Heart Failure: Evaluation and Treatment

Anecita Fadol, PhD, RN,FNP-BC Nurse Practitioner Department of Cardiology UT MD Anderson Cancer Center

Objectives
• Identify the different types of cardiomyopathy • Describe the pathophysiologic mechanism of cardiomyopathy/heart failure • Discuss diagnostic testing/procedures for heart failure diagnosis

• Discuss the clinical guidelines for the management of heart failure.

Case Examples
• A 16 year old male with a history of pneumonia. He was brought to the clinic by his mother because he did not seem to get better after 8 weeks since the initial flu like symptoms. Last night he had severe fatigue and shortness of breath while brushing his teeth.

• A 63 year old female with a known history of breast cancer, treated with anthracycline-based chemotherapy 30 years ago. Recently, she noted progressively increasing shortness of breath with exertion, PND and lower extremity swelling.

Cardiomyopathy and Heart Failure • Cardiomyopathy is a weakening or deformity of the heart muscle that causes decreased pumping force. 2003. Hunt et al. 2005 . Yahalom et al. 2005. DeMartinis et al. 2008a. AHA.

congenital heart defects Diabetes Valvular heart disease Thyroid disease Hyperlipidemia Sleep apnea Overweight (elevated body mass index [BMI]) Sedentary lifestyle Advanced age Viral Others (e. hypertension. Hunt et al.. DeMartinis et al.g. 2005 .g. 2007. smoking. coronary artery disease) – Nonischemic underlying diseases (e.Risk Factors for Cardiomyopathy/HF • Major causes of CMP/HF – Ischemic heart disease (e. alcohol..g.. valvular heart disease) • Risk factors for cardiomyopathy/HF – – – – – – – – – – – – – History of or active coronary artery disease Hypertension (75% of patients) Genetic predisposition. 2003. illicit or therapeutic cardiotoxic drugs) Chang.

Non – ischemic Cardiomyopathy .

Heart Failure (HF) Definition A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. .

The Donkey Analogy Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living… .

1997. J Am Coll Cardiol.3:S42-S47. 3Ho KKL et al.5 1Adapted from Gilbert E.Epidemiology of HF in the US 12 10 8 6 4 2 0 1991 2001 2037 10 HF Patients in US (millions) • 5 million symptomatic patients in 2001. 2American Heart Association.22:6A-13A.000 new cases/year2 • Prevalence is 1% between the ages of 50 and 59 years3. . 4Rich M. 2003. 2002. estimated 10 million in 20371. Rev Cardiovasc Med.2 • Incidence: about 550.45:968-974. J Am Geriatric Soc. 2004 Heart and Stroke Statistical Update. progressively increasing to 10% over age 804 5 3. 1993.

Part I: Pathophysiology of Heart Failure .

335:490–498. Bazzano LA. et al. 1996. 161: 996-1002. N Engl J Med. Arrhythmia Left ventricular injury Pathologic remodeling Low ejection fraction Death Pump failure Symptoms: Dyspnea Fatigue Edema Chronic heart failure . Ogden LG.Pathological Progression of CV Disease 1 Endothelial Dysfunction CAD CM HTN Valvular Dz Chemo • Neurohormonal stimulation • Endothelial dysfunction • Myocardial toxicity • Vasoconstriction • Renal sodium retention 1 Adapted from Cohn JN. Risk Factors for Congestive Heart Failure in US Men and women: NHANES I epidemiologic follow-up study. 2 He J. Arch Intern Med 2001.

Left Ventricular Dysfunction • Systolic: Impaired contractility/ejection – Approximately two-thirds of heart failure patients have systolic dysfunction1 • Diastolic: Impaired filling/relaxation 30% (EF > 40 %) (EF < 40%) 70% Diastolic Dysfunction Systolic Dysfunction 1 Lilly. Pathophysiology of Heart Disease. L. Second Edition p 200 .

2002.38:2101-2113. . patients with HTN or CAD) NYHA Functional Class2 I Asymptomatic II Symptomatic with moderate exertion B Structural heart disease but without symptoms of HF C Structural heart disease with prior or current symptoms of HF III Symptomatic with minimal exertion D Refractory HF requiring specialized interventions IV Symptomatic at rest Symptomatic 1Hunt SA et al.287:890-897. 2005. J Am Coll Cardiol.Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class Asymptomatic ACC/AHA HF Stage1 A At high risk for HF but without structural heart disease or symptoms of HF (eg. 2New York Heart Association/Little Brown and Company. 1964. Adapted from: Farrell MH et al. JAMA.

Part II: Assessing Heart Failure .

Cardiac Assessment • A comprehensive cardiac assessment includes the following: – Patient history – Physical assessment – Diagnostic testing .

Fadol. liver. Hunt et al. 2003. infection • Organ function as a contributing factor or resulting from HF Creatinine kinase (CK. cardiac troponins I and T Brain natriuretic peptide (BNP) Cardiac enzymes Cardiac markers • Follow-up: Assess signs and symptoms. wall thickness/mobility.Cardiac Assessment: Diagnostic Testing Initial diagnostic evaluation for HF patient Echocardiogram (ECHO) Electrocardiogram Chest x-ray Standard laboratory tests • Blood chemistry. conduction. understanding of treatment. arrhythmias Detects heart enlargement. CK-MB). thyroid tests Measures heart size. creatinine. body weight. can detect myocardial infarction. compliance. 2007. urinalysis • Complete blood count (CBC) • Renal. fluid around heart or lungs • Blood urea nitrogen (BUN). 2006. albumin (liver function). 2005 . functional capacity. LVEF Assesses cardiac rhythm. glucose (diabetes) • CBC detects anemia. valvular function. flow gradients. exacerbating factors for HF DeMartinis et al. Chang.

Part III: Current Treatment of Heart Failure .

The Vicious Cycle of Heart Failure Management Chronic HF Diurese & Home SOB  Weight Hospitalization IV Lasix or Admit MD’s Office PO Lasix Emergency Room .

Goals of Heart Failure Therapy • Relieve heart failure symptoms – Improve overall clinical status – Stabilize acute episodes of decompensation • Decrease morbidity and mortality – Slow and/or reverse disease progression – Identify and treat reversible causes of LV dysfunction .

General Approach to Treatment • Determine etiology and/or precipitating factors – Avoid drugs which may aggravate HF • Treat underlying disorders – Anemia. valvular disease – Revascularization or anti-ischemic therapy in patients with CAD may reduce symptoms of HF • Physical activity (low-intensity) if stable • Restrict fluid (~2 L/day) and sodium intake (<1. hypo/hyperthyroidism.5-2 g/day) .

Established Therapy: Drugs with a mortality benefit in HF • Beta-blockers • Angiotensin converting enzyme (ACE) inhibitors – Angiotensin Receptor Blocker (Candesartan) • Spironolactone or Eplerenone • Isordil/Hydralazine .

prolong AV refractoriness.Digoxin • Mechanism of action: –  contractility • Inhibition of sodium/potassium ATPase pump which acts to increase intracellular sodium-calcium exchange to increase intracellular calcium leading to increased contractility – Neurohormonal • Blunt SNS activation • Increase vagal tone – Slow conduction. slowing ventricular response in atrial fibrillation .

Pharmacologic Management
Digoxin • Enhances inotropy of cardiac muscle • Reduces activation of SNS and RAAS

• Controlled trials have shown long-term digoxin therapy:
– – – – – – Reduces symptoms Increases exercise tolerance Improves hemodynamics Decreases risk of HF progression Reduces hospitalization rates for decompensated HF Does not improve survival

Digoxin
• Warnings/Precautions
– Acute myocardial infarction – Acute myocarditis or amyloid cardiomyopathy

– Correct electrolyte imbalances
– Adjust dose in renal disease – Bradycardia – Withdrawal in CHF patients may lead to recurrent CHF symptoms – Drug interactions – Digoxin toxicity

Digitalis Compounds
Like the carrot placed in front of the donkey

Pharmacologic Management Diuretics • Used to relieve fluid retention • Improve exercise tolerance • Facilitate the use of other drugs indicated for heart failure • Patients can be taught to adjust their diuretic dose based on changes in body weight • Electrolyte depletion a frequent complication • Should never be used alone to treat heart failure • Higher doses of diuretics are associated with increased mortality .

htm .org/clinical/guidelines/failure/hf_index. LOE C) – Use until euvolemic stage is achieved – Continue to prevent recurrence of fluid retention • Increase urinary sodium excretion • Improve pulmonary and peripheral congestion – Decrease preload • No long-term studies – Effects on morbidity and mortality are unknown ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.Diuretics • Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention (Class I.acc.

acc.Dosing Oral Diuretics ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.htm .org/clinical/guidelines/failure/hf_index.

Dosing IV Diuretics ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.org/clinical/guidelines/failure/hf_index.htm .acc.

ACE inhibitors • Mechanism of action: –  preload and afterload – Arterial and venous dilatation • Reduces formation of Angiotension II (vasoconstrictor) • Reduces breakdown of bradykinin (vasodilator) • Clinical Effects: – Improve symptoms – Reduce remodeling / progression – Reduce hospitalization – Improve survival .

org/clinical/guidelines/failure/hf_index.Ace Inhibitors • Recommendations – ACEIs are recommended for all patients with current or prior symptoms of HF and reduced LVEF .htm . LOE A) – ACEIs or ARBs can be beneficial in patients with HTN and LVH and no symptoms of HF (Class IIa. LOE B) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www. LOE A) – ACEIs should be used in all patients with reduced LVEF and no symptoms of HF. even if they have not experienced MI (Class I. unless contraindicated (Class I.acc.

325:303-310.Effect of ACE Inhibitors on Survival in Heart Failure Cumulative Mortality 20 15 10 5 0 Placebo Enalapril Cumulative Predictability of Death 25 Mortality From All Causes (%) P=0.316.1429-1435. 3The CONSENSUS Trial Study Group.0036 0. 1987. 2Cohn J et al.5 Enalapril P<0. 1991.75 0.003 0.25 Hydralazine Isosorbide Dinitrate Enalapril 12 24 36 48 0 0 0 6 12 18 24 30 36 42 48 54 60 Months 0 1 2 3 4 5 6 7 8 910 11 12 Months Months SOLVD-P NYHA Class Treatment Results 1The SOLVD-T Class II-III (N=2569) Enalapril 16% CONSENSUS Class IV (N=253) Enalapril 27% Class I-II (N=4228) Enalapril 8% (% reduction in all-cause mortality) SOLVD Investigators.4 0.6 0.325:293-302.8 0. 1991. N Engl J Med. N Engl J Med.2 0 Placebo P<0.30 0. N Engl J Med. .

25-2.htm .5 mg bid 5-10 mg daily 2.ACE inhibitors ACEI Captopril Initial Dose 6.25 mg tid Maximum Dose 50 mg tid Enalapril Fosinopril Lisinopril Quinapril Ramipril Trandolapril 2.5-5 mg daily 5 mg bid 1.5 mg daily 1 mg daily 10-20 mg bid 40 mg daily 20-40 mg daily 20 mg bid 10 mg daily 4 mg daily ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.

especially after 1st dose – Hereditary angioedema – Bilateral renal artery stenosis – Pregnancy (2nd and 3rd trimester) – Careful BP monitoring with 1st dose (hypotension) • Captopril>Lisinopril>Enalapril – May cause hyperkalemia. rise in Scr .Ace Inhibitors • Contraindications: – Hypersensitivity – Angioedema related to previous treatment with ACEI • Warnings/Precautions: – Anaphylactic reactions can occur – Angioedema can occur at any time during treatment.

volume depletion. particularly in patients with DM or CRF – Monitor K+ early after initiation of therapy. or nephrotoxin administration • Correct or remove these factors • Consider bilateral renal artery stenosis • ACEIs should be discontinued temporarily while precipitating factors for ARF are corrected – ARBs are not an appropriate substitute under these conditions!!! – ACEI therapy can be reinstituted once these factors are corrected • Hyperkalemia is a potential complication.Principles of ACEI therapy • Occurrence of ARF should prompt a search for: – Hypotension (MAP <65 mmHg). reduce dietary K+. avoid agents that aggravate hyperkalemia .

ACE inhibitors • Start with a low dose • Increase dose if well tolerated (hold parameters for BP and HR) • Dose NOT determined by symptoms. titrate to target dose • Monitor renal function & serum K+ • Avoid initiating while volume depleted .

Diuretics. ACE Inhibitors Reduce the number of sacks on the wagon .

htm .acc.ARBs • Recommendations – ARBs approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI intolerant (Class I. LOE A) – ARBs are reasonable to use as alternatives to ACEIs as 1st line therapy for patients with mild to moderate H F and reduced LVEF. especially for patients already taking ARBs for other indications (Class IIa. LOE A) – The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who have already been treated with conventional therapy (Class IIb.org/clinical/guidelines/failure/hf_index. LOE B) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.

htm .org/clinical/guidelines/failure/hf_index.ARBs ARB Candesartan Losartan Not FDA approved Initial Dose 4-8 mg daily 25-50 mg day 20-40 mg bid Maximum Dose 32 mg daily 50-100 mg day 160 mg bid Valsartan ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.

acc.htm .Beta-blockers • Recommendations – Beta-blockers and ACEIs should be used in all patients with recent or remote history of MI regardless of EF or presence of HF (Class I: LOE A) – Beta-blockers are indicated in all patients without a history of MI who have reduced LVEF with no HF symptoms(Class I: LOE C) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adul http://www.org/clinical/guidelines/failure/hf_index.

betablockers reduce the combined risk of morbidity and mortality. 20. . 2001 p. beta blocker decreases myocardial contractility.Pharmacologic Management Beta-Blockers • Cardioprotective effects due to blockade of excessive SNS stimulation • In the short-term. et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. SA. or disease progression1 1 Hunt. increase in EF after 1-3 months of use • Long-term. placebo-controlled trials have shown symptomatic improvement in patients treated with certain beta-blockers1 • When combined with conventional HF therapy.

slow upward titration • Antiischemic • Antihypertensive • Antiarrhythmic • Antioxidant.Beta-blockers • Mechanism of action: –  Density of ß1 receptors –  Neurohormonal activation • Slow/reverse ventricular remodeling • Decreased myocyte death from catecholamine. Antiproliferatiev .induced necrosis or apoptosis –  HR • Symptomatic worsening of HF • Low doses.

Beta-blockers • Increase EF • Decrease ventricular mass • Reduce systolic and diastolic volumes • Decrease hospitalization and mortality – Greater benefit seen at higher doses .

carvedilol (n=261). †P.25 mg bid 12. *Results from the Multicenter Oral Carvedilol Heart Failure Assessment (MOCHA) trial (n=345). vs placebo.0001 .5 mg bid Carvedilol Patients receiving diuretics. follow-up 6 months.Even low doses of B-blockade can have a dramatic effect Ejection Fraction* 8 LVEF (EF units) † 6 † ‡ 4 2 0 Placebo 6. ACE inhibitors. ± digoxin.005 25 mg bid vs placebo. Circulation. 1996. placebo (n=84). Adapted from Bristow MR et al.94:2807–2816. ‡P.

6 0.353:2001-2007. . 3.353:9-13. 2001.0 b -blocker 1.6 P<0. Lancet.344:1651-1658. Lancet.Effects of Beta-Blockers on Mortality 1.0 b -blocker Mortality 0.0001 P=0. 2.0 b -blocker 1. 1999. N Engl J Med.006 0 1 MERIT-HF II . Packer M et al. MERIT-HF Study Group.00013 0 1 2 Time (years) 0 1 CIBIS II 2 COPERNICUS IV (N=2289) LVEF  25% Carvedilol 35% NYHA Class III-IV (N=2647) Entry criteria LVEF 35% Treatment Bisoprolol Results 34% (% reduction in death) 1.8 Placebo Risk  35 % 0. CIBIS II Investigators and Committees. 1999.8 Placebo Risk  34 % Placebo 0.6 P <0.8 Risk  34 % 0.IV (N=3391) LVEF 40% Metoprolol CR/XL 34% 2 0.

htm .acc.org/clinical/guidelines/failure/hf_index.Beta-blockers • Recommendations – Beta-blockers and ACEIs should be used in all patients with recent or remote history of MI regardless of EF or presence of HF (Class I: LOE A) – Beta-blockers are indicated in all patients without a history of MI who have reduced LVEF with no HF symptoms(Class I: LOE C) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.

1blocker b1-selective II-IV 3.Beta-blockers Medication Mechanism of action b1-selective NYHA Class III-IV Initial dose Target Dose Bisoprolol (Zebeta®) not FDA-approved 1.25 mg/day 10 mg/day Carvedilol (Coreg®) Coreg CR Metoprolol succinate (Toprol XL®) Non-selective b-blocker.125 mg bid 25 mg bid (< 85 kg) 50 mg bid (> 85 kg) II-III 10 mg/day 12.5-25 mg day 80 mg/day 200 mg/day .

ß-Blockers Limit the donkey’s speed. thus saving energy .

symptomatic hypotension – Hypersensitivity – Bradycardia HR<45 – 2nd and 3rd degree heart block.Beta-blockers Contraindications: – Cardiogenic shock.24 sec) – unless pacemaker places . (P-R interval greater than or equal to 0.

and sudden death) – discontinue over 1-2 weeks .Beta-blockers Warnings/Precautions: – Anesthesia/surgery (myocardial depression) – Bronchospastic disease (less with cardioselective agents) – Decompensated HF – May mask s/sx hypoglycemia – May mask signs of hyperthyroidism/thyrotoxicosis – PVD – use with caution since may aggravate arterial insufficiency – Avoid abrupt withdrawal (may result in hypertension. tachycardia. ischemia. MI. angina.

Pharmacologic Management Aldosterone Antagonists • Generally well-tolerated • Shown to reduce heart failure-related morbidity and mortality • Generally reserved for patients with NYHA Class III-IV HF • Side effects include hyperkalemia and gynecomastia. Potassium and creatinine levels should be closely monitored .

348(14):1309-21.341(10):709-17. 2003. .Aldosterone Antagonists • Randomized Aldactone Evaluation Study (RALES) – 30% relative risk reduction in all-cause mortality and 35% reduction in hospitalizations • The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival (EPHESUS) Trial – 15% relative risk reduction in all-cause mortality and hospitalizations for HF N Engl J Med. N Engl J Med. 1999.

Effect of Spironolactone on Survival (Aldosterone blockade) 1. N Engl J Med.00 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Study Design  NYHA Class III-IV (N= 1663)  EF 35%  Frequent monitoring of potassium  Result: 30% reduction in death Pitt B et al.341:709-717.90 Spironolactone 0. 1999.00 P<0.70 0.60 Placebo 0. .50 0.80 0.001 Probability of Survival 0.

NEJM 2003.1309 .Effect of Eplerenone on Sudden Cardiac Death Pitt.348.p.

LOE B) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.Aldosterone Antagonists • Recommendations – Addition of an aldosterone antagonist is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration.htm .0 mEq/L (Class I.5 mg/dL in men or  2.acc. • Creatinine should be  2.0 mg/dL in women and potassium should be  5.org/clinical/guidelines/failure/hf_index.

5-25 mg daily 25 mg daily Maximum Dose 25 mg daily or bid 50 mg daily ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.htm .acc.org/clinical/guidelines/failure/hf_index.Aldosterone Antagonists ARB Spironolactone Eplerenone Initial Dose 12.

Vasodilators • Hydralazine + Nitrates – Nitrates • Activate guanylate cyclase to  cGMP in vascular smooth muscle  venodilation  preload • Inhibit ventricular remodeling process – Hydralazine • Direct-acting vasodilator on predominantly arterial smooth muscle   SVR (afterload) • Prevent nitrate tolerance. antioxidant effects .

and 3 years • V-HeFT-II – Hydralazine 75 mg po qid + ISDN 40 mg qid vs. and 23% at 1. enalapril and enalapril was superior . 2. 25%.Vasodilators: Clinical Data • Veteran Affairs Cooperative Studies • V-HeFT-I – Hydralazine 75 mg po qid + ISDN 40 mg qid vs prazosin 5 mg qd in addition to std therapy • Hydralzine + nitrates   mortality by 38% .

placebo-controlled. self-identified as black2 with stable symptomatic HF – LVEF <35% or left ventricular internal diastolic dimension >2. 40% women – Patients randomized to receive either their current standard therapies + BiDil (n=518) or their current standard therapies + placebo1 (n=532) – BiDil® tablet = Hydralazine 37.Vasodilators: Clinical Data • A-HeFT – Randomized. 95% NYHA class III . 4% NYHA class IV • Mean age upon entry: 571 • 60% men. double-blind clinical trial2 – 1.5 mg/ISDN 20 mg • 2 tablets po tid .050 pts.9 cm/m2 plus LVEF <45%2 • 1% NYHA class II.

001) – Significant additional improvement in symptoms of heart failure1 .012)1 – Additional 39% risk reduction in first hospitalization for heart failure beyond current standard therapies (P<0.Vasodilators: Clinical Data • A-HeFT Results – Additional 43% reduction in mortality beyond current standard therapies (P=0.

org/clinical/guidelines/failure/hf_index.Vasodilators • Recommendations – The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta-blocker for symptomatic HF and who have persistent symptoms (Class IIa. hypotension. or renal insufficiency (Class IIb. LOE C) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc. LOE A) – A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who are who cannot be given a ACEI or ARB because of drug intolerance.htm .

and tingling.like drugs . numbness. • Pyridoxine should be added to therapy if such symptoms develop.Vasodilators: Precautions • Hydralazine – Systemic lupus erythematosus – Hypotension • Nitrates – Hypotension – Headaches – Tachycardia – Peripheral neuritis. – Tolerance – separate dosing by 10-12 hours • Example: Dose at 9am. 9 pm – Drug interactions with Viagra®. which may be related to an antipyridoxine effect. 3pm. evidenced by paresthesia.

et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.Treatment Approach for the Patient with Heart Failure Stage A Stage B Stage C Stage D At high risk. 2005 . SA. no structural disease Structural heart disease.B. and C • Mechanical assist devices • Heart transplantation • Continuous (not intermittent) IV inotropic infusions for palliation • Hospice care Therapy • Treat Hypertension • Treat lipid disorders • Encourage regular exercise • Discourage alcohol intake • ACE inhibition Therapy • All measures under stage A • ACE inhibitors in appropriate patients • Beta-blockers in appropriate patients Hunt. asymptomatic Structural heart disease with prior/current symptoms of HF Therapy • All measures under stage A Drugs: • Diuretics • ACE inhibitors • Beta-blockers • Digitalis • Dietary salt restriction Refractory HF requiring specialized interventions Therapy • All measures under stages A.

Current Treatment Options .

Cardiac Resynchronization Therapy (CRT) • Symptomatic heart failure despite OPT • Wide QRS complex • LV dysfunction EF < 35% • NYHA Class III/IV .

Cardiac Resynchronization Therapy Increase the donkey’s (heart) efficiency .

Reverse Remodeling in HF 10/10/03 8/13/07 .

Implanted Cardioverter Defibrillator (ICD)  ICD prevents SCD  CRT improves Quality of Life and NYHA  Heart Failure patients should be managed on optimal background therapy .

Assist Devices: Bridge to Transplant .

Other New Modalities – Research Stage • Cell and Gene Therapy * Utility in treating acute myocardial infarction -we cannot limit infarct size -we can rebuild infarcted muscle • Potential Cells to use: * cardiac myocytes * skeletal muscle cells * endothelial cells * progenitor cells * pluripotent cells .

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Goethe . we must do.” . Willing is not enough. we must apply.“Knowing is not enough.

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