Heart Failure - Dentistry Course PDF

‫אי ספיקת לב‬ ‫קורס קרדיולוגיה‬ ‫מקטע ‪1‬‬ ‫מבוא‬ ‫פרופ' אבישי גרופר‬ ‫מנהל היחידה לאי ספיקת לב‬ ‫קורס יק"ר ‪2023‬‬ ‫מרכז רפואי שמיר‬...

‫אי ספיקת לב‬ ‫קורס קרדיולוגיה‬ ‫מקטע ‪1‬‬ ‫מבוא‬ ‫פרופ' אבישי גרופר‬ ‫מנהל היחידה לאי ספיקת לב‬ ‫קורס יק"ר ‪2023‬‬ ‫מרכז רפואי שמיר‬ ‫(אסף הרופא)‬ Heart Failure - Definition ▪ A complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood that leads to failure of the heart to adequately perfuse organ systems. ACC/AHA guidelines for the Management of Heart Failure 2013 ‫אי ספיקת לב היא התוצאה של כל מחלה‬ ‫שגורמת לפגיעה בתפקוד של שריר הלב‬  Causes of heart failure, common modes of presentation and specific investigations (1) Causes Causes of heartoffailure, heart failure, common common modesmodes of presentation of presentation and specific and specific Causes of heart(1) failure,(1) investigations investigations common modes of presentation and specific Causes of heart failure, Causes of heart failure, common common modes modes of presentation of presentation and specific and specific investigations (1) investigations investigations (1) (1) ©ESC ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ECG = electrocardiogram; GGT= gamma-glutamyl transferase; LFT = liver function test. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) ©ESC ©ESC ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ©ESC ©ESC ECG =right ARVC = arrhythmogenic electrocardiogram; GGT= gamma-glutamyl ventricular cardiomyopathy; transferase; BP = blood pressure; CAD= LFTcoronary = liver function test. CMP = cardiomyopathy; CMR= cardiac magnetic resonance; artery disease; ©ESC ARVC ECG == arrhythmogenic electrocardiogram;right GGT= ventricular cardiomyopathy; gamma-glutamyl ARVC = arrhythmogenic right transferase; ventricular BP LFT==blood pressure; liver function cardiomyopathy; CAD= test. BP = blood coronary pressure; artery disease; CAD= coronary CMP =2021 artery disease; cardiomyopathy; CMPESC GuidelinesCMR= for the = cardiomyopathy; cardiac diagnosis CMR= magnetic cardiacand resonance; treatment magnetic of acute and chronic heart failure resonance; ECG =ARVC www.escardio.org/guidelines = arrhythmogenic electrocardiogram; right gamma-glutamyl GGT= ventricular ECG = electrocardiogram; GGT=cardiomyopathy; BP transferase; transferase; gamma-glutamyl =LFT blood pressure; = liver CAD= function LFT = liver coronary test. function artery test. disease; 2021 CMP = cardiomyopathy; ESC Guidelines for the diagnosisCMR= cardiac and treatment magnetic (European acuteresonance; of Heart Journal 2021heart and chronic – doi:10.1093/eurheartj/ehab368) failure www.escardio.org/guidelines ECG = electrocardiogram; GGT= gamma-glutamyl transferase; LFT = liver function test. (European 2021 ESC2021 ESC Guidelines for Heart Guidelines thefor Journal diagnosis 2021 and –treatment the diagnosis doi:10.1093/eurheartj/ehab368) and treatment of acute of acute andand chronic chronic heart heart failure failure www.escardio.org/guidelines www.escardio.org/guidelines 2021 ESC Guidelines for the diagnosis and (European treatment of acute and chronic heart failure www.escardio.org/guidelines (European HeartHeart Journal Journal 20212021 – doi:10.1093/eurheartj/ehab368) – doi:10.1093/eurheartj/ehab368) (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368)  Causes of heart failure, common modes of presentation and specific ausesinvestigations of Causes (1) heart failure, of heartcommon modesmodes failure, common of presentation andand of presentation specific specific Causes of heart failure, common modes of presentation and specific nvestigations Causes (2) failure, investigations of heart (2)common modes of presentation and specific investigations Causes of(1) heart failure, common modes of presentation and specific investigations (1) (2) investigations ©ESC ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ECG = electrocardiogram; GGT= gamma-glutamyl transferase; LFT = liver function test. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) ©ESC ACE = angiotensin-converting enzyme; CMR= cardiac magnetic resonance; CK = creatinine kinase; CT = computed tomography; ECG = electrocardiogram; Echo = echocardiography; ©ESC EMB = endomyocardial biopsy; FDG = fluorodeoxyglucose; HIV = human immunodeficiency virus; h = hour; MEK =mitogen-activated protein kinase; PET = positron emission ARVC = arrhythmogenic right ventricular tomography; VEGF =cardiomyopathy; BP =growth vascular endothelial blood pressure; factor CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ©ESC ©ESC ECG = electrocardiogram; GGT= gamma-glutamyl ACE = angiotensin-converting transferase; enzyme; LFT =magnetic CMR= cardiac liver function test. CK = creatinine kinase; CT = computed tomography; ECG = electrocardiogram; Echo = echocardiography; resonance; ©ESC ACE = angiotensin-converting ARVC = arrhythmogenic enzyme; EMB = endomyocardial CMR= right ventricularcardiac biopsy; magneticBPresonance; FDG = fluorodeoxyglucose; cardiomyopathy; = blood HIV =CK = creatinine human pressure; CAD= kinase; immunodeficiency coronary CT artery 2021 =ESC computed virus; hGuidelines disease; =CMP hour; tomography; MEK2021 ESC ECG = electrocardiogram; Guidelines =mitogen-activated = cardiomyopathy; for the CMR= diagnosis for the magnetic protein cardiac and treatment diagnosis kinase; of acute and PET = Echo = echocardiography; treatment positron resonance; and of acute failureand chronic heart failure emission chronic heart www.escardio.org/guidelines www.escardio.org/guidelines EMB = endomyocardial biopsy; tomography; ECG = electrocardiogram;FDG VEGF= =fluorodeoxyglucose; GGT= vascular endothelial gamma-glutamyl HIV =factor growth transferase; human LFT = liverimmunodeficiency function test. virus; h = hour; MEK =mitogen-activated (European Heart Journalprotein 2021 kinase; (European HeartPET = positron Journal emission 2021 – doi:10.1093/eurheartj/ehab368) – doi:10.1093/eurheartj/ehab368) tomography; VEGF = vascular endothelial growth factor 2021 ESC Guidelines for the diagnosis www.escardio.org/guidelines 2021 ESC Guidelines for the and treatment diagnosis of acute and and treatment chronic of acute heart and failure chronic heart failure www.escardio.org/guidelines (European(European Heart Journal 2021 Heart – doi:10.1093/eurheartj/ehab368) Journal 2021 – doi:10.1093/eurheartj/ehab368) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) Causes of heart Causes failure, of heart common failure, common modes modesofofpresentation presentationand andspecific specific Causes Causes Causes of of of heartheart heart failure, failure, failure, common commoncommonmodes modes modes of of ofpresentation presentation presentation and and andspecific specific specific investigations Causes of heart(1)failure, investigations (1) common modes of presentation and specific investigations Causes of (1) (1)heart investigations investigations (3) failure, common modes of presentation and specific investigations (3) investigations (3) ©ESC ©ESC ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ©ESC ARVC = arrhythmogenic right ventricular ECG = electrocardiogram; cardiomyopathy; GGT= gamma-glutamyl BP = blood transferase; pressure; LFT CAD= coronary = liver function test. artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ©ESC ©ESC ECG = electrocardiogram; 5-HIAA GGT= gamma-glutamyl ARVC = =arrhythmogenic 5-hydroxyindoleacetic transferase; acid; ANA right ventricular LFT = liver function = anti-nuclear cardiomyopathy; antibody; BP = blood test. ANCA = anti-nuclear pressure; cytoplasmic CAD= coronary2021artery antibody; ESC Guidelines disease; for CK CMP = =cardiomyopathy; the creatinine diagnosis andkinase; CMRcardiac treatment CMR= of= acute cardiac andmagnetic chronic magnetic resonance; heart failure resonance; www.escardio.org/guidelines ARVC = arrhythmogenic CT ECG= =computedright ventricular tomography; electrocardiogram; cardiomyopathy; GGT= EMB gamma-glutamyl BP transferase; = endomyocardial = blood pressure; biopsy CAD= TFT == liver LFT thyroidcoronary artery function function test. test. 2021disease; CMP = cardiomyopathy; ESC Guidelines (European for the diagnosis CMR= Heart cardiac andJournal treatment magnetic 2021 acuteresonance; of– doi:10.1093/eurheartj/ehab368) and chronic heart failure www.escardio.org/guidelines ©ESC ECG == 5-hydroxyindoleacetic 5-HIAA electrocardiogram; GGT=acid;gamma-glutamyl transferase; ANA = anti-nuclear LFT = ANCA antibody; liver function test. =antibody; anti-nuclear ANCAcytoplasmic antibody; CK =antibody; creatinine (European kinase; Heart CMR Journal =2021 cardiac –and magnetic resonance; doi:10.1093/eurheartj/ehab368) ©ESC 5-HIAA = 5-hydroxyindoleacetic acid; ANA = anti-nuclear = anti-nuclear 2021 cytoplasmic ESC Guidelines CK =for the diagnosis creatinine kinase; CMRtreatment of magnetic = cardiac acute andresonance; chronic heart failure CT = computedwww.escardio.org/guidelines tomography; CT = computedEMBtomography; = endomyocardial EMB = biopsy TFT = thyroid endomyocardial biopsyfunction TFT = thyroid 2021 ESC Guidelines for the diagnosis test. function test. and treatment (European Heart of acute Journal 2021and chronic heart failure – doi:10.1093/eurheartj/ehab368) www.escardio.org/guidelines 2021 ESC Guidelines (European forJournal Heart the diagnosis 2021 – and treatment of acute and chronic heart failure doi:10.1093/eurheartj/ehab368) www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) 2021 ESC Guidelines for Guidelines 2021 ESC the diagnosis for and treatmentand the diagnosis of acute and of treatment chronic acute heart failureheart failure and chronic www.escardio.org/guidelines www.escardio.org/guidelines (European Heart Journal Heart 2021 –Journal doi:10.1093/eurheartj/ehab368) (European 2021 – doi:10.1093/eurheartj/ehab368) HF is a major global health problem Proportion of the population with HF across the globe1 North America Europe ~1–2% Asia Canada 1.5% UK 1.3% China 1.3% USA 1.9% France 2.2% Japan ~1% Malaysia 6.7% Singapore 4.5% Australasia Australia 1.3% Africa No population- based estimates Middle East Oman 0.5% The global prevalence of HF in 2016 was 63.6 million2 HF, heart failure; YLD, years lost due to disability Lippi G, Sanchis-Gomar F. AME Medical J 2020;5:1–6  HF is a major global health problem Trends in worldwide prevalence of HF and associated YLD HF prevalence 13.0 and associated YLD 12.5 have increased 12.0 by 36% since 1990 11.5 11.0 10.5 Cases (×1000) 10.0 HF-related 9.5 YLD are expected to 9.0 increase by a further 8.5 ~10% by 2030 8.0 7.5 7.0 YLD HF prevalence 6.5 Prevalence is expected to 6.0 increase by a further ~15% by 2030 Time (years) HF, heart failure; YLD, years lost due to disability Lippi G, Sanchis-Gomar F. AME Medical J 2020;5:1–6 Heart Failure HF is a chronic condition interspersed with acute episodes The main goals in treating chronic HF: Cardiovascular mortality HF hospitalizations Chronic decline Cardiac Mortality function and quality of life Hospitalizations for acute decompensation episodes Disease progression Classification of Heart Failure STAGE A STAGE B STAGE C STAGE D At high risk for HF, Structural heart Structural heart Refractory HF without structural disease, without disease with requiring heart disease or signs or prior or current specialized symptoms of HF symptoms or HF symptoms of HF interventions New York Heart Association (NYHA) Class Proportion of the population with HF across the globe1 Disease progression  ‫אי ספיקת לב‬ ‫קורס קרדיולוגיה‬ ‫מקטע ‪2‬‬ ‫חלוקה לסוגים שונים של המחלה‬ ‫פרופ' אבישי גרופר‬ ‫מנהל היחידה לאי ספיקת לב‬ ‫קורס יק"ר ‪2023‬‬ ‫מרכז רפואי שמיר‬ ‫(אסף הרופא)‬ Forms of Heart Failure Systolic vs. Diastolic Backward vs. Forward failure Low vs. High Cardiac Output Right vs. Left side HF Right-sided failure Primary cause is left-sided failure Pulmonary Hypertension Cor pulmonale ▪ RV dilation and hypertrophy caused by pulmonary pathology RV infarction Arrhythmogenic right ventricular cardiomyopathy (ARVC) Ventricular Ejection Fraction (EF)  Causes Causes of heart of heart failure, failure, common common modes modes of presentation of presentation and specific and specific Causes of heart Causes failure, of heart (1) common modes ofofpresentation presentationand andspecific (1) failure, investigations investigations common modes specific investigations (1)(1) investigations Definition Definition ofofheart of heartfailure failurewith withreduced reducedejection ejection fraction, fraction, mildly mildly reduced reduced Definition heart failure with reduced ejection fraction, mildly reduced ejection fractionand ejection fraction fraction andpreserved preservedejection ejectionfraction fraction ejection and preserved ejection fraction Type of HF Type of of HF HFrEF HFrEF HFmrEF HFmrEF HFpEF HFpEF Type HF HFrEF HFmrEF HFpEF 1 Symptoms Signsa a Symptoms±±Signs Symptoms± Signs ± Signs a Symptoms ± Signs aa Symptoms Signsaa a 11 Symptoms ± Signsa Symptoms Symptoms ± Signs b Symptoms ±± Signs 222 LVEF LVEF≤40% LVEF ≤40% ≤40% LVEF41–49% LVEF LVEF 41–49% 41–49% bb LVEF LVEF LVEF ≥50% ≥50% ≥50% 333 --- -- - Objective Objective evidence evidence of cardiac of cardiac cardiac structural structural CRITERIA Objective evidence of structural CRITERIA CRITERIA and/or and/or and/or functional functional functional abnormalities abnormalities abnormalities consistent consistent consistent withwith with the the the presence presence presence of LV LV of LV of diastolic diastolic diastolic dysfunction/raised dysfunction/raised dysfunction/raised LV filling LV filling pressures, LV filling pressures, pressures, including including raised including natriuretic raised raised natriuretic natriuretic peptides cc peptides peptides c HF == heart HF failure; heartfailure; HFmrEF HFmrEF===heart failure;HFmrEF heart failure heartfailure with failurewith withmildly mildlyreduced reduced ejection fraction; ejection HFpEF fraction; = heart HFpEF failure = heart with preserved failure ejection fraction; HFrEF = heart failurefailure with reduced ejection HF = heart mildly reduced ejection fraction; HFpEF = heart failure withwith preserved preserved ejection ejection fraction; fraction; HFrEFHFrEF = heart= failure heart with reduced with reduced ejectionejection fraction; LV fraction; LV===left left ventricle; leftventricle; LVEF LVEF== =left ventricle;LVEF left ventricular leftventricular ventricular ejection ejectionfraction. fraction. fraction; LV ejection fraction. aSigns may not be present in the early stages of HF (especially in HFpEF) and in optimally treated patients. aaSigns Signs may maynotnotbe bepresent presentininthe theearly earlystages stagesofofHFHF (especially (especially in HFpEF) in HFpEF) andand in optimally in optimally treated treated patients. patients. ©ESC bFor the diagnosis of HFmrEF, the presence of other evidence of of structural heart disease (e.g. increased left atrial size, LV hypertrophy or echocardiographic measures of bbFor ©ESC For the the diagnosis diagnosisof ofHFmrEF, HFmrEF,thethepresence presence ofof other other evidence evidence structural of structural heart heart disease disease (e.g.(e.g. increased increased left atrial left atrial size, size, LV hypertrophy LV hypertrophy or echocardiographic or echocardiographic measures measures of of ©ESC impaired LV filling) makes the diagnosis more likely. impaired impaired LVfilling) LV filling)makes makesright thediagnosis the diagnosis more more likely. likely. ©ESC ARVC cFor the= arrhythmogenic diagnosis of HFpEF, the ventricular greater the cardiomyopathy; number of BP abnormalities= blood pressure; present, the CAD= higher the coronary likelihood artery of disease; HFpEF. CMP = cardiomyopathy; CMR= cardiac magnetic resonance; ARVCARVC= arrhythmogenic c For the For =ECG the rightright diagnosis diagnosis arrhythmogenic ventricular ofof = electrocardiogram; HFpEF, HFpEF, the cardiomyopathy; the greater greater ventricular GGT= the the number number cardiomyopathy; gamma-glutamyl BPofBP =of blood pressure; =abnormalities abnormalities blood transferase; CAD= =present, LFTpresent, pressure; coronary the CAD= liver the higher coronary function artery higher the the disease; likelihood likelihood artery test. disease; CMP == cardiomyopathy; of HFpEF. of HFpEF. CMP cardiomyopathy; CMR= CMR=cardiac cardiacmagnetic magneticresonance; resonance; ECG ARVC =ECG electrocardiogram; = arrhythmogenic right GGT= = electrocardiogram; gamma-glutamyl ventricular GGT= cardiomyopathy; gamma-glutamyl transferase; LFTLFT BP = blood transferase; =pressure; liver function = liver CAD=test. function coronary test. artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance; 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure ©ESC ECG = electrocardiogram; GGT= gamma-glutamyl transferase; LFT = liver function test. www.escardio.org/guidelines 2021 2021ESC ESCGuidelines Guidelines for the the diagnosis diagnosis andtreatment and treatment ofofacute acute and and chronic heart failure –chronic heart failure ©ESC ©ESC www.escardio.org/guidelines www.escardio.org/guidelines (European Heart Journal 2021 doi:10.1093/eurheartj/ehab368) 2021 ESC Guidelines for the (European (European diagnosis Heart Heart Journal andJournal 2021 2021 treatment of––doi:10.1093/eurheartj/ehab368) doi:10.1093/eurheartj/ehab368) acute and chronic heart failure www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure www.escardio.org/guidelines 20212021 ESC Guidelines for the ESC Guidelines fordiagnosis theHeartand treatment diagnosis and of acute treatment ofand chronic acute heart failure and chronic heart failure www.escardio.org/guidelines (European Journal 2021 – doi:10.1093/eurheartj/ehab368) www.escardio.org/guidelines (European Heart Heart (European JournalJournal 2021 –2021 doi:10.1093/eurheartj/ehab368) – doi:10.1093/eurheartj/ehab368) Classification of Heart Failure HF with Reduced EF HF with Preserved EF HFrEF HFpEF EF ≤ 40% EF < 50% Men > Women Women = Men Higher incidence of Patients are older coronary artery disease Higher prevalence of hypertension Eccentric LV remodelling Concentric LV remodelling Patients with HFrEF have abnormalities in LV systolic function Normal Heart Heart Failure Weakened heart muscle 1. McMurray et al. Eur Heart J 2012;33:1787–847 2. Harrison’s ‘Principles of Internal Medicine’, Seventeenth Edition p1442–55 Images from: Wilde and Behr. Nat Rev Cardiol 2013;10:571–83 Patients with HFpEF have abnormalities in LV diastolic function In patients with HFpEF, end-diastolic pressure is increased and end-diastolic volume is decreased, compared with healthy controls Diastolic dysfunction suggests the presence of increased chamber stiffness in patients with HFpEF Diastolic pressure–volume relationship* Left ventricular diastolic 30 pressure (mmHg) 25 Diastolic dysfunction: 20 curve shifted upwards and left 15 10 Control curve for diastolic 5 pressure-volume 0 relationship 0 20 40 60 80 100 120 Left ventricular diastolic volume (mL) Zile et al. N Engl J Med 2004;350:1953–9  Patterns of ventricular remodelling are different for HFrEF and HFpEF HFrEF – a condition of HFpEF – a condition of volume overload Left ventricle: pressure overload normal characterized by characterized by eccentric hypertrophy HFpEF concentric hypertrophic Volume Pressure growth results in thinning of overload overload results in normal sized LV the LV walls, decreased systolic function and Increased Increased cavity with thickened enlarged LV volume diastolic pressure systolic pressure walls and preserved systolic function Increased Increased diastolic wall stress systolic wall stress – Series addition of Parallel addition new sarcomeres – of new myofibrils Chamber Wall enlargement thickening Eccentric Concentric Left ventricle: hypertrophy hypertrophy Left ventricle: volume pressure overload overload  Heart failure pathology: preserved vs. reduced election fraction HFpEF Normal HFrEF Cross pathology sections1,2 Isolated cardiac muscle cells2 Concentric LV remodeling Eccentric remodeling Normal end-diastolic volume ↑ end-diastolic volume Characterized by2: ↑ wall thickness and mass Little change in wall thickness High ratio of mass: volume Low ratio of mass: volume HFrEF=heart failure with reduced ejection fraction; HFpEF=heart failure with preserved ejection fraction; LV=left ventricular 1. Konstam. J Cardiac Fail 2003;9:1–3; 2. Aurigemma. Circulation 2006; 113; 296–304 Similar CV risk factors with different pathophysiologic effect Obesity Volume COPD overload Hypertension HFrEF HFpEF Myocarditis Age Type 2 Diabetes Myocardial infarction Kidney disease Inflammation COPD = chronic obstructive pulmonary disease; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction. Simmonds SJ et al. Cells. 2020;9:242.  ‫אי ספיקת לב‬ ‫קורס קרדיולוגיה‬ ‫מקטע ‪3‬‬ ‫הסתמנות קלינית‬ ‫פרופ' אבישי גרופר‬ ‫מנהל היחידה לאי ספיקת לב‬ ‫קורס יק"ר ‪2023‬‬ ‫מרכז רפואי שמיר‬ ‫(אסף הרופא)‬ Heart Failure symptoms Differential Diagnosis of Heart Failure Primary Metabolic Cadriomyopathy Hypertension valvular disease disease Chronic Anemia / Atrial Obesity Iron kidney fibrillation defficency disease Chronic Infiltretive Coronary pulmonary heart artery disease with disease disease right HF  Symptoms of HFpEF are similar to those of HFrEF Presenting symptoms in patients with HFpEF are largely similar to those in patients with HFrEF the main differences are that patients with HFpEF have lower rates of acute pulmonary edema and paroxysmal nocturnal dyspnea p=0.11 100 96.2 94.9 Reduced ejection fraction (50%) (n=880) 80 Patients (%) 60 p=0.06 46.4 42.5 40 p=0.007 p=0.47 30.1 p=0.02 25.0 25.4 24.1 21.1 20 17.3 p=0.26 1.7 1.1 0 n=1,511 835 729 374 473 220 399 212 322 152 27 10 Dyspnea or shortness Orthopnea Paroxysmal Chest pain Acute pulmonary Syncope of breath nocturnal dyspnea edema Bhatia et al. N Engl J Med 2006;355:260–9  Signs of HFpEF are similar to those of HFrEF Presenting signs in patients with HFpEF are largely similar to those in patients with HFrEF the main differences are that patients with HFpEF have a lower rate of S3 heart sounds and chest radiographic signs and a higher rate of bilateral ankle edema 100 Reduced ejection fraction (50%) (n=880) 80 p1 year, and where the intent is to increase survival  Causes Causes of heart of heart failure, failure, common common modes modes of presentation of presentation and specific and specific Causesinvestigations of heart failure, common modes of presentation and specific investigations (1) (1) investigations (1) Causes of heart failure, common modes of presentation and specific investigations (1) Recommendations for an implantable cardioverter-defibrillator in patients with heart failure (1) Recommendations Class Level Secondary prevention An ICD is recommended to reduce the risk of sudden death and all-cause mortality in patients who have recovered from a ventricular arrhythmia causing haemodynamic instability, and who are expected to survive for >1 year with good I A functional status, in the absence of reversible causes or unless the ventricular arrhythmia has occurred 1 unplanned visit or hospitalization in the last 12 months. combinations) or episodes of low output requiring inotropes or vasoactive drugs or ©ESC 4. Severe impairment of exercise capacity with inability to exercise or low 6MWT (