1. Objectives 1- to know the common causes of heart failure. 2- Types of heart failure.differentiation between systolic & diastolic failure. Staging of H.F 3- Clinical signs of heart failure & lab tests &their findings in diagnosis of H.F. 4- Treatment of systolic & diastolic failure.

2. SUGAR LAND HEART CENTER Pathophysiology Hemodynamic changes Neurohormonal changes Cellular changes

3. SUGAR LAND HEART CENTER Neurohormonal changes in CHF RAS, renin-angiotensin system; SNS, sympathetic nervous system. Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Morbidity and mortality Arrhythmias Pump failure Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Remodeling and progressive worsening of LV function Initial fall in LV performance,  wall stress Activation of RAAS and SNS Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity Fatigue Activity altered Chest congestion Edema Shortness of breath

4. SUGAR LAND HEART CENTER Neurohormonal changes N/H changesFavorable effectUnfavor. effect  Sympathetic activity  HR,  contractility, vasoconst.   V return,  filling Arteriolar constriction  After load  workload  O 2 consumption  Renin-Angiotensin – Aldosterone Salt & water retention  VRVasoconstriction   after load  Vasopressin Same effect  interleukins &TNF  May have roles in myocyte hypertrophy Apoptosis  Endothelin Vasoconstriction  VR  After load

5. SUGAR LAND HEART CENTER Volume overload: Regurgitate valve Volume overload: Regurgitate valve High output status High output status Pressure overload: Systemic hypertension Pressure overload: Systemic hypertension Outflow obstruction—AS Outflow obstruction—AS Loss of muscles: Post MI, Chronic ischemia Loss of muscles: Post MI, Chronic ischemia Connective tissue diseases Connective tissue diseases Infection, Poisons (alcohol,cobalt,Doxorubicin) Infection, Poisons (alcohol,cobalt,Doxorubicin) Restricted Filling: Pericardial diseases, Restricted Filling: Pericardial diseases, Restrictive cardiomyopathy Restrictive cardiomyopathy Tachyarrhythmia Tachyarrhythmia Causes of CHF

6. SUGAR LAND HEART CENTER Types of CHF Systolic & Diastolic Systolic & Diastolic High Output Failure High Output Failure Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagets disease Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagets disease Low Output Failure Low Output Failure Acute Acute large MI, aortic valve dysfunction---large MI, aortic valve dysfunction--- Chronic Chronic

7. CLINICAL STAGES OF HEART FAILURE. STAGE A: risk factors,no structural disease or symptoms. STAGE B : structural disease but no symptoms. STAGE C : structural disease with prior or current symptoms. STAGE D : refractory disease with severe symptoms.

8. Precipitants of H F: 1- Myocardial ischemia. As ACS. 2- Hypertension. 3- Arrhythmias. 4- Infections. 5- Drugs & Toxins. 6- Diet. 7- Noncompliance. 8- acute pulmonary embolism. 9- Anaemia.

9. SUGAR LAND HEART CENTER Rhythm problems leading to CHF

10. DIAGNOSIS OF HEART FAILURE

11. Signs & Symptomes Of H F Dyspnea on exertion & later on at rest.NYHA 1 – 4. Orthopnea & PND. Fatigue & poor exercise tolerance. Plapitation & syncope. Cough specialy at night. Leg swelling. Raised JVP. Basal rales. S3 gallop.

12. SUGAR LAND HEART CENTER Framingham Criteria for CHF Major Criteria: PNDPND JVDJVD RalesRales CardiomegalyCardiomegaly Acute Pulmonary EdemaAcute Pulmonary Edema S 3 GallopS 3 Gallop Positive hepatic Jugular reflexPositive hepatic Jugular reflex ↑ venous pressure >16 cm H 2 O ↑ venous pressure >16 cm H 2 O

13. 1- Bilateral leg odema. 2- Dyspnea on exertion. 3- Pleural effusion. 4- Hepatomegaly. 5- Heart rate more than 120 per min.

14. SUGAR LAND HEART CENTER EKG Old MI or recent MI Arrhythmia Some forms of Cardiomyopathy are tachycardia related LBBB → may help in management Heart Block

15. SUGAR LAND HEART CENTER Chest X-ray Look for Heart size Pulmonary vascular markings COPD, pneumonia, Pneumothorax, widened mediastinum Pleural effusions

16. Chest X- ray

17. SUGAR LAND HEART CENTER Echocardiogram Function of both ventricles Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pericardial effusion Restrictive pericarditis Pulmonary hypertension

18. Diagnostic tests: 4- B-type natriuretic peptide ( BNP ). Cutoff level 150 pg / ml. senstivity =90 % specificity 70%. Use in acute setting only. Affected by age,renal function & BMI. 5- other tests : BUN, s.electrolytes, CBC, thyroid function test, s.iron & s.ferritin.

19. SUGAR LAND HEART CENTER Cardiac Catheterization Coronary artery disease Dilated ventricle Hyperdynamic small ventricle Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pulmonary hypertension

20. Systolic versus diastolic failure SYSTOLIC DYSFUNCTION DIASTOLIC DYSFUNCTION Dilated cardiac chambers. Cardiomegaly on CX-ray. Low EF < 40 %. Worse prognosis. Normal size or LVH. Pulmonry congestion +normal cardiac size. Normal EF > 40 %,E/A< 1 Good prognosis.

21. SUGAR LAND HEART CENTER Goals for CHF management in a hospital 1.Relieve symptoms rapidly 2.Reverse hemodynamic abnormalities 3.Prevent end-organ dysfunction 4.Initiate patient education and survival-enhancing medications before discharge 5.Optimize survival-enhancing oral medications (ACE inhibitor, beta blocker, aldosterone receptor antagonist) 6.Optimize patient education and HF disease management

22. SUGAR LAND HEART CENTER CHF Management-long term

23. SUGAR LAND HEART CENTER Diet and Activity Salt restriction (2 grams per day) Fluid restriction (Less than 1-2 liters per day) Daily weight (tailor therapy) Gradual exercise programs Blood sugar monitoring

24. SUGAR LAND HEART CENTER Treatment of CHF Correction of reversible causes MedicationsMedications Diuretics, ACE inhibitors, beta blokers etc. IschemiaIschemia Arrhythmia: A fib, flutter, PJRTArrhythmia: A fib, flutter, PJRT Valvular heart diseaseValvular heart disease Thyrotoxicosis and other high output statusThyrotoxicosis and other high output status ShuntsShunts

25. SUGAR LAND HEART CENTER CHF treatment-Acute Pharmacological Morphine sulfate Nitrates Diuretics ACE inhibitors Beta blockers Aspirin therapy statins Vasodilators Neurohormonal antagonists – Anticoagulant therapy – Antiarrhymics

26. SUGAR LAND HEART CENTER Diuretics Loop diuretics for more severe heart failure Lasix (20 – 320 mg QD), FurosemideLasix (20 – 320 mg QD), Furosemide Bumex (Bumetanide 1-8mg)Bumex (Bumetanide 1-8mg) Torsemide (20-200mg)Torsemide (20-200mg) Mechanism of action: Inhibit chloride reabsortion in ascending limb of loop of Henle results in natriuresis, kaliuresis and metabolic alkalosis Adverse reaction: pre-renal azotemia Hypokalemia Skin rash Ototoxicity

27. SUGAR LAND HEART CENTER Diuretics K sparing diuretics Triamterene Amiloride – acts on distal tubules to ↓ K secretion Spironolactone (Aldosterone inhibitor) R ecent evidence suggests that it may improve survival in CHF patients due to the effect on renin-angiotensin-aldosterone system with subsequent effect on myocardial remodeling and fibrosis R ecent evidence suggests that it may improve survival in CHF patients due to the effect on renin-angiotensin-aldosterone system with subsequent effect on myocardial remodeling and fibrosis

28. SUGAR LAND HEART CENTER Renin, angiotensin, aldasterone blockers Renin-angiotensin-aldosterone system is activation early in the course of heart failure and plays an important role in the progression of the syndrome: Angiotensin converting enzyme inhibitors (ACE inhibitors)Angiotensin converting enzyme inhibitors (ACE inhibitors) Angiotensin receptors blockers (ARBS)Angiotensin receptors blockers (ARBS) SpironolactoneSpironolactone

29. SUGAR LAND HEART CENTER Renin-angiotensin blockers They block the R-A-A system by inhibiting the conversion of angiotensin I to angiotensin II: → Vasodilation → Vasodilation → Na retention ↓ → Na retention ↓ → Decreased Bradykinin degradation ↑ its level → ↑ PG secretion & nitric oxide Ace Inhibitors improve survival in CHF patients Delay onset & progression of HF in pts with asymptomatic LV dysfunctionDelay onset & progression of HF in pts with asymptomatic LV dysfunction ↓ cardiac remodeling ↓ cardiac remodeling

30. SUGAR LAND HEART CENTER Beta Blockers Has been traditionally contraindicated in pts with CHF Has been traditionally contraindicated in pts with CHF Now they are the main stay in treatment on CHF & may be the only medication that shows substantial improvement in LV function Now they are the main stay in treatment on CHF & may be the only medication that shows substantial improvement in LV function In addition to improved LV function multiple studies show improved survival In addition to improved LV function multiple studies show improved survival The only contraindication is severe decompensated CHF The only contraindication is severe decompensated CHF

31. SUGAR LAND HEART CENTER Inotropic agents-Digoxin The role of digitalis has declined somewhat because of safety concern Recent studies have shown that digitals does not affect mortality in CHF patients but causes significant Reduction in hospitalizationReduction in hospitalization Reduction in symptoms of HFReduction in symptoms of HF Rate control in At fib.Rate control in At fib.

32. SUGAR LAND HEART CENTER Inotropic agent-Digoxin action +ve inotropic effect by ↑ intracellular Ca & enhancing actin-myosin cross bride formation (binds to the Na-K ATPase → inhibits Na pump → ↑ intracellular Na → ↑ Na-Ca exchange Vagotonic effect Arrhythmogenic effect

33. SUGAR LAND HEART CENTER Inotropic agent-Digitalis toxicity Narrow therapeutic to toxic ratio Non cardiac manifestations Anorexia, Anorexia, Nausea, vomiting, Nausea, vomiting, Headache, Headache, Xanthopsia sotoma, Xanthopsia sotoma, Disorientation Disorientation Treatment: Digibind (Fab antibody) Treatment: Digibind (Fab antibody)

34. SUGAR LAND HEART CENTER Antiarrhythmics Most common cause of SCD in these patients is ventricular tachyarrhythmia Patients with h/o sustained VT or SCD → ICD implant Patients with CHF with an ejection fraction of less than 30% may receive ICD implant Amiodarone for patients with frequent VPCs and at fib Dranedone for patients with recurrent paroxysmal at fib.

35. SUGAR LAND HEART CENTER Anticoagulation Atrial fibrillation H/o embolic episodes Left ventricular apical thrombus Low LV ejection fraction

36. SUGAR LAND HEART CENTER Inotropic Agents These are the drugs that improve myocardial contractility ( β adrenergic agonists, dopaminergic agents, phosphodiesterase inhibitors), Dopamine DopamineDobutamineMilrinone,Aamrinone Several studies showed ↑ mortality with oral inotropic agents So the only use for them now is in acute sittings such as cardiogenic shoc k

37. SUGAR LAND HEART CENTER New Treatment Choices Implantable ventricular assist devices Biventricular pacing (only in patient with LBBB & CHF) Artificial Heart

38. SUGAR LAND HEART CENTER Achieving Cardiac Resynchronization Mechanical Goal: Atrial-synchronized bi-ventricular pacing Standard pacing lead in RAStandard pacing lead in RA Standard pacing or defibrillation lead in RVStandard pacing or defibrillation lead in RV Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinusSpecially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right Atrial Lead Right Ventricular Lead Left Ventricular Lead

39. SUGAR LAND HEART CENTER Pacing

40. SUGAR LAND HEART CENTER CHF treatment-Acute NTG- SL and IV infusionNTG- SL and IV infusion Morphine sulfate: 2-6 mg IVMorphine sulfate: 2-6 mg IV Lasix 40-80 mg IVLasix 40-80 mg IV O2—High flow O2O2—High flow O2 CPAPCPAP Foley catheterFoley catheter

41. SUGAR LAND HEART CENTER Differential Diagnosis of CHF Pericardial diseases Liver diseases Nephrotic syndrome Protein losing enteropathy