7Classification(NYHA) Functional ClassDescriptionIPatient w cardiac disease but wout limitation of physical activity.Ordinary activity does not cause undue fatigue, dyspnea or palpitationIIPatient w cardiac disease that results in slight limitation of physical activity.Ordinary activity results in fatigue, dyspnea or palpitationIIIPatient w cardiac disease that results in marked limitation of physical activity.although patients are comfortable at rest, less than ordinary activity will lead to symptomsIVPatient w cardiac disease that results in an inability to carry on physical activity wout discomfort.symptoms are present even at rest with any physical activity, increased discomfort is experienced.
8Classification(AHA) Stage Description A B C D Patient is at high risk for the development of HF but has no apparent structural abnormality of the heartBPatient has structural abnormality of the heart but wout symptomsCPatient has structural abnormality f the heart & current or previous symptoms of HFDPatient has end-stage symptoms of HF that are refractory to standard treatment
10Treatment (Con,t) Stage A: Treat Risk factors: Control Glucose level Control BPDyslipidemiaThyroid disorderValvular diseaseAvoid drugs which aggravate heart failure
11Class II Wet Sx Diuretics (loop) + ACE Dry Sx ACE + B (no diuretics)Sx resolveSx don’t resolveimproveddidn’t improvegive digoxinSpironolactone + BdigoxinSpironolactoneimproveddidn’t improveimproveddidn’t improvedGive BSpironolactonePlan BSpironolactonePlan B
12 directly give ACE inh & Loop Class III directly give ACE inh & LoopSx still existPx respondedDigoxinB & SpironolactoneDidn’t respondDidn’t respondPlan BPlan B
13(see if you hospitalize him or not) Class IV(see if you hospitalize him or not)ACE + Loop D + digoxin(don’t start B)If Px was already on BDid not respondoptimize itPlan BPlan BStage Dworsening Stage C (II, III, IV)
14if not improved Plan B Stage D or worsening Stage C Hospitalize your Px.Optimize drug therapyif not improvedwetdryGive aggressive diuretic therapy IV (thiazide and loop) to cause profound diuresis(give IV due to diuretic resistanceGive iv high dosegive combinationGive positive inotropic agents(he is already on ACE inh, digoxin)improveTaper down +inotrop and go back to chronic Txnot improvedTissue hypoperfusionSBP < 80Worsening renal function↙Na hypervolemia dilutional hyponatremia cyanosisHemodynamic Monitoring(monitor BP, temp., CO, T0).
16Treatment (Con,t) Stage B=Class I ACE inhibitors Or Beta blocker if recent or previous MI& reduced ejection fraction due to remodelingStage C Є class II,III,&IVACE inhibitors & Beta blockers In all PxIf Sx still exist Or EF still low Add DigoxinWhen symptoms resolves add aldactone
22DIGOXIN + inotropic effect sympathetic output from CNS(NE) Not mortality but improve SxTherapeutic level: 0.5-1ng/ml for CHFMax: 1-1.5ng/ml for A fib
23Clinical Pharmacokinetics of Digoxin Oral bioavailability:Tablets %Elixir %Capsules %Onset of action:Oral hrIV hrTerminal half –life:Normal renal function hrAnuric patient daysVolume of distribution L/kgFraction unbound in plasma %Fraction excreted unchanged in urine %
24Diuretics Sx relief of edema & pulmonary congestion Direct vasodilation , PreloadDOC: Furosamide: Na excretion 20-25%Thiazide: Na Excretion 5-8%Dose: 20-40mg bidUp to 400mg as max doseIf Clcr>30ml/min dose up to 1-3g/d
25Loop Diuretics Used in HF FurosemideBumetanideUsual daily dose20-160mg/day0.5-4mg/dayNormal renal function80-160mg1-2mgClcr:20-25ml/min160mg2mgClcr<20ml/min400mg8-10mgBioavailabilityAverage50%80-90%Affected by foodYesT1/2hrhr
26Spironolactone Aldosterone, preload,ventricular remodeling Morbidity &mortality(Rales study)Used if Scr<2.5mg/dl & K<5meq/LAplerenoneNo gynecomastiaMortality & morbiity in acute MI
27ANGIOTENSIN RECEPTOR BLOCKER Persistent cough &angioedema due to ACE inhibitorsIf persistent HTN Add ARB or CaCh blocker (amlodepine)If concomitant angina: add nitrate or amlodepine