Heart Failure Post MI - गृहपृष्ठ CHF NYHA II Inotropes Specialized therapy...
Transcript of Heart Failure Post MI - गृहपृष्ठ CHF NYHA II Inotropes Specialized therapy...
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Post MI Congestive Heart failure
Dr .Badri Paudel
HIS WALK IS HISTORY
• CCF IS A MYSTERY
“The very essence of cardiovascular practice is the recognition of early heart failure”
- Sir Thomas Lewis 1933
ALL ROADS LEAD TO CCF
Heart Failure• Final common pathway for many cardiovascular
diseases whose natural history results in symptomatic or asymptomatic left ventricular dysfunction
• Prevalence: Asymptomatic- 4%. Symptomatic 2-3%, 10-20% in those
aged>75yrs.
• Risk of death is 5-10% annually in patients with mild symptoms and increases to as high as 30-40% annually in patients with advanced disease.
Epidemiologyè Most common cause of hospitalization >65 years of
age
INDEX
è 1 per 1000 Indiansè Prevalence: 18.8 million (1.76% of total population)è Incidence: 1.57 million cases per year (0.15% of total
population)è Mortality ~5-10% per year at early stages
è Up to 30-40% per year at advanced stages
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Congestive Heart Failure
“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return”
- Eugene Braunwald
Definition• AHA/ACC defines…
A complex syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricles to fill with or eject blood.
• ESC defines…A Clinical symptoms/ signs secondary to abnormal ventricular function.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…
Main causes
• Coronary artery disease - 70%• Hypertension
• Valvular heart disease – 10%• Cardiomyopathy – 10%• Others – Drugs, Toxins, Nutritional,
Infective, Infiltrative, Cor pulmonale, etc.
Risk Factorsè Coronary heart disease is the foremostè CHD as a primary cause:-
• SOLVD Trial (75% of the cases) • Hillingdon trial (36% of cases)• Framingham heart study (46% in men and 27% in
women
è Coronary artery disease and hypertension (either alone or in combination) account for cases > 90% in the Framingham study
NYHA Functional Classification of heart failure
• Class I: No limitation of physical activity
• Class II: Slight limitation of physical activity
• Class III: Marked limitation of physical activity
• Class IV: Unable to carry out physical activity without discomfort
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EVOLUTION OF CLINICAL STAGES –‘Heart Failure is a Continuum’
EVOLUTION OF CLINICAL STAGES –‘Heart Failure is a Continuum’
NORMALNORMAL
Asymptomatic LV DysfunctionAsymptomatic LV Dysfunction
CompensatedCHF
CompensatedCHFDecompensated
CHFDecompensated
CHF
No symptomsNormal exerciseNormal LV fxn
No symptomsNormal exerciseNormal LV fxn
No symptomsNormal exerciseAbnormal LV fxn
No symptomsNormal exerciseAbnormal LV fxn
No symptomsExercise
Abnormal LV fxn
No symptomsExercise
Abnormal LV fxnSymptoms
ExerciseAbnormal LV fxn
SymptomsExercise
Abnormal LV fxnRefractory
CHF
Refractory
CHFSymptoms not controlled with treatmentSymptoms not controlled with treatment
DecompensatedCHF
DecompensatedCHF
Classification of HFComparison Between ACC/AHA Stage and
NYHA Functional Class
1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)
B Structural heart disease but withoutsymptoms of heart failure
C Structural heart disease with prior orcurrent symptoms of heart failure
D Refractory heart failure requiringspecialized interventions
I Asymptomatic
II Symptomatic with moderate exertion
IV Symptomatic at rest
III Symptomatic with minimal exertion
None
Framingham Criteria for CHF
o Major criteria- PND - CVP >16 cms of H2O- Neck vein distention - Circulation time >25sec - Rales - Hepatojugular reflux - Radiographic cardiomegaly - S3- Acute pulmonary edema- Pulmonary edema, visceral congestion or cardiomegaly at
autopsy- Weight loss > 4.5 kg in 5 days in response to Rx of CHF
oMinor Criteria- Bilateral ankle edema- Nocturnal cough- Dyspnea on ordinary exertion- Hepatomegaly- Pleural effusion- ↓ in Vital capacity by 1/3rd from
maximal value recorded- Tachycardia (>120/min)
Framingham Criteria for CHF
SurvivalMorbidityExercise capacityQuality of lifeNeurohormonal changes Progression of CHFSymptoms
SurvivalMorbidityExercise capacityQuality of lifeNeurohormonal changes Progression of CHFSymptoms
TREATMENT OBJECTIVESTREATMENT OBJECTIVESPathophysiological Mechanismso Sympathetic over activity o RAASo BNPo Vasopressin
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Adverse prognostic indicatorso Low systolic blood pressure o Poor end organ perfusiono Renal dysfunctiono Elevated catecholamineso Raised BNP, Vasopressino Low serum sodiumo Widening QRS duration on ECG
Management• Non Pharmacological:
• Pharmacological:– Diuretics, Digitalis– ACEi, ARBs– Beta Blockers– Aldosterone Antagonists– Vasodilators– others
oTherapies that improve symptoms- Diuretics- Digoxin- InotropesoTherapies that improve survival- ACEI- Beta blockers- Aldosterone antagonists- ARB
PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPYo Investigational \ Emerging Drugs- Vasopeptide inhibitors- Cytokine antagonists- Endothelin antagonists- Vasopressin receptor antagonist- Adenosine antagonists- Metabolic modulators- Statins\ Omega3 fatty acids- If channel inhibitors - Cardiac myosin activators
PHARMACOLOGIC THERAPY (Cont’d)
PHARMACOLOGIC THERAPY (Cont’d)
TREATMENT IN VARIOUS STAGESTREATMENT IN VARIOUS STAGES
NormalNormalAsymptomaticLV dysfunctionEF <40%
AsymptomaticLV dysfunctionEF <40%
Symptomatic CHFNYHA II
Symptomatic CHFNYHA II
InotropesSpecialized therapyTransplantation
InotropesSpecialized therapyTransplantation
Symptomatic CHFNYHA - IV
Symptomatic CHFNYHA - IV
Symptomatic CHFNYHA - III
Symptomatic CHFNYHA - III
Pharmacotherapy has a rolein ALL stages of Heart failure
Pharmacotherapy has a rolein ALL stages of Heart failure
ACEIACEI
Diuretics NeurohormonalantagonismDigoxin?
Diuretics NeurohormonalantagonismDigoxin?
Loop DiureticsDigoxin
Loop DiureticsDigoxin
Conventional Treatments of ADHF
Fonarow GC. Rev Cardiovasc Med. 2001;2(suppl 2):S7–S12.
Reducefluid
volume
Decreasepreloadand/or
afterload
Augmentcontrac-
tility
IV Diuretics
Loop Diuretics
Reduce Volume Overload
VasodilatorsDecrease Preload
and AfterloadNitroglycerinNitroprusside
Nesiritide
InotropesAugment
Contractility
DobutamineMilrinone
McBride BF, White M. Pharmacotherapy. 2003;23:997-1020
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VASOCONSTRICTIONVASOCONSTRICTION VASODILATATION VASODILATATION
KininogenKininogen
KallikreinKallikrein
Inactive FragmentsInactive Fragments
AngiotensinogenAngiotensinogen
Angiotensin IAngiotensin IRENINRENIN
Kininase IIKininase IIInhibitorInhibitor
ALDOSTERONEALDOSTERONE
SYMPATHETICSYMPATHETICVASOPRESSINVASOPRESSIN
PROSTAGLANDINSPROSTAGLANDINStPAtPA
ANGIOTENSIN IIANGIOTENSIN II
BRADYKININBRADYKININ
ACEIMECHANISM OF ACTION
ACEIMECHANISM OF ACTION
A.C.E.A.C.E.
PlaceboPlacebo
EnalaprilEnalapril
1212111110109988776655
PROBABILITYOFDEATH
PROBABILITYOFDEATH
MONTHSMONTHS
0.10.1
0.80.8
00
0.20.2
0.30.3
0.70.7
0.40.4
0.50.5
0.60.6p< 0.001p< 0.001
p< 0.002p< 0.002
CONSENSUSN Engl J Med 1987;316:1429CONSENSUSN Engl J Med 1987;316:1429
ACEIs and SURVIVALACEIs and SURVIVAL
4433221100
ACEIs and SURVIVALACEIs and SURVIVAL
5050
4040
3030
2020
1010
00
MonthsMonths00 66 1212
p = 0.30p = 0.30
24241818 3030 3636 4242 4848
Enalapriln=2111Enalapriln=2111
Placebon=2117Placebon=2117
SOLVD (Prevention)N Engl J Med 1992;327:685SOLVD (Prevention)N Engl J Med 1992;327:685
%MORTALITY
%MORTALITY
n = 4228No CHF symptomsEF < 35
n = 4228No CHF symptomsEF < 35
SAVE trial – post MI Captopril TrialTRACE trial – post MI Trandolapril
• 26% RRR in Death
• 27% RRR in Death or HF Hospitalisation
AIRE – post MIAIRE Study demonstrated efficacy of Ramipril on mortality and morbidity in CHF post-MI NYHA class I-III patients
• 2006 patients enrolled in a double-blind,randomized, placebo-controlled study
• 27% reduction in the risk of death
• 23% decrease in progression to severe / resistant heart failure
Lancet. 1993; 342:821-828
ACE Inhibitors in Heart failure • For many years, diuretics and digitalis were accepted as
standard first-line therapy for HF.
• More recently, however, large and well designed clinical studies have shown consistently that ACE inhibitors improve survival and reduce morbidity in patients with LVSD, a condition that leads to chronic HF.
• A meta-analysis of 32 randomised controlled trials in which ACE inhibitors were compared with standard therapy or placebo in 7105 patients with symptomatic HF has shown statistically significant overall reductions with ACE inhibition in both total mortality and in a combined end-point of mortality or hospitalisation*
* Garg R, Yusuf S. Overview of randomised trials of angiotensin- converting enzyme inhibitorson mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450-6
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Summary • In sum, both ACE inhibitors and ARB are
considered appropriate first-line therapy for the treatment of patients with heart failure and LVSD barring a contraindication to therapy.
• Although there is some overlap in the contraindications to their use, existing data indicates significant differences in side effect profiles and tolerability between the two classes.
SENIORS: Primary and secondary outcomes
100
90
80
70
60
50
100
90
80
70
60
500 6 12 18 24 30 0 6 12 18 24 30
HR 0.86 (0.74–0.99) P = 0.039
Time (months)
All-cause mortality or CV hospital admission
(primary outcome)
Nebivolol
Time (months)
All-cause mortality (main secondary outcome)
HR 0.88 (0.71–1.08) P = 0.214
Nebivolol 332 (31.1%)Placebo 375 (35.3%)
Placebo
Event-free
survival (%)
169 (15.8%) 192 (18.1%)
Flather MD et al. Eur Heart J. 2005;26:215-25.
No. of events:
Nebivolol
Placebo
HR = hazard ratio
Beta-Blockers in HF - New Paradigms
o Safe in mild, moderate and severe HFo May initiate early rather than late
n Start low, go slown Initiate in the hospital when euvolemic
and off inotropeso If on a BB and decompensated CHF
n Continue or reduce dosagen Rarely discontinue
o Long acting Metoprolol, Carvedilol, Bisoprolol, preferred
Major Trials of Beta Blockers in CHF
o MDCo MERIT HFo PRECISEo MOCHAo US Carvedilol heart study groupo ANZ trial Carvedilolo CIBIS IIo CAPRICONo COPERNICUSo CARMENo COMET
Mechanism of actionè Density of ß1 receptorsè Inhibit cardiotoxicity of catecholaminesè Neurohormonal activationè HRè Anti-ischemicè Anti-hypertensiveè Anti-arrhythmicè Anti-oxidant, Anti-proliferative
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Initial Target
Bisoprolol 1.25 / 24h 10 / 24h
Carvedilol 3.125 / 12h 25 / 12h
Metoprolol tartrate 6.25 / 12h 75 / 12h
Metoprolol succinnate 12.5-25 / 24h 200 / 24h
• Start Low, Increase Slowly• Increase the dose every 2 - 4 weeks
ß-Adrenergic Blockers- Dose (mg)
MSA; prototypical beta-blocker√√√√propranolol
ά, β-blocking activity√√carvedilol
Non-selective b1/b2
CommentsCHFMIArrhy.AnginaHTNClass/DrugClinical Uses
Different Classes of Beta-Blockers and Specific Drugs
MSA√√√√√metoprolol
√√√bisoprolol
√√√√atenolol
b1-selective
CommentsCHFMIArrhyAnginaHTNClass/Drug
Clinical Uses
MSA√√√√√metoprolol
√√√bisoprolol
√√√√atenolol
b1-selective
CommentsCHFMIArrhyAnginaHTNClass/Drug
Clinical Uses
Different Classes of Beta-Blockers and Specific Drugs
INDEX
Results from COMETè Carvedilol improves vascular outcomesè Carvedilol provides better protection against vascular eventsè Carvedilol significantly reduces the occurrence of all MIs by 29%è Carvedilol reduces hospitalization for unstable angina by 17%
As compared to metoprolol…è Carvedilol reduces the risk of any MI, any unstable angina or
any stroke by 19%è The effect of v on the combined end point of MI or stroke was
significant (HR 0.75) and the effect on fatal MI or fatal strokewas highly significant (HR 0.46)
Reduces Mortality, Improves Survival
Concluding Remarksè Administering carvedilol in addition to conventional
therapy reduces mortality and attenuates myocardial re-modelling in patients with left ventricular dysfunction following acute MI
è Moreover, mortality has been significantly lower with carvedilol than with metoprolol in patients with mild to severe CHF, suggesting that carvedilol may be the preferred β-blocker
INDEX
Diuretics in HF • Diuretics produce symptomatic benefits
more rapidly than any other drugs for heart failure.
• They can relieve peripheral oedema within hours or days, whereas the clinical effects of digitalis, ACE inhibitors, or beta-blockers may require weeks or months to become apparent (Hall 1995; Packer 1983)
Diuretics for heart failure (Review) 2 Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons,Ltd.
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CortexCortex
MedullaMedulla
ThiazidesInhibit active exchange of Cl-Na
in the cortical diluting segment of the ascending loop of Henle
ThiazidesInhibit active exchange of Cl-Na
in the cortical diluting segment of the ascending loop of Henle
K-sparingInhibit reabsorption of Na in the
distal convoluted and collecting tubule
K-sparingInhibit reabsorption of Na in the
distal convoluted and collecting tubule
Loop diuretics Inhibit exchange of Cl-Na-K in
the thick segment of the ascending loop of Henle
Loop diuretics Inhibit exchange of Cl-Na-K in
the thick segment of the ascending loop of Henle
Loop of HenleLoop of Henle
Collecting tubuleCollecting tubule
DIURETICSDIURETICSDiuretics
o Thiazide group loop diuretics- Hyponatremia- Hypokalemia- Reduction of GFR- Reduction of Renal blood flow
Vasopression antagonists Aquauresis Adenoreceptor antagonists Maintains renal blood
flow / GFR
èOverall incidence and prevalence increasingèAging of populationèAdvances in MI managementèMost common cause of hospitalization in age group
>65 years (US)èEdema commonly associated with CHFèLoop diuretics -- the preferred diureticsè Indicated for symptomatic treatment of CHFèRecommended by all guidelines (ESC, ACC, AHA)
CHF & Loop diureticsINDEX
Torsemide or Frusemide Torsemide or Frusemide
Torsemide in Congestive Heart Failure (TORIC)
o Efficacy of Torsemide Vs Furosemide in CHFo Fewer deaths in Torsemide group (2.2% Vs
4.5%in the Furosemide group)o Fewer episodes of hypokalemia but similar
NYHA class improvement with Torsemideo Torsemide, which has a more predictable
bioavaliability may be safer than Furosemide.
Eur J Heart Failure 2002;4:507-513
Pharmacological advantages of torsemideover frusemide (Summary)
è More potent diuresis and natriuresis
è Reduced kaliuresis
è Longer duration of action
è Greater secretion of prostacylin
è More complete and predictable bioavailability
è Alternative metabolic pathways
INDEX
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1- VENOUS VASODILATATION
Preload
2- Coronary vasodilatationMyocardial perfusion
3- Arterial vasodilatation Afterload
1- VENOUS VASODILATATION
Preload
2- Coronary vasodilatationMyocardial perfusion
3- Arterial vasodilatation Afterload
Pulmonary congestionVentricular sizeVent. Wall stressMVO2
Pulmonary congestionVentricular sizeVent. Wall stressMVO2
NITRATESHEMODYNAMIC EFFECTS
NITRATESHEMODYNAMIC EFFECTS
• Cardiac output• Blood pressure
• Cardiac output• Blood pressure
0.60.6
PROBABILITYOFDEATH
PROBABILITYOFDEATH
00
Placebo (273)Prazosin (183)Hz + ISDN (186)
Placebo (273)Prazosin (183)Hz + ISDN (186)
MONTHSMONTHS
0.70.7
0.50.5
0.30.3
0.40.4
0.20.2
0.10.1
VHefT-1N Engl J Med 1986;314:1547VHefT-1N Engl J Med 1986;314:1547
NITRATES – SURVIVAL BENEFITNITRATES – SURVIVAL BENEFIT
00 66 1212 1818 2424 3030 3636 4242
Digoxin Investigational Group Digoxin Investigational Group (DIG) Study (DIG) Study
%WORSENING
OF CHF
%WORSENING
OF CHF
p = 0.001p = 0.001DIGOXIN: 0.125 - 0.5 mg /d (0.7 - 2.0 ng/ml)
EF < 35%
Class I-III (digoxin+diuretic+ACEI)
Also significantly decreased exercisetime and LVEF.
DIGOXIN: 0.125 - 0.5 mg /d (0.7 - 2.0 ng/ml)
EF < 35%
Class I-III (digoxin+diuretic+ACEI)
Also significantly decreased exercisetime and LVEF.
DIGOXIN EFFECT ON CHF PROGRESSION
DIGOXIN EFFECT ON CHF PROGRESSION
RADIANCEN Engl J Med 1993;329:1RADIANCEN Engl J Med 1993;329:1
Placebo n=93DIGOXIN Withdrawal
Placebo n=93DIGOXIN Withdrawal
DIGOXIN n=85DIGOXIN n=85
3030
1010
00
2020
1001008080202000 4040 6060DaysDays
Aldosterone and Aldosterone and Aldosterone Antagonists Aldosterone Antagonists
Na & Water RetentionIncrease Preload
Potentiation of Sympathetic Activity
Role of Aldosterone in CHF
Mg Loss: Coronary Artery Spasm & Arrhythmia
Endothelial Dysfunction
Stimulate FibrosisHypertrophy
Reduction of Parasympathetic
Activity: Death
Aldosterone
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Increase Na & Water Excretion reduce
Preload
Reduce Sympathetic Activity:
Reduce Arrhythmia
Need of Aldosterone Antagonist
Retains Mg & K levels :Reduces Arrhythmias
Improved Endothelial Dysfuction
Reduce Myocardial Collagen Turnover
Increase of Parasympathetic
Activity
AldosteroneAntagonist
INDEX
N Engl J Med. 1999;341:709–717.
1.00
Placebo
Months
Prob
abili
ty o
f Sur
viva
l
Spironolactone*
0.95
0.90
0.85
0.80
0.75
0.70
0.65
0.60
0.55
0.50
0.45
0.000 3 6 9 12 15 18 21 24 27 30 33 36
P<.001
Randomized AldactoneEvaluation Study (RALES)
*NOT INDICATED TO REDUCE MORTALITY IN HF
Relative Risk of All Cause MortalityRelative Risk of All Cause Mortality
Months Since Randomization
Cum
ulat
ive
Inci
denc
e (%
)C
umul
ativ
e In
cide
nce
(%)
22
02
20
1618
141210864
RR=0.85 (95% CI, 0.75-0.96) P=.008
3633302724211815129630
15%15%RelativeRelative
Risk Risk reductionreductionPP=.008=.008
PlaceboEplerenone
Above and
BeyondStandard Therapy
EPHESUS—All Cause Mortality
In patients with baseline LVEF ≤30%, risk of all-cause mortality was 21% lower with Eplerenon compared with placebo (P=.01)*
Endothelin Antagonistso ENCOR – ENRASENTAN à Fared
worse than placeboo REACH –1 – BOSENTAN à similar to
placeboo ENABLE 1 & 2 – BOSENTAN àLow
dose not superior to placeboo DARUSENTAN – ETA selective
antagonist - Results awaited
Remodeling and Survival Benefits by Drug Class
No BenefitNo BenefitTNFα-BAdverseAdverseIbopamine
No BenefitNo BenefitET-1-BBenefit (ACEI-neutral)Benefit (ACEI-neutral)Vasop-I
Newer TherapiesBenefitBenefitBeta-BBenefitBenefitAldo-B
Benefit (+ACEI better)Benefit (+ACEI better)ARBBenefitBenefitACE-I
Survival EffectsRemodeling EffectsEstablished Rx
Treat risk factorsAvoid toxics
ACE-I in selectedpatients
A
ACE-Iβ blockers
Diuretics / DigitalisC
Palliative therapyMechanical Assisted
Devices Heart TransplantD
Stages in the Evolution ofHF-Treatment
ACE-Iβ blockers
In selectedpatients
B
INDEX
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Despite Current Drug Therapies, Heart Failure Morbidity and Mortality Remain High
• 30% to 40% of patients are in NYHA class III or IV
• Re-hospitalization rates• 2% at 2 days • 20% at 1 month• 50% at 6 months
• 5-year mortality ranges from 15% to more than 50%• Asymptomatic LVD ≈ 15%• Mild-moderate HF ≈ 35%• Advanced HF >50%
Atrial Depolarization
Heart rateAFIB/ATACH
APACE
Ventricular Rate ResponseHeart rate
VT/VFVPACE
Patient ActivityHeart Rate VariabilityImpedance
(fluid status, respiration)
2005 ACC/AHA Heart Failure Guideline: CRT in Stage C Heart Failure
• Class I Indication: Patients with LVEF ≤35%, sinus rhythm, and NYHA functional Class III or ambulatory Class IV symptoms despite recommended optimal medical therapy and who have cardiac dysynchrony, which is currently defined as a QRS >120 msec, should receive CRT, unless contraindicated
Level of Evidence: A
Hunt SA, Abraham WT, Chin MH, et al., Circulation and JACC, 2005
ACC/AHA Heart Failure Guideline:ICDs in Heart Failure
• Class I Indication: ICD therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-MI, a LVEF less than or equal to 35%, and NYHA functional class II or III symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 yearLevel of Evidence: A
Jessup M, Abraham WT, Casey DE, et al., Circulation and JACC 2009
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ICDs Save Lives In Heart Failure
• Second Multicenter Automatic Defibrillator Implantation Trial (MADIT II) – 31% ↓
• Prophylactic Defibrillator Implantation in Patients with Nonischemic Dilated Cardiomyopathy (DEFINITE) trial – 30% ↓
• Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) – 23% ↓
Implantable Hemodynamic Monitors
LV Pressure Sensor
PA Pressure Sensors
RV Pressure Sensors
LA Pressure Sensor
CARDIAC TRANSPLANT CONCLUSION • MORBIDITY & MORTALITY REMAINS HIGH IN HEART FAILURE
DEPITE CURRENT DRUG THERAPHY. • PHARMCO THERAPHY-TREATMENT OF CHOICE- ALL STAGES
OF CCF. • CORONARY INTERVENTIONS IN REVASCULARABLE ANATOMY. • DEVICES & SURGERY – HAS A ROLE IN REFRACTORY
FAILURE.
• CARDIAC TRANSPLANT IS AN OPTION .
MY TIME IS UP KINDLY WAKEUP
SMILE PLEASE
TORTURE IS OVER