Predicting Life Expectancy in Heart Failure Thierry H.Le Jemtel, M.D.

Predicting Life Expectancy in Heart Failure Thierry H.Le Jemtel, M.D.

Predicting Life Expectancy in Heart Failure
Thierry H.Le Jemtel, M.D.
Tulane University School of Medicine
Impact of Heart Failure on the Health Care
System
• 20% of the elderly will develop some form of
heart failure.
• 1 - 2% of the total health care budget
• More hospitalizations for heart failure than for
cancer and myocardial infarction combined
NEJM: 2002;Vol 347:1442-1444
Heart Failure with reduced ejection fraction i.e. Systolic Heart Failure.
Heart Failure with preserved ejection fraction i.e. Diastolic Heart Failure
Heart Failure Paradigm Shift
Reduced LV
Eject. Fraction
80
Women = 1/3
Men
Preserved LV
Eject. Fraction
Women = 3/1
Men
WOMEN
Systolic Heart Failure (CAD)
70
MEN
Prevalence (%)
60
Non-Systolic Heart Failure (HTN)
50
Systolic Heart Failure (CAD)
40
WOMEN
30
MEN
Non-Systolic Heart Failure (HTN)
20
50
60
70
80
Age (years)
Clinical Population in SOLVD, VHeFT, CONSENSUS
90
Vasculopathy
• Hypertension
• Diabetes
• CAD
Chronic
Kidney
Disease
30-40%
Obesity
Congestive
Heart
Failure
PPCM
IDCM
Circulation 1993: 88:107-115
NEJM: 2000; 342:1077-1084
• Physician’s standpoint:
< 1 year- Cardiac transplantation
Mechanical Circulatory Support
< 6 months- Referral to Hospice
> 2 years- Implantable cardioverter defibrillators
when ejection fraction is less than 35%
JAMA 2008; 299 :2566
PATIENT’S STANDPOINT ?
Solomon SD et al; Circulation 112 (24) 3738 (2005)
Peak VO2 = Peak CO x Peak (A-V) O2
Circulation 1991; 83 :778-786
Levy et al; Circulation 113 (11):1424 (2006)
Levy et al; Circulation 113 (11):1424 (2006)
Aaronson et al; Circulation 95:2660 (1997)
Heart Failure Survival Score
Coronary artery disease
(yes=1, no=0)
(………×0.6931)=+
Intraventricular conduction
delay (yes=1, no=0)
(………×0.6083)=+
Left ventricular ejection
fraction (%)
(………×−0.0464)=+
Heart rate (b.p.m.)
(………×0.0216)=+
Na+ concentration (mmol/L)
(………×−0.0470)=+
Mean arterial pressure
(mmHg)
(………×−0.0255)=+
Peak VO2 (mL/min/kg)
(………×−0.0546)=
HFSS=………
High risk <7.19 (35%, 1-year survival)
Medium risk=7.20–8.09 (60%, 1-year survival)
Low risk >8.10 (88%, 1-year survival).
Fang, et al J Am Coll Cardiol. Volume 41, Issue 4, 19 February 2003, Pages 611-617
Circulation. 2005 May 31;111(21):2837-49
60
IV
45
III
30
II
15
I
1
2
3
4
5
6
Time course (years)
7
8
9
10
NYHA Class
LVEF (%)
Dissociation b/w Cardiac Performance and
Functional Class
Circulation: 1994; 90:2757-2760
Lancet: 1999; 353: 9-13
Lancet Vol. 353 : 2001-2007
Lancet: 1999; 353: 9-13
NEJM: 2001; Vol 344:1651-1658
Lancet 2001; 357:1385-1390
Am J Cardiol 2005; 95:1114-1116
Kaplan-Meier Survival Curves for Patients with Heart Failure and Preserved or Reduced Ejection Fraction
Owan T et al. N Engl J Med 2006;355:251-259
Owan, T.E; N Engl J Med 2006; 355:251-9
Henkel, D. et al. Circ Heart Failure. 2008;1:91-97
Panel 1 : Event free survival according to the presence of anemia in 98 patients with
heart failure and preserved LV ejection fraction
1
Event free survival (%)
0.9
No anemia
0.8
0.7
0.6
0.5
0.4
Anemia
0.3
0.2
χ2 = 9.345, P = 0.002
0.1
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Follow up (months)
1
0.9
0.8
eGFR ≥ 40 mL/min/m²
0.7
0.6
0.5
eGFR < 40 mL/min/m²
0.4
0.3
0.2
χ2 = 9.615, P = 0.002
0.1
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Follow up (months)
Diastolic Heart Failure
Hypertensive Cardiorenal Disease
Hypertension
CKD
LV Diastolic
Dysfunction
Anemia
OBESITY