4Types of Heart Failure Low-Output Heart Failure Systolic Heart Failure:decreased cardiac outputDecreased Left ventricular ejection fractionDiastolic Heart Failure:Elevated Left and Right ventricular end-diastolic pressuresMay have normal LVEFHigh-Output Heart FailureSeen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism, beri-beri, carcinoid, anemiaOften have normal cardiac outputRight-Ventricular FailureSeen with pulmonary hypertension, large RV infarctions.
6Clinical Presentation of Heart Failure Due to excess fluid accumulation:Dyspnea (most sensitive symptom)EdemaHepatic congestionAscitesOrthopnea, Paroxysmal Nocturnal Dyspnea (PND)Due to reduction in cardiac ouput:Fatigue (especially with exertion(Weakness
7Physical Examination in Heart Failure S3 gallopLow sensitivity, but highly specificCool, pale, cyanotic extremitiesHave sinus tachycardia, diaphoresis and peripheral vasoconstrictionCrackles or decreased breath sounds at bases (effusions) on lung examElevated jugular venous pressureLower extremity edemaAscitesHepatomegalySplenomegalyDisplaced PMIApical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>
9Lab Analysis in Heart Failure CBCSince anemia can exacerbate heart failureSerum electrolytes and creatininebefore starting high dose diureticsFasting Blood glucoseTo evaluate for possible diabetes mellitusThyroid function testsSince thyrotoxicosis can result in A. Fib,and hypothyroidism can results in HF.Iron studiesTo screen for hereditary hemochromatosis as cause of heart failure.ANATo evaluate for possible lupusViral studiesIf viral mycocarditis suspected
10Laboratory Analysis (cont.) BNPWith chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressuresUsually is > 400 pg/mL in patients with dyspnea due to heart failure.
11Chest X-ray in Heart Failure CardiomegalyCephalization of the pulmonary vesselsKerley B-linesPleural effusions
16Cardiac Testing in Heart Failure Electrocardiogram:May show specific cause of heart failure:Ischemic heart diseaseDilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular blockAmyloidosis: pseudo-infarction patternIdiopathic dilated cardiomyopathy: LVHEchocardiogram:Left ventricular ejection fractionStructural/valvular abnormalities
17Further Cardiac Testing in Heart Failure Exercise TestingShould be part of initial evaluation of all patients with CHF.Coronary arteriographyShould be performed in patients presenting with heart failure who have angina or significant ischemiaReasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.
18Further testing in Heart Failure Endomyocardial biopsyNot frequently usedReally only useful in cases such as viral-induced cardiomyopathy
19Classification of Heart Failure New York Heart Association (NYHA)Class I – symptoms of HF only at levels that would limit normal individuals.Class II – symptoms of HF with ordinary exertionClass III – symptoms of HF on less than ordinary exertionClass IV – symptoms of HF at rest
20Classification of Heart Failure (cont.) ACC/AHA GuidelinesStage A – High risk of HF, without structural heart disease or symptomsStage B – Heart disease with asymptomatic left ventricular dysfunctionStage C – Prior or current symptoms of HFStage D – Advanced heart disease and severely symptomatic or refractory HF
21Chronic Treatment of Systolic Heart Failure Correction of systemic factorsThyroid dysfunctionInfectionsUncontrolled diabetesHypertensionLifestyle modificationLower salt intakeAlcohol cessationMedication complianceMaximize medicationsDiscontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers)
22Order of Therapy Loop diuretics ACE inhibitor (or ARB if not tolerated)Beta blockersDigoxinHydralazine, NitratePotassium sparing diuretcs
23Diuretics Loop diuretics Potassium-sparing diuretics Furosemide, buteminideFor Fluid control, and to help relieve symptomsPotassium-sparing diureticsSpironolactone, eplerenoneHelp enhance diuresisMaintain potassiumShown to improve survival in CHF
24ACE InhibitorImprove survival in patients with all severities of heart failure.Begin therapy low and titrate up as possible:Enalapril – 2.5 mg po BIDCaptopril – 6.25 mg po TIDLisinopril – 5 mg po QDailyIf cannot tolerate, may try ARB
25Beta Blocker therapyCertain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV.Contraindicated:Heart rate <60 bpmSymptomatic bradycardiaSigns of peripheral hypoperfusionCOPD, asthmaPR interval > 0.24 sec, 2nd or 3rd degree block
26Hydralazine plus Nitrates Dosing:HydralazineStarted at 25 mg po TID, titrated up to 100 mg po TIDIsosorbide dinitrateStarted at 40 mg po TID/QIDDecreased mortality, lower rates of hospitalization, and improvement in quality of life.
27DigoxinGiven to patients with HF to control symptoms such as fatigue, dyspnea, exercise intoleranceShown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality.
28Other important medication in Heart Failure -- Statins Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease.Some studies have shown a possible benefit specifically in HF with statin therapyImproved LVEFReversal of ventricular remodelingReduction in inflammatory markers (CRP, IL-6, TNF-alphaII)
29Meds to AVOID in heart failure NSAIDSCan cause worsening of preexisting HFThiazolidinedionesInclude rosiglitazone (Avandia), and pioglitazone (Actos)Cause fluid retention that can exacerbate HFMetforminPeople with HF who take it are at increased risk of potentially lethic lactic acidosis
30Implantable Cardioverter-Defibrillators for HF Sustained ventricular tachycardia is associated with sudden cardiac death in HF.About one-third of mortality in HF is due to sudden cardiac death.Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.
31Management of Refractory Heart Failure Inotropic drugs:Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerinMechanical circulatory support:Intraaortic balloon pumpLeft ventricular assist device (LVAD)Cardiac TransplantationA history of multiple hospitalizations for HFEscalation in the intensity of medical therapyA reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.
32Acute Decompensated Heart Failure Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress.Characterized by the transudation of excess fluid into the lungs secondary to an increase in left atrial and subsequently pulmonary venous and pulmonary capillary pressures.
33Acute Decompensaated Heart Failure (cont.) Causes:Acute MIRupture of chordae tendinae/acute mitral valve insufficiencyVolume OverloadTransfusions, IV fluidsNon-compliance with diuretics, diet (high salt intake)Worsening valvular defectAortic stenosis
34Decompensated Heart Failure SymptomsSevere dyspneaCoughClinical FindingsTachypneaTachycardiaHypertension/HypotensionCrackles on lung examIncreased JVDS3, S4 or new murmur
36Decompensated Heart Failure TreatmentStrict I’s and O’s, daily weightsOxygen, mechanical ventilation if neededLoop diuretics (Lasix!)MorphineVasodilator therapy (nitroglycerin)Nesiritide (BNP) – can help in acute setting, for short term therapy
37Case # 1A 65-year old male with a history of hypertension, DM, CAD s/p MI and three-vessel CABG in 2002, presents with worsening dyspnea on exertion. He states that he occassionally has a dry cough, but denies any recent chest pain, fevers, N/V. Patient states that he usually can get up a flight of stairs if he stops half-way, but over the last several days, has not been able to climb them at all.
38Case # 1 (cont.) PMH: Allergies: Outpatient Meds: CAD – MI and CABG in 2002HypertensionDiabetes MellitusHypothyroidismAllergies:NKDAOutpatient Meds:SynthroidMetforminNorvasc
39Case # 1 (cont.) Physical Exam: 97.6, 168/72, 99, 28, 93% on RA Gen: Alert and oriented x 3, breathing rapidlyCV: RRR, no murmurs; mod. JVDResp: Crackles throughout lungsAbd.: soft, nontender, NABSExt: 2 + pitting edema bilaterally
42Case # 1 What studies would you like to check in this patient? What medications would you like to start/change?What vital signs do you want to monitor?
43Case # 2A 45-year old obese woman with diabetes mellitus is evaluated for a 1-month history of progressive shortness of breath. Two months ago, she had a flu-like illness with nausea, vomiting, and sweating. She has not followed up with a physician regularly. One of her siblings has “heart problems” and her mother died suddenly and unexpectedly at age 55 years.
44Case # 2On examination her heart rate is 75/min and her blood pressure is 185/93 mm Hg. BMI is Jugular venous pressure is mildly elevated. Lung examination reveals a few bibasilar crackles. Cardiac examination reveals regular rhythm, normal S1 and S2 and the presence of an S3. There is mild peripheral edema. An echocardiogram is significant for left ventricular hypertrophy and severely decreased systolic function (left ventricular ejection fraction, 20%) An electrocardiogram shows a previous anteroseptal MI.
45Case # 2Which of the following is the most appropriate next diagnostic test?Measurement of plasma BNPSerum Protein ElectrophoresisCardiac Stress TestCardiac catheterizationEndomyocardial biopsy