kenali, ceagh dan obati gagal jantung !
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Kenali, Ceagh dan Obati Gagal Jantung !. M. Saifur Rohman, MD, PhD Cardiologist Medical Faculty, Brawijaya University. Definition of HF. A syndrome associated with inadequate performance of the heart. Leading to neurohormonal and circulatory abnormalities. - PowerPoint PPT PresentationTRANSCRIPT
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MSR, May4 2010
Kenali, Ceagh dan Obati Gagal Jantung !
M. Saifur Rohman, MD, PhDCardiologist
Medical Faculty, Brawijaya University
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Definition of HF A syndrome associated with inadequate
performance of the heart.
Leading to neurohormonal and circulatory abnormalities
Adam KF et al. HFSA 2006 comprehensive heart failure guideline J Card Fail 2006; 12: e1-e122
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Epidemiology
Heart failure is a major and growing cause of cardiovascular morbidity and mortality throughout the world
Approximately 5 million patients in USA have HF, and over 550 000 patients are diagnosed with HF for the first time each year.
HF is the primary reason for 12 to 15 million office visits and 6.5 million hospital days each year.
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008
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Causes of HF
• CAD• Hypertension• Valve disease (RHD, endocarditis)• Arrhythmias• Cardiomyopathy• Congenital heart disease• Pericardial Effusion
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Systolic vs. Diastolic HF
Heart failure is a major and growing cause of cardiovascular morbidity and mortality throughout the world
Previously, it had often been assumed that most heart failure patients have underlying systolic dysfunction, which is responsible for their clinical presentation
It has become increasingly apparent over the last decade that many heart failure patients have a normal or nearly normal ejection fraction described as heart failure with preserved systolic function or preserved ejection fraction
HF-PEF affects primarily older patients, especially women; hypertension is the primary underlying condition, with CAD and prior MI being relatively infrequent
Hogg K, Swedberg K, McMurray J. J Am Coll Cardiol 2004; 43:317-327.
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Systolic vs. Diastolic HF
Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
Diastolic Heart Failure/HF-PEF
Systolic Heart Failure
ACC-AHA guidelines 2001
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Normal
Systolic heart failure
Heart failure with preserved systolic
function
Pathological/Echocardiographic Differences in LV Thickness with Different Forms of HF
Aurigemma GP et al. Circulation. 2006;113:296-304.
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ParametersParameters SystolicSystolic HF-PSFHF-PSF
HistoryHistory• Coronary artery diseaseCoronary artery disease• HypertensionHypertension• DiabetesDiabetes• Valvular heart diseaseValvular heart disease• Paroxysmal dyspneaParoxysmal dyspnea
+ + ++ + ++ ++ ++ ++ +
+ + + ++ + + ++ ++ +
+ ++ ++ + + ++ + + +
+ ++ +——
+ + ++ + +
Physical ExaminationPhysical Examination• CardiomegalyCardiomegaly• Soft heart soundsSoft heart sounds• S3 gallopS3 gallop• S4 gallopS4 gallop• HypertensionHypertension• Mitral regurgitationMitral regurgitation• RalesRales• EdemaEdema• Jugular venous distentionJugular venous distention
+ + ++ + ++ + + ++ + + ++ + ++ + +
+++ ++ +
+ + ++ + ++ ++ +
+ + ++ + ++ + ++ + +
++++++
+ + ++ + ++ + + ++ + + +
+++ ++ +++++
Chest Roentgenogram (X-ray)Chest Roentgenogram (X-ray)• CardiomegalyCardiomegaly• Pulmonary congestionPulmonary congestion
+ + ++ + ++ + ++ + +
+++ + ++ + +
+ + + ++ + + +
+ + ++ + ++ + + ++ + + +
Systolic HF vs HF-PEF: Signs and Symptoms
Givertz MM et al. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease, A Textbook of Cardiovascular Medicine. 7th edition. Philadelphia, WB Saunders. 2001;534-561.
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CHF vs. AHF
Current management of acute coronary syndrome has resulted in an improved survival after acute myocardial infarction.
This fact has created a rapid growth in the number of patients currently living with chronic heart failure.
Decompensation of preexisting chronic heart failure may cause acute heart failure (AHF).
Eur Heart J 2005;26:384-416
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• AHF is defined as the rapid onset of symptoms and signs, secondary to abnormal cardiac function
• Cardiac dysfunction can be related to systolic or diastolic, to abnormalities in cardiac rhythm or to preload and afterload mismatch
• It is often life threatening and requires urgent treatment
Definition of Acute Heart Failure
ESC guideline for Acute Heart Failure, 2005
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Cause of Acute Heart Failure
Acute coronary syndrome, hypertensive crisis and other cardiac or non cardiac also precipitate an AHF.
CAD contributes to 60-70 % in elderly Cardiomyopathy, CHD, arrhythmia, myocarditis and
valve diseases found in young
AHF therefore has significantly become the single most costly medical syndrome in emergency.
Eur Heart J 2005;26:384-416
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Cause of Acute Heart Failure
Ischemic heart Disease Circulatory failureAcute Coronary Syndromes SepticemiaMechanical complication of acute MI ThyrotoxicosisRV infarction ShuntsValvular TamponadeValve stenosis Pulmonary embolismValve regurgitation DecompensationEndocarditis of preexisting CHFAortic disection Lack of adherenceMyopathies Volume overloadPostpartum cardiomyopathy Infection; pneumoniaAcute myocarditis Cerebrovascular insultHypertension/arrhythmia SurgeryHypertension Renal dysfunctionArrhythmia Asthma, COPD Drug abuse Alcohol abuse
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Classification of AHF
• Patient with AHF present with six distinct
clinical conditions :
Worsening decompensated of chronic HF
Pulmonary edema
Cardiogenic shock
Hypertensive HF
Isolated right HF
ACS and HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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In Hospital mortality ( 60 days) : 9.6% Rehospitalization and mortality : 32,5% 1 year mortality : 30%.
Mortality of AHF
Fonarow GC. Rev Cardiovasc Med. 2001;2(suppl 2):S7–S12.
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Diagnosis of Heart Failure
Symptoms typical of HF Sign typical of HF Objective evidence of a structural or functional
abnormality of the heart at rest
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Framingham Heart Failure Study Criteria
Major Acute pulmonary edema PND or orthopnea Crackles S3 gallop HJR/Increased JVP Cardiomegaly Wt loss >4.5 kg 5d into
Rx
Minor Night cough Tachycardia >120 Pleural effusion Hepatomegaly Ankle edema Vital capacity decrease
>1/3 from max
*Two major or one major and two minor*
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NYHA I: no symptoms on ordinary activity
NYHA II: symptoms on ordinary exertion
NYHA III: symptoms on less-than ordinary
exertion
NYHA IV: symptoms at rest
NYHA Functional Heart Class
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At Risk for CHF (ACC/AHA)
Stage A
At high risk of HF but without structural heart disease or HF symptoms:
Pts. with HTN, CHD, diabetes,obesity, metabolic syndrome OR Pts. using cardiotoxins or
family hx. cardiomyopathy
Stage B
Structural Heart Disease but without signs or symptoms of HF:
Pts. with previous MI, LV remodeling including LVH, and low LVEF OR asymptomatic valvular disease
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Heart Failure (ACC/AHA)
Stage C
Structural heart disease with prior or current HF:
Pts. with known structural heart disease ANDSOB, fatigue, reduced exercise tolerance
Stage D
Refractory HF requiring specialized intervention:
Pts. with marked symptoms atrest despite maximalmedical therapyRecurrent hospitalizationUnsafe hospital discharge
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Common Clinical Manifestation of HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Common ECG abnormalities in HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Common X-ray abnormalities in HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Common lab. abnormalities in HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Common echo. abnormalities in HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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Diagnosis of HFClinical examination, ECG, Xray, Echocardiography
Natriuretic peptides
BNP 100-400 pg/mlNT-proBNP 400-2000 pg/ml
BNP<100 pg/mlNT-proBN P<400 pg/mL
BNP>400 pg/mlNT-proBNP>2000 pg/ml
Uncertain diagnosis
Chronic HF likelyChronic HF unlikely
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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A
L C
B
Congestion at rest
Yes
Yes
No
NoWarm & dry
Cold & WetCold & dry
Warm & wet
Low
perf
usi
on
at
rest
Sign of low perfusion:
Narrow pulse pressure,cool extremities,sleepy, suspect from ACEI hypotension, low Na, renal worsening
Sign of congestion:
Orthopnea,elevated JVP,edema,pulsatile hepatomegaly, ascites, rales,louder S3,P2 radiation left ward, abdomino-jugular reflex, valsava square wave
European Heart Journal of Heart Failure,2005; 7:323-331
Assessment of Haemodynamic Profile
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Treatment HF
Bed rest Fluid management Drug Device Stem cell
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ERAS OF HEART FAILURE MANAGEMENT
pre -1980’s 1980’s 1990’s 2000’s 2020’s ⇒
Pharmacological
• Digitalis
• Diuretics
• Vasodilators
• Inotropes
Device
• CRT
• ICDs
• LVADs
• Others?
Pharmacological
• Digitalis
• Diuretics
• Neurohormonal interventions
Non-pharmacological
• Bed rest
• Inactivity
• Fluid restriction
• (Digitalis, diuretics)
Cellular/genetic
• Gene therapies
• Cell implantation/ regeneration
• Xenotransplantation
Heart Failure Updates, 2003
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THE DONKEY ANALOGY
Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…
HEART FAILURE
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TREATMENT OPTION FOR HF
Like the carrot placed in front of the donkeyLike the carrot placed in front of the donkeyINOTROPIC
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Reduce the number of sacks on the wagon
ACEI AND DIURETICS
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ß-BLOKERS
Limit the donkey’s speed, thus saving energy
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C
A
L
BWarm
Dry
Cold
Wet DiureticVasodilator
Inotropic drugs :DobutamineMilrinoneLevosimendan
Patient Treatment Selection
Fonarow GC. Rev Cardiovasc Med. 2001;2(suppl 2):S7–S12.
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Treatment Algorithm in AHF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008
Acute Heart Failure
Immediate symtomatic treatment
Patient distress or in pain
Pulmonary congestion
Arterial Oxygen saturation < 95%
Normal heart rate and rhythm
Yes
Yes
Yes
No
Analgesia, sedation
Medical therapyDiuretic/vasodilator
Increase FiO2,consider CPAP, NIVMechanical ventilation
Pacing, antiarrhythmias,electroversion
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Treatment Algorithm in AHF
ESC Guideline for Acute Heart Failure, 2005
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Treatment Algorithm in AHF
ESC Guideline for Acute Heart Failure, 2005
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AHF with Systolic DysfunctionOxygen/CPAP
Furosemide + vasodilatorClinical evaluation (leading to mechanistic therapy)
SBP > 100 mmHg SBP 85-100 mmHg SBP <85 mmHg
Vasodilator(NTG, nitroprusside, BNP)
Vasodilator and/orInotropic (dobutamin
PDEI or Levosimendan)
Volume loading ?Inotrope and/or
Dopamin > 5mcg/kg/mntAnd/or norepinephrine
Good responseOral therapy
Furosemide, ACE-I
No respon :Reconsider mechanistic
therapyInotropic agent
Eur Heart J 2005;26:384-416
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Treatment of HF
ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart
Failure , 2008
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HF Prevention
Early diagnosis and prompt treatment of MI = ACS treatment
Treat Hypertension Treat and prevent DM to prevent
Cardiomyopathy DM Early diagnosis of Myocarditis to prevent
cardiomyoptahy
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From MI to HF
Early diagnosis and vascularization prevent HF
Delay and inadequate treatment iireversible cardiomyocyte loss
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Myocardial infarction leads to heart failure
Obstruction of coronary arteries leads to myocardial infarction (heart attack) with the associated death of cardiomyocytes
Regenerative capacity ? Not adequately compensate
Overloads the surviving myocardium and eventually leads to heart failure
Segers VF, Lee RT. Nature 2008; 451: 937-942.
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Terminal differentiation of cardiomyocytes
Cardiac myocytes rapidly proliferate during fetal life but exit the cell cycle soon after birth in mammals1
The vast majority of adult cardiac myocytes the predominant form of growth postnatally is an increase in cell size (hypertrophy)2
This limits the ability to restore function after any significant injury2
1. Ahuja P, et al. Physiol Rev 2007; 87: 521–544. 2. Segers VF, Lee RT. Nature 2008; 451: 937-942.
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Problem with Infarcted Heart
Current medical therapies of heart failure only delay progression of the disease
The only standard therapy for cardiomyocyte loss is cardiac transplantation
New discoveries on the regenerative potential of stem cells have transformed experimental research and led to an explosion in clinical investigation
Results ?
Segers VF, Lee RT. Nature 2008; 451: 937-942.
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HF Prevention
Treat Hypertension Early diagnosis and prompt treatment of
MI Treat and prevent DM to prevent
Cardiomyopathy DM Early diagnosis of Myocarditis to prevent
cardiomyoptahy
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MyocardialMyocardialinfarctioninfarction
Arrhythmia &Arrhythmia &loss of muscleloss of muscle
RemodellingRemodelling
VentricularVentriculardilatationdilatation
CongestiveCongestiveheart failureheart failure
DeathDeath
CoronaryCoronarythrombosisthrombosis
Myocardialischaemia
CADCAD
AtherosclerosisAtherosclerosisLVHLVH
Sudden DeathSudden Death
Risk factorsRisk factors HHypertensionypertension,, smoking, cholesterol, diabetessmoking, cholesterol, diabetes
Dzau V. Braunwald E, Am Heart J. 1991
The Cardiovascular Continuum
XPrevention I
XPrevention II
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Optimal : <120 and < 80
Normal : 120-129 and/or 80 - 84
High Normal : 130-139 and/or 85-89 Pre-hypertension
Normal
Grade 1 : 140-159 and/or 90-99
Grade 2 : 160-179 and/or 100-109
Grade 3 : > 180 and/or > 110
Stage 1
Stage 2
ESC-ESH 2007 JNC-VII
Classification of Blood Pressure
JNC VII committee, JAMA 2003: 289;2560-2572
HYPERTENSION
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90% lifetime risk of developing hypertension in people normotensive at age 55
People with lower educational and income levels tend to higher levels of blood pressure
American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006
Epidemiology of Hypertension
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Prevalence of Hypertension
± 2x
Kearney et al Lancet 2005Est
ablis
hed
Mar
ket
Econom
ies
Latin
Am
eric
a &
the
Carib
bean
Mid
dle E
aste
rn
Cresc
ent
Other
Asia
&
Isla
nds
Sub -Sah
aran
Africa
Former
Soci
alis
t
Econom
ies
Rate of hypertension%
Prevalence of hypertension in different regions of the world: Actual figures for 2000 - predicted for 2025
India
China
0
10
20
30
40
50
2025
0
10
20
30
40
50Men 2000Women
number of people with HT (millions)
number of people with HT (millions)
116.2 40.8 60.4 60.0 35.9 98.5 38.4 38.2123.3 52.5 57.8 54.3 37.9 83.1 33.0 41.6
147.9 44.0 107.3 102.1 72.2 151.7 67.3 73.6161.8 59.7 106.2 98.5 80.4 147.5 62.1 77.1
± 2x
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Hypertension is Not Adequately Treated
Off all the USA people with high blood pressure:
11% are not on treatment regimen 25% are not on adequate treatment 34% are on adequate treatment
American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006
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Hypertension Prevalence and Treatment
Prevalence of Hypertension
0
5
10
15
20
25
30
35
40
45
50
55
Country
%
USCanada
Germany
ItalySwedenEnglandSpainFinland
0
10
20
30
40
50
60
70
80
90
100
Country
%
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
Patients on Therapy USCanada
Germany
ItalySwedenEnglandSpainFinland
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Adapted from G. Mancia / L. Ruilope
USA: JNC VI. Arch Intern Med 1997Canada: Joffres et al. Am J Hypertens 1997 England: Colhoun et al. J Hypertens 1998France: Chamontin et al. Am J Hypertens 1998
< 140/90 mmHg< 140/90 mmHg
Canada
16
USA
27
England6
France
24
Marques-Vidal P et al. J Hum Hypertens 1997
< 160/95 mmHg< 160/95 mmHg
Finland
20.5
Spain
20
Australia
19
Germany
22.5
> 65 years
Scotland
17.5
India
9
Controlled Hypertension
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Uncontrolled BP in Outpatient Clinic
HTN65.8%
Non HTN34.2%
Controlled39.3%
Uncontrolled60.7%
Three hundred third teen patients were randomly chosen among patients with or without known hypertension visited to Harapan Kita out patient
Hypertensinwas diagnosed in 65.8 % patients visiting to outpatient clinic Harapan Kita Cardiovascular Center
Among hypertensive patients only 39.3% reached blood pressure target of SBP<140 and DBP<90 mmHg Saifur Rohman et al. unpublished data, 2008
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Blood Pressure Target Achievement in dr. Saiful Anwar Hospital
Optimized antihypertensive drug and Education for Compliance
Mifetika Lukitasari et al. ASMIHA abstract book, 2012Saifur Rohman et al. Asean Heart Journal 2011;19:20-23Mifetika Lukitasari et al. INASH abstract book, 2013
2011 2012
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BP in AMI pts on EDAdmission : Awareness
Unaware of HT Aware of HT
SBP<140 and DBP<90
SBP≥140 and DBP≥90
Saifur Rohman et al. unpublished data, 2010
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Increased blood pressure
Structural changes in compliance arteries
Compliance
Load on heart
Left Ventricular Hypertrophy
Left Ventricular Hypertrophy
Loss of buffering Function
Transmits Systolic pressure
Wave to small arteries
Perpetuation of Hypertension
Perpetuation of Hypertension
Shear stress on Artery wall
Endothelial dysfunction
Predisposes of AtherosclerosisPredisposes of Atherosclerosis
Consequences Structural Changes in Hypertension
Dzau VJ. Hypertension. 2001;37:1047-1052
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The Progression from Hypertension to Heart Failure
HypertensionHypertension
M IM I
L V HL V H
DeathDeathC H FC H F
Diastolic dysfunction
Systolic dysfunction
Normal LVStructure & Function
LV remodeling
SubclinicalLV dysfunction
OvertHeart Failure
Time (months)
Time (decades)
Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796
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The Importance of HTN in Development of HF
Hypertension (HTN) is present in 91% of patients who develop CHF, tripling the risk of normotensive
HTN is a common risk factor of HF, treatable, and often under-treated
Hypertension remains the major preventable factor
Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796
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CHFCumulativeIncidence
(%)
Years From Baseline Exam
5 10 15
20
15
10
5
0
Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.Data from Levy D et al. JAMA. 1996;275:1557-1562.
Stage 2 hypertension
Stage 1 hypertension
Normal BP
Cumulative Incidence of Heart failure in Normotensive and Hypertensive Patients
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1 1.5 3.0 4.5 7.5
Hypertension
MI
Angina pectoris
Diabetes
LVH
Valvular disease
Prevalence (%)
6062
103
119
85
43
58
Attributable risk (%)
3959
3413
56
612
45
78
femaleLevy et al JAMA 1996
Heart failure development:Population-attributable risk
Hazard Ratio
male
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Cost model based on 29 million adults in 5 EU countries(13% of population) with BP >160/95 mm Hg and a further
46 million (21%) with BP 140/90-160/95 mm Hg
Hansson et al Blood Press 2002
Annual acute management costs of inadequately treated hypertension
CV event Events (000s)
Costs (billion Euros)
Cost associated with uncontrolled BP
Acute MI
Heart failure
Stroke
All (95% CI)
442
815
964
2220
2.22
2.99
5.09
10.3 (9.8,10.8)
Events (000s)
Costs (billion Euros)
Cost saving if BP target attained
19
122
141
281
0.09
0.45
0.72
1.26 (0.80,1.90)
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HF Prevention
Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Treat and prevent DM to prevent
Cardiomyopathy DM Early diagnosis of Myocarditis to prevent
cardiomyoptahy
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Adequate and prevent recurrence of RHD
Recognition of acute rheumatic fever Prompt treatment AB prophylaxis Refer to cardiologist
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HF Prevention
Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Early diagnosis and refer congenital heart
disease Early diagnosis of Myocarditis to prevent
cardiomyoptahy
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Prevent development of HF in congenital heart disease
Early diagnosis Sent to cardiologist at proper time AB prophylaxis
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HF Prevention
Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Treat and prevent DM to prevent
Cardiomyopathy DM Early diagnosis of Myocarditis to prevent
cardiomyoptahy
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Prevent cardiomyopathy
Carditis : Viral, RHD, etc PPCM, SLE Prevent by early diagnosis and prompt
treatment
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Summary
High mortality and morbidity of HF Preventable by HF Risk factor intervention,
Early diagnosis and prompt treatment
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