ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ Η έκταση του προβλήματος. Ι.Ε.ΚΑΝΟΝΙΔΗΣ Καθηγητής Καρδιολογίας

ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ Η έκταση του προβλήματος Ι.Ε.ΚΑΝΟΝΙΔΗΣ Καθηγητής Καρδιολογίας

ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ Καρδιακή ανεπάρκεια ονομάζεται η κατάσταση εκείνη κατά την οποία η καρδιά αδυνατεί να αποστείλει στην περιφέρεια την αναγκαία ποσότητα αίματος για να ανταποκριθεί στις μεταβολικές ανάγκες του οργανισμού ή το κάνει υπό καθεστώς υψηλών πιέσεων.

Chronic Congestive Heart Failure DEFINITION The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return." E. Braunwald

Chronic Congestive Heart Failure No symptoms Normal exercise Normal LV fxn EVOLUTION OF CLINICAL STAGES NORMAL Asymptomatic LV Dysfunction No symptoms Normal exercise Abnormal LV fxn Compensated CHF Decompensated CHF No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Refractory CHF Symptoms not controlled with treatment

Staging system of Heart Failure A - patients at risk, but no structural or functional defects, (CAD,HTN, DM, metabolic syndrome, obesity) B - pts with structural heart disease but do not manifest symptoms of heart failure (LV enlargement or dysfunction, LVH, valvular heart disease)

Staging system of Heart Failure C - pts with prior or current symptoms that can be controlled with standard medications D - pts with severe disease, frequent hospitalizations, often requiring advanced therapies

NYHA Functional Classification Class I - pts with disease but no symptoms that limit activity Class II - pts with slight limitations of physical activity related to symptoms of HF (dyspnea, fatigue) Class III - pts with marked limitations of physical activity, but no symptoms at rest Class IV- pts cannot carry out any physical activity without limitation and may have symptoms even at rest

Chronic Congestive Heart Failure

Risk Factors for the Development of HF Risk Factor Sex Age- and Risk-Factor- Adjusted Hazard Ratio (95% CI) Prevalence (%) Population- Attributable Risk (%) Hypertension M 60 39 F 62 59 Myocardial infarction M 10 34 F 3 13 Angina pectoris M 11 5 F 9 5 Diabetes M 8 6 F 5 12 Left ventricular hypertrophy M 4 4 F 3 5 Valvular heart disease M 5 7 Levy D et al. JAMA. 1996;275:1557-1562. F 8 8 1 2 4 6 8 10

Chronic Congestive Heart Failure Aetiology of HF in UK

Diagnosis of HF type by Clinical Signs and Symptoms The clinical signs and symptoms of HFREF and HFNEF are similar. HFNEF Systolic HF Symptoms Dyspnea on exertion 85% 96% PND 55% 50% Orthopnea 60% 73% Physical Findings Jugular venous distension 35% 46% Rales 72% 70% Displaced apical impulse 50% 60% S3 gallop 45% 65%* S4 gallop 55% 66% Edema 30% 40% Zile MR, Brutsaert DL. Circulation 2002; 105: 1389

Chronic Congestive Heart Failure Επιδημιολογία

Heart Failure Statistics Prevalence Heart failure (HF) affects an estimated 5.1 million Americans > 20 years of age. By 2013 the prevalence of HF will increase by 25%. 400,000 new cases of heart failure are diagnosed in the United States annually. Incidence One-percent of adults 50 to 60 years of age. Seventy-five percent of HF cases have antecedent hypertension. Ten-percent of adults 80 years of age or older. Mortality and Morbidity The lifetime risk for people with BP > 160/90 mmhg is double that of those persons with BP < 140/90 mmhg At 40 years of age, the lifetime risk of developing HF for both men and women is 1 in 5; at 80 years of age, the lifetime risk of developing new HF is 20%. Most frequent cause of hospitalizations in the elderly and is responsible for 7 to 12 percent of all hospital admissions. Contributes to approximately 275,000 deaths every year.

Heart Failure Patients in US (Millions) Epidemiology of HF in the US -I 12 10 8 6 4 2 3.5 4.7 10 More deaths from heart failure than from all forms of cancer combined 550,000 new cases/year 4.7 million symptomatic patients; estimated 10 million in 2037 0 1991 2000 2037* *Rich M. J Am Geriatric Soc. 1997;45:968 974. American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

HF Patients in US (millions) Epidemiology of HF in the US -II 12 10 8 10 Prevalence is 1% between the ages of 50 and 59 years 3 ; progressively increasing to 10% over age 80 4 6 4 3.5 5 The 5 year mortality rate following diagnosis with heart failure is almost 50%. 2 0 1991 2001 2037 1 Adapted from Gilbert E. Rev Cardiovasc Med. 2002;3:S42-S47. 2 American Heart Association. 2004 Heart and Stroke Statistical Update. 2003. 3 Ho KKL et al. J Am Coll Cardiol. 1993;22:6A-13A. 4 Rich M. J Am Geriatric Soc. 1997;45:968-974.

PREVALENCE - ΕΠΙΠΟΛΑΣΜΟΣ

Prevalence of Congestive Heart Failure by Age and Sex NHANES: 1999-2002 Percent of Population 10 8 6 4 2 0 9.8 10.9 5.8 6.2 4.1 1.8 2.3 1.5 0.3 0.3 0.5 0.4 20-34 35-44 45-54 55-64 65-74 75+ Ages Men Women Source: CDC/NCHS and NHLBI.

Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI. Percent of Population 16 14 12 10 8 6 4 2 0 13.8 12.2 9.3 4.8 2.2 1.2 0.1 0.2 20-39 40-59 60-79 80+ Men Women

Chronic Congestive Heart Failure Prevalence of HF in UK

PREVALENCE IN THE ELDERLY

ΕΠΙΠΤΩΣΗ INCIDENCE

Chronic Congestive Heart Failure INCIDENCE OF HF - FRAMINGHAM

Chronic Congestive Heart Failure Incidence of HF in UK

Chronic Congestive Heart Failure Νοσηρότητα Hospitalizations

Hospital Discharges for Congestive Heart Failure by Sex United States: 1970-2002 Discharges in Thousands 600 500 400 300 200 100 0 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 Years Males Females Note: Hospital discharges include people living and dead. Source: CDC/NCHS.

Hospital discharges for heart failure by sex. (United States: 1979-2006). Source: NHDS/NCHS and NHLBI. Discharges in Thousands 700 600 500 400 300 200 100 0 79 80 85 90 95 00 06 Years Male Female Note: Hospital discharges include people discharged alive, dead and status unknown.

Chronic Congestive Heart Failure HOSPITALISATIONS HOSPITALISATIONS THE EFFECT OF TREATMENT

Chronic Congestive Heart Failure Prognosis Επιβίωση

A growing burden Deaths from HF 1979-1997 (USA) 50000 40000 HF deaths 30000 20000 10000 0 1979 1985 1991 1997 Vital Statistics of the United States, National Center for Health Statistics 43

Chronic Congestive Heart Failure Progression of HF

Survival Survival Risk of Sudden Death c/w EF 1.00 1.00 0.98 p log-rank 0.002 0.98 0.96 0.96 0.94 0.94 0.92 0.90 0.92 0.90 p log-rank 0.0001 0.88 0.86 A 0 30 60 90 120 150 180 Days 0.88 B 0.86 0 30 60 90 120 150 180 Days Patients without LV Dysfunction (LVEF >35%) No PVBs 1-10 PVBs/h > 10 PVBs/h Patients with LV Dysfunction (LVEF < 35%) Maggioni AP. GISSI-2 Trial Circulation. 1993;87:312-322.

Prognosis depends on Etiology 1230 pts. referred for unexplained CM. Felker GM. NEJM 2000;342:1077

Influence of EF on Survival in Patients with Heart Failure Vasan RS et al. J Am Coll Cardiol. 1999;33:1948-55

Chronic Congestive Heart Failure Prognosis of heart failure

Chronic Congestive Heart Failure SURVIVAL BY AGE GROUP

Chronic Congestive Heart Failure DISEASE SURVIVAL

ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΣΥΣΤΟΛΙΚΗ ΔΙΑΣΤΟΛΙΚΗ

ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΣΥΣΤΟΛΙΚΗ Αδυναμία αποστολής επαρκούς ποσότητας αίματος από τις κοιλίες κατά την συστολή στην περιφέρεια ΑΙΤΙΑ Μειωμένη συσταλτική ικανότητα των μυοκαρδιακών ινών

ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΔΙΑΣΤΟΛΙΚΗ Αδυναμία αναρρόφησης επαρκούς ποσότητας αίματος κατά την διαστολή από τις κοιλίες και κατά συνέπεια αποστολή ανεπαρκούς ποσότητας αίματος κατά την συστολή στην περιφέρεια ΑΙΤΙΑ Αδυναμία επαρκούς διάτασης των μυοκαρδιακών ινών και κατά συνέπεια αδυναμία επαρκούς αύξησης του όγκου της κοιλότητας των κοιλιών κατά την διαστολή

Δεξιά καρδιακή ανεπάρκεια Αριστερή καρδιακή ανεπάρκεια Ολική καρδιακή ανεπάρκεια

LV Systolic Function in Elderly with HF in CHS Population-based reports from several studies suggest that 50% or more of elderly HF patients have HFNEF with a female preponderance in HFNEF. Men Women 12% 29% 30% 41% 21% 67% Normal EF Mildly Reduced EF Mod/Sev Reduced EF Kitzman DW, Gardin JM, Gottdiener JS, et al. Importance of heart failure with preserved systolic function in patients 65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol 2001;87:413-9

Mortality with HF Stratified by EF Elderly HF patients with HFNEF have similar survival to those with HFREF but the modes of death tend to differ with more non-cardiovascular causes among the HFNEF cohort.. Olmstead County Study Senni et al, Circulation 1998

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