF clinic
Establish a Net work of
Community
Heart Failure
Services
Under supervision of
Makkah Heart Failure
cluster.
Establish
KAMC
Permanent Virtual Heart
Failure Clinic
Under umbrella of
Nurse led multi disciplinary
Heart Failure
Clinic
Reduce your burden of Heart Failure ER Visits and re admissions through these alternatives
Other wise, we can not break vicious cycle of disposal and re appearance as new cases,
will cost more ??

10. King Abdullah Medical City Holy Makkah
From the desk of Heart failure Clinic
“Feed back letter to referring hospital/community physician ”
Dear Doctors,
I had the pleasure of meeting your patient Mr./ Miss / Mrs.__________________________________ in Rapid Access Heart Failure clinic today. I
have reviewed the records that you have kindly forwarded to me, although you are familiar with patients history. I will briefly review it for your
record and ours.
Above named Patient is a _______ year old man/woman who gives thorough history including concomitant medical problems. A social history,
family, occupational history and current medications __________________
__________________________________________________________________________________________
He/she now complaining of
____________________________________________________________________________________________with past medical history of
_________________________________________________________ he/she does/ does not smoke or drink alcohol, he /she lives with
____________________________ and worked as _________ but unable to work for
________________________________________________________________________
Overall Patient is suffering from heart failure Stage ________________ due to an____________ ____________. Precipitated by
___________________ there is / is no evidence of fluid overload at this time. Other pertinent diagnosis and problems include,
____________________________________________________________________________________________
I would suggest the following further diagnostic tests to assess present status and prognosis. I have taken the liberty to adjust her current
medications as follows __________________________________________________
____________________________________________________________________________________________
I have also suggested the initiation of Beta blocks / ACE inhibitors / others _______________________________.
I have also introduced her to Dr. / Nurse _________________________ members of the team for follow-up care.
Once the above testing is completed and medications adjusted. I will plan on seeing him/her to discuss results and plans. At that time I will
communicate my findings to you.
I appreciate the opportunity to participate in patient care with you.
Sincerely,
Physician Name & Signature
Note ( Modify your description according to patient and type of clinic)

11. Summary
Heart Failure is a science and a art ,guide line are to guide
us ,but decision is your. Devices are revolutionary but at
the cost of complications especially infections.
Do not treat only ejection fraction, treat heart failure and
patient as a whole. Things keep changing beyond our
expectations .
Devices are life changing and saving indeed but
effectiveness of drugs and idiopathic dynamic etiology
must be considered and, review your patient from time to
time for devices.

12. Summary
HF clinic is a old and tiny part of multidisciplinary
heart failure programe.
Non Dilated non ischemic cardiomyopathy is new
entity in heart failure world ,especially idiopathic.
Improved HF & ejection fraction was because of drugs
or underlying idiopathic etiology is a mysterious
question ,credit goes to physician scientist or industry
?? 50-50% or 70-30% ? You are the best judge.
( Be Ever green)

13. Thanks to all colleagues for giving us opportunity to take care
of this Pleasant gentleman,& to learn some thing new in heart
failure world of tigers and elephants .