The document summarizes the past, present, and future of heart failure treatment. In the past (1950s-1970s), treatment focused on rest, sodium restriction, and drugs like digitalis and diuretics. Currently (2000s), guidelines recommend optimal medical therapy including ACE inhibitors, ARBs, beta-blockers, diuretics, and devices like ICDs, CRT, and LVADs which have improved outcomes. The future holds promise for gene and cell-based therapies, left ventricular assist devices, and prevention through understanding of genetic factors influencing heart failure.

1. Heart Failure An overview

2. The Management of Heart Failure: The Past, the Present, and the Future Eugene Braunwald, MD Volume 1, Issue 1; May, 2008

3. OBJECTIVES Disease Burden 2.Heart Failure Therapy in the Past, Present and Future.

4. IS IT A PANDEMIC???

5. Number 1 Killer

6. 5.7Million Americans

7. Mortality has more than doubled since 1979

8. >65years Leading cause of hospitalization

9. 1-2% of Health Care cost $ 39.2 Billion

10. 5 years from diagnosis only 50% alive

11. The Past

12. In 1950 first edition of Harrison’s Principles of Internal Medicine D ecubitus D ietary sodium restriction D igitalis D iuretics (mercurial) Venesection and Morphine The Management of Heart Failure: The Past, the Present, and the Future Eugene Braunwald,MD Circulation: Heart Failure. 2008;1:58-62

13. In 1970 Sixth edition of Harrison’s Principles of Internal Medicine Diuretics ( Thiazide, Loop, Potassium sparing ) β-adrenergic agonist Precipitating cause The Management of Heart Failure: The Past, the Present, and the Future Eugene Braunwald,MD Circulation: Heart Failure. 2008;1:58-62

14. The Present

15. Level of Evidence LEVEL OF EVIDENCE C A

16. ACE INHIBITORS or ARB BETA BLOCKERS DIURETICS DIGOXIN SPIRONOLACTONE OPT: Optimal Pharmacologic Therapy ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2001; 1-56. ADJUNCT: HYDRALAZINE and NITRATES

17. Copyright ©2008 American Heart Association Management of heart failure over the past 40 years Katz, A. M. Circ Heart Fail 2008;1:63-71

19. Biventricular pacing therapy INDICATIONS: Sinus rhythm, QRS interval >=120 ms LV systolic dysfunction LVEF (<=35%) Persistent, moderate to severe HF (NYHA III) despite optimal medical therapy. (Strength of Evidence = A) http://www.heartfailureguideline.org 2010 Comprehensive Heart Failure Practice Guideline

20. Cardiac Resynchronization Therapy Prolongs Survival in Patients With Left Ventricular Dysfunction: A Meta-Analysis McAlister FA. JAMA. 2007;297:2502 .

21. Cardiac Resynchronization Therapy Prolongs Survival in Patients With Heart Failure (The CARE-HF Trial) Percentage of Patients Free of Death from Any Cause or Unplanned Hospitalization for Major Cardiovascular Event Percentage of Patients Free of Death from Any Cause Cleland JG et al. N Engl J Med. 2005:352;1539 .

23. ICD Therapy CLASS I INDICATIONS: Ischemic cardiomyopathy with LVEF < 35%, at least 40 days post MI, NYHA class II OR III. (Strength of Evidence = A) 2. Ischemic cardiomyopathy with LVEF < 30%, at least 40 days post MI, NYHA class I. (Strength of Evidence = A) 3. Non Ischemic cardiomyopathy with LVEF ≤ 35%, NYHA class II OR III. (Strength of Evidence = B) The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

24. Left Ventricular Assist Devices (LVAD) The Jarvik-7 The Jarvik 2000 The World's First Artificial Heart

25. Indications Bridge to Transplantation Bridge to Recovery Destination Therapy

26. Transcutaneous Ventricular Assist Device

27. Implantable Ventricular Assist Device

28. Ventricular Assist Device in the market HeartMate II® Arrow LionHeart DeBakey LVAD Thoratec CentriMag® Thoratec PVAD™ Thoratec IVAD™ HeartMate® XVE

29. Surgeries for heart failure

30. Coronary Revascularization

31. Valvular Surgery

32. Left Ventricular Reconstructive Surgery (Dor Procedure)

33. Batista Procedure

34. Cardiac Transplant At Groote Schuur Hospital On December 3 rd 1967

35. Mr. Louis Washkansky lived for 18 days Smithsonian‘s National Museum of American History

36. 250,000 deaths per year Only 2000 donor hearts available

37. Never make predictions

38. Genetic Mutations

39. Insertion/deletion polymorphism within the ACE gene Polymorphism of the adrenergic α 2c receptor and of the β1 adrenergic receptor

40. CELL BASED THERAPY

42. PREVENTION

43. Thank you