Advanced HF syndromes ,unique entity in heart failure world.

1. Altamash
General Hospital ST – 9 /A
Block 1 Clifton Karachi
Time, 10 am to 1 Pm
6 Pm to 8 Pm Daily
Sunday Closed
Advanced ( Stage D )Heart Failure Syndromes ( Huge Elephant
Heart )
Advances in medical therapy for chronic, ambulatory
heart failure (HF stage C ) have improved survival but
simultaneously increased the number of patients with
refractory, advanced HF syndromes .
These advanced HF patients typically have limiting HF
symptoms at rest, ( NYHA FC III & IV ) and thus
require frequent hospitalizations . Advanced HF not
only carries a dismal prognosis, but ( Its Costly and
deadly indeed ) with up to 75% of patients dying
within 6 months despite optimal medical
( GDMT ) therapy.
The gold standard for management of advanced
HF is cardiac transplantation, with 1-year survival
approaching 90% and 11-year survival of 50%.
So Only Option for countries like Pakistan is to focus
on prevention of asymptomatic HF ( Stage A & B ) to
Symptomatic HF stage C and Stage D , by establishing
multidisciplinary HF programme and network .
Advanced Heart Failure need advanced therapies
( Left Ventricular Assist devices ( LVAD ) & Heart Transplant )
“ Diagnostic challenge and no advanced HF center to offer
advanced therapies “ So only option is , to prevent this tiny HF syndromes “
Early Diagnosis of HF is a science or art ??
Which Heart Failure is Benign , malignant or Complex ??

2. Altamash
General Hospital ST – 9 /A
Block 1 Clifton Karachi
Time, 10 am to 1 Pm
6 Pm to 8 Pm Daily
Sunday Closed
Advanced ( Stage D )Heart Failure Syndromes ( Huge Elephant
Heart )
Despite advances in medical therapy for chronic heart failure ( HF stage C ), advanced HF Stage D carries a dismal prognosis. Options such as Heart
transplantation and durable mechanical circulatory support ( LVAD as bridge /destination therapy ) have greatly improved outcomes for these patients but at
the cost of significant complexities to patient management. Although much of this management occurs at specialized heart transplant centres .
Prevalence of advanced heart failure range from 6% to 25%. Largest registry of chronic advanced HF suggest that roughly 5% patients with heart failure have
end stage disease with symptoms refractory to guideline directed medical therapy ( AHA GDMT ).
Recognizing Advanced HF requires integration of clinical, imaging, hemodynamic, functional and biomarker parameters in setting of unresponsive optimal
medical treatment. Cardiopulmonary exercise test ( CPET ) is gold standard in diagnosis of advanced HF . ( I doubt its availability in Pakistan ) ESC Criterias ,
1) NYHA class 111 or 1V symptoms. With major organ dysfunction ( renal injury & passive liver congestion )
2) Episodes of volume overload /or peripheral hypoperfusion. Despite on I/V furosemide and inotropes .
3) Objective evidence of severe cardiac dysfunction ( EF <30%, restrictive filling pattern, PCWP >16mm, or RAP >12mm Hg) low LV function is not only criteria
4) Severely impaired functional capacity ( inability to exercise 6min walk <300m, peak oxygen consumption VO2 max <12-14ml/kg/min on CPET ).
5) Recurrent HF hospitalization ( >1 in past 6month). Persistently raised pro BNP /BNP and Troponin
According to ESC/AHA, despite attempts to optimize diuretics, RAAS antagonists, beta blockers, CRT or in setting of intolerance to optimal medical treatment.
Progression to advanced heart failure from stage C to stage D may be gradual and it is often complex, and indeed difficult to determine weather
decompensation in a previously stable heart failure patient is an isolated incident due to reversible precipitants or the transition to a refractory stage D .
This rapidly changing field requires specialization and establishment of advanced HF Centre ( Which we don’t have in Pakistan ?? If we do kindly correct me )
In countries where we have MDHFP & advanced HF centre ( I worked in advanced HF centres like PSCCH & King Abdullah Medical City Makkah ) We observed
lack of doner hearts to cope long waiting list for heart transplant ,LVAD was an alternative but , Unfortunately, many patients were referred to heart transplant
centres “ too late or not at all “. So Attack swiftly on Stage A & B HF ( Like millions heart after MI and cancer therapy ) to prevent HF .
Early diagnosis of HF is a science or art ??
Which Heart Failure is Benign , malignant or Complex ??

3. oomro’s ion of Heart Syndromes
.
Chronic Advanced heart
failure journey stage D.
Their journey starts from de-novo
heart failure, then progressed to
chronic heart failure ,followed by
recurrent episodes of acute on chronic
decompensation of heart failure , they
usually shuttle from ER to hospital
admission, progress to advanced HF
stage D , with major organ dysfunction,
Persistently raised BNP recurrent ER
Visits and prolong hospitalizations,
until die suddenly or in hospital with
pump failure .
Heart Failure journey from symptoms till death
In advanced HF we are fighting with tigers and elephants, Can we win the war ????
Orange is ER Visit
Green is Hospital ist
admission and red are
readmissions
Advanced Heart Failure
Journey
Death
ER
VISITS
Last Admission
Ist
A
D
M
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