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					       Heart Failure Matters
The Invisible Part of the Iceberg:
  Stage A and B Heart Failure

 Prof. Dr. Yüksel ÇAVUŞOĞLU, MD, FESC
 Board Member of the Working Group of Heart Failure
         of Turkish Society of Cardiology
Eskisehir Osmangazi University, Cardiology Department
                 Eskisehir, Turkey

           Joint Session UKBIH - TKD
           5th Congress of the UKBIH,
            Bosnia and Herzegovina,
                   27 May 2010
Heart failure is a major public health problem
        that affects millions of people




                     Davis RC et al. BMJ 2002; 325: 1156.
                     Lloyd-Jones D et al. Circulation 2009;119:e21-e181.
HF is a progressive disease with a poor prognosis

The 1-year mortality rate for HF is estimated as 21% in men and 17% in women




                                     Roger VL et al. JAMA 2004;292:344-50.
                                     Heart Disease and Stroke Statistics 2010 update.
     Hospital discharges for heart failure

                                                n=1 106 000



                  n=399 000




                                                175% ↑




“From 1979 to 2006, hospital discharges for HF have increased by 175%”
  “HF causes a substantial economic burden on the healthcare system”

                                  Heart Disease and Stroke Statistics 2010 update.
                                  Circulation published online Dec 17, 2009
 The risk of HF incidence increases with older age
       The elderly population (≥65 y) is expected to grow in the community.




                       Even if HF incidence remains constant,
the total number of people with HF is expected to double during the next two decades

                                          Heart Disease and Stroke Statistics 2010 update.
                                          Circulation published online Dec 17, 2009
Clinical HF increases in prevalence with advancing age
         The prevalence of HF will likely continue to increase
               in developed and developing countries




          Heart failure will become a major public health burden

                                    Heart Disease and Stroke Statistics 2010 update.
                                    Circulation published online Dec 17, 2009
     Symptomatic disease is only the tip of the iceberg

                                 Death

       Visible                            Refractory HF
                         Symptomatic HF
        Part
                               Systolic/diastolic dysfunction

                                         LV Dilatation
                         Valvular heart disease
                                     LVH
                                              MI
     Invisible               Atherosclerozis
                                         Diabetes
       Part                 Toxins
                                             Dyslipidemia
                                 Obesity
                                        Smoking
                                      Hypertension
                            Aging
                                                Genes
The majority of people are in a preclinical stage of the disease
        Prevention of Heart Failure
 Prevention programs targeting this growing population will
likely reduce HF incidence

 Essential strategies for prevention of HF should focus on
modification of risk factors for HF development

 Objectives include:
      Early idendification of patients at high risk
      Early detection of asymptomatic LV dysfunction
      Optimal treatment plan for each individuals
      Agressive therapeutic lifestyle changes
      Targeted pharmacological intervention
      Persistent follow-up
New Approach to the Classification of Heart Failure




                      Hunt, S. A. et al. J Am Coll Cardiol 2009;53:e1-e90
               Prevention of Heart Failure
              A Scientific Statement From AHA




Stage A and stage B present ideal opportunities to intervene to prevent HF

                                 Schocken DD et al. Circulation 2008;117:2544-65.
Established and Possible Risk Factors for HF
               A Scientific Statement From AHA

 Major Clinical Risk Factors       Minor Clinical Risk Factors
    Age, male sex                      Smoking
    Hypertension, LVH                  Dyslipidemia
    Myocardial infarction              Sleep-disordered breathing
                                        Chronic kidney disease
    Diabetes
                                        Albuminuria
    Valvular heart disease
                                        Homocysteine
    Obesity                            Immune activation, IGF1,
                                         TNFα, IL-6, CRP
                                        Natriuretic peptide
                                        Anemia
                                        Dietary risk factors
                                        Increased HR
                                        Sedentary lifestyle
                                        Low socieconomic status
                                        Phychological stress

                              Schocken DD et al. Circulation 2008;117:2544-65.
Established and Possible Risk Factors for HF
               A Scientific Statement From AHA

 Toxic Risk Precipitants      Morphological Risk Predictors
    Chemotherapy                   Increased LVID, mass
        Anthracyclines             Asymptomatic LV
        Cyclophosphamide            dysfunction
        5-FU                       LV diastolic dysfunction
        trastuzumab
    Cocaine
                              Genetic Risk Predictors
    NSAIDs
    Thiazolidinediones             Single-nucleotide polymorphism
    Doxazosin                        (eg, α2CDeI322-325, β1Arg389)
    Alcohol




                            Schocken DD et al. Circulation 2008;117:2544-65.
Coronary heart disease is the leading cause of HF
              NHANES I Epidemiologic Follow-up Study

                                              n= 13 643
                                          19 years follow-up




         CAD is the underlying cause of HF in 62% of patients

   He, J. et al. Arch Intern Med 2001;161:996-1002.
Hypertension is a most common risk factor for HF


   HT is associated with a 2- to 3-
  fold increase in the risk of HF

   Seventy-five percent of HF cases
  have antecedent HT

   The lifetime risk for people with
  BP >160/90 mmHg is double that of
  those with BP <140/90 mmHg




                                    Heart Disease and Stroke Statistics 2010 update.
                                    Circulation published online Dec 17, 2009
    Heart Failure Event Rate in HT Trials




Heart failure incidence may be higher than MI or stroke incidence
Risk of HF in Different HT Subgroups




                         Tocci G et al Hypertension 2008
Results of Randomised Trials of
 Antihypertensive Drug Therapy




Adequate BP control reduces development of incident HF

                              Moser and Hebert J Am Coll Cardiol 1996
                              Collins R et al. Lancet 1990
Effect of Antihypertensive Therapy on CV Events
     Comparison of more or less intensive BP control




                                           BPLTTC Lancet 2003
   Reduction in HF Risk by SBP Reduction
26% risk reduction per 10 mmHg decrease in SBP (p<0.001)




56% risk reduction per 10 mmHg decrease in SBP in diabetics
Diabetes is an independent risk factor for HF

   The Framingham study revealed a 2.4-fold increase in diabetic
  men and a 5-fold increase in diabetic women.

   Approximately 12% of type 2 diabetics have established HF.
   Approximately 3.3% of type 2 diabetics develop HF each year.
   Incrementally increased risk for HF is seen at higher HbA1c
  levels
Abnormal Lipid Levels Increase Risk of HF
              Framingham Heart Study




  Patients with high non-HDL-C have a 29% higher HF risk.
  Patients with low HDL-C have a 40% higher HF risk.

                     Velagaleti RS et al. Circulation 2009;120:2345-51.
                    BMI & Risk of heart Failure

                       The Finnish FINMONICA study
        59,178 participants, free of HF at baseline, 18.4 years follow-up

 BMI                      <25                    25-29.9                          >30                     p
 Male, n                10,984                   13,375                          4,483
 HR                       1.00             1.25 (1.12-1.39)               1.99 (1.74-2.27)             <0.001
 Female, n              14,254                   10,357                          5,725
 HR                       1.00             1.33 (1.16-1.51)               2.06 (1.80-2.37)             <0.001
The multivariable-adjusted (age, study year, smoking, education, alcohol consumption, history of
myocardial infarction, history of valvular heart disease, systolic blood pressure, total cholesterol, history
of diabetes and physical activity) hazard ratios (HRs) of HF


          Obesity and overweight are independently associated with
                          an increased risk of HF

                                                            Hu G. Circulation. 2010;121:237-244.
  Physical activity & Risk of heart Failure

                     The Finnish FINMONICA study
      59,178 participants, free of HF at baseline, 18.4 years follow-up

Physical activity               Low                 Moderate                      High                  p
Male, n                         2,269                   8,745                    17,828
HR                               1.00            0.79 (0.68-0.92)          0.69 (0.60-0.80)          <0.001
Female, n                       2,900                   9,226                    18,210
HR                               1.00            0.86 (0.75-0.99)          0.68 (0.59-0.78)          <0.001
The multivariable-adjusted (age, study year, smoking, education, alcohol consumption, history of
myocardial infarction, history of valvular heart disease, BMI, systolic blood pressure, total cholesterol,
and history of diabetes) hazard ratios (HRs) of HF


          Physical activity is associated with a reduced risk of HF


                                                          Hu G. Circulation. 2010;121:237-244.
Recommended Therapy for Stage A and B HF
      In patients at high risk for developing HF, risk factors should be
          controlled in accordance with contemporary guidelines

                                 Stage A                    Stage B
ACE Inhibitors              HT, DN, CV Risk        LVH, Post MI, Reduced EF
Angiotensin II Blockers     HT, DN, CV Risk        LVH, Post MI, Reduced EF
Beta Blockers                      HT                 Post MI, Reduced EF
Aldosterone Blockers               HT                       Post MI
Digoxin                             -                           -
Rhythm or Rate Control    SV Tachyarrhythmias         SV Tachyarrhythmias
Coronary Revasculariza            CAD                        CAD
Valve Surgery             Valvular Heart Disease     Valvular Heart Disease
                      Conclusions

 HF represents the final common pathway of many risk factors
and cardiovascular diseases

 Stage A and stage B HF confer ideal opportunities to
intervene to prevent HF

 Many risk factors and CV diseases can be prevented by
aggressive lifestyle and pharmacologic interventions

 Prevention of HF must begin with increasing public/professional
awareness of HF and risk factors

				
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