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CHRONIC HEART FAILURE. Heart Failure What is Heart Failure?

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Presentation on theme: "CHRONIC HEART FAILURE. Heart Failure What is Heart Failure?"— Presentation transcript:

1 CHRONIC HEART FAILURE

2 Heart Failure What is Heart Failure?

3 Basic Definition Heart failure is a medical term that describes an inability of the heart to keep up its work load of pumping blood to the lungs and to the rest of the body.

4 Statistic It is estimated that as many as two million Americans suffer from congestive heart failure and that up to 29, 000 die annually from this chronic disorder. »Cannobio, Mary. Cardiovascular Disorders. Missouri: C.V. Mosby Company, 1990.

5 Symptoms (involving gravity/exhaustion of heart Swelling of the ankles, legs, and hands Orthopnea, or the shortness of breath when lying flat Shortness of breath during exertion

6 Symptoms (involving circulation) Cyanosis, or a bluish color that is seen in the lips and fingernails from a lack of oxygen Fatigue or weakness Rapid or irregular heart beat Changes of behavior such as restlessness, confusion, and decreased attention span

7 Symptoms (involving congestion) Unexplained or unintentional weight gain Chronic cough Increased urination Distended neck veins Loss of appetite or indigestion

8 Congestive heart failure is a syndrome that can be caused by multiple underlying diseases such as: Congenital heart disease Atherosclerosis Rheumatic fever Cardiomyopathy Valve disorders Ventricular failure Left or right-sided failure Hypertension Prolonged alcohol or drug addiction Previous heart attack Diabetes Chronic rapid heartbeats

9 Congenital Heart Disease CHD affects one out of every one thousand babies. In these babies the marvelously intricate combination of chambers, valves, and vessels making up the heart and circulatory systems fails to form properly before birth. Septal, atrial, and ventricular defects are the most common. “Heart.” The World Book Encyclopedia ed.

10 Rheumatic Fever Strep throat from the streptococcal infection begins a disease process where the heart valves are damaged. This condition is called rheumatic fever and it affects the connective tissues of the body.

11 Cardiomyopathy Cardiomyopathy is the stretching and enlarging of the heart cavity that occurs making the heart weak so it does not pump correctly

12 Ventricular Failure Ventricular failure occurs when there are weak spots in the ventricular walls causing a bulge, or an aneurysm.

13 Atherosclerosis Atherosclerosis is the gradual clogging of the arteries by fatty, fibrous deposits. A tiny lump of fibrous tissue grows as the artery tries to repair the damage. Cholesterol accumulates and more tissue builds up. The arteries are thickened and hardened making a loss of elasticity causing congestion.

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17 KEY ISSUES IN CHRONIC HEART FAILURE Common  1-3 % of the population, rising to 6-10 % of people aged >65 years  Incidence x2 in the last 10 years  Dangerous – high mortality (>50% over 5 yrs, 50% of these deaths occur suddenly)  Disabling – high morbidity (on average, 1 in 5 patients is readmitted within 12 months)  Costly – % of health care budget

18 Contributors to Increased Incidence -Improvements in: - Survival post-MI - Technologies (i.e.. Laser, stents etc.) - Medical Treatments for ischemic heart disease - Overall survival

19 DEFINITION OF HEART FAILURE AHA / ACC HF guidelines 2001 Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood Clinical symptoms / signs secondary to abnormal ventricular function ESC HF guidelines 2001

20 DEFINITION OF HEART FAILURE I.Symptoms of heart failure, typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling II.Objective evidence (preferably by echocardiography) of cardiac dysfunction (systolic and/or diastolic) at rest III.Response to treatment directed towards heart failure Criteria I. and II. should be fulfilled in all cases ESC HF guidelines 2005

21 Q’s to be answered while facing a patient with suspected heart failure 1.Are the patient’s symptoms cardiac in origin? 2.If so, what kind of cardiac disease is producing these symptoms

22 HEART FAILURE should never be the only diagnosis !

23 Etiology of Chronic Heart Failure Coronary artery disease accounts for about 65% Non-ischemic Cardiomyopathy: Hypertension Valvular Heart Disease Idiopathic Thyroid Toxic or drug-induced

24 SYMPTOMS I.There is a poor relationship between symptoms and the severity of cardiac dysfunction. Mild symptoms should not be equated with minor cardiac dysfunction II.Symptoms may be related to prognosis particularly if persisting after therapy III.Once a diagnosis of heart failure has been established, symptoms may be used to classify the severity of heart failure and should be used to monitor the effects of therapy

25 Electrocardiogram A normal electrocardiogram (ECG) suggests that the diagnosis of CHF should be carefully reviewed The presence of pathological Q-waves may suggest myocardial infarction as the cause of cardiac dysfunction. A QRS width >120 ms suggests that cardiac dyssynchrony may be present and a target for treatment

26 Types of Rhythms Associated with CHF

27 –Left Ventricular Failure with Pulmonary Edema Aka—systolic heart failure –Right Ventricular Failure Aka—diastolic heart failure

28 The smooth, glistening pleural surface of a lung is shown here. This patient had marked pulmonary edema, which increased the fluid in the lymphatics that run between lung lobules. Thus, the lung lobules are outlined in white.

29 –Occurs when the left ventricle fails as an effective forward pump –  back pressure of blood into the pulmonary circulation –  pulmonary edema –Cannot eject all of the blood delivered from the right heart. –Left atrial pressure rises  increased pressure in the pulmonary veins and capillaries –When pressure becomes to high, the fluid portion of the blood is forced into the alveoli. –  decreased oxygenation capacity of the lungs –AMI common with LVF, suspect

30 –Severe resp. distress– Evidenced by orthopnea, dyspnea Hx of paroxysmal nocturnal dyspnea. –Severe apprehension, agitation, confusion— Resulting from hypoxia Feels like he/she is smothering –Cyanosis— –Diaphoresis— Results from sympathetic stimulation –Pulmonary congestion Often present Rales—especially at the bases. Rhonchi—associated with fluid in the larger airways indicative of severe failure Wheezes—response to airway spasm

31 –Jugular Venous Distention—not directly related to LVF. Comes from back pressure building from right heart into venous circulation – Vital Signs— Significant increase in sympathetic discharge to compensate. BP—elevated Pulse rate—elevated to compensate for decreased stroke volume. Respirations—rapid and labored

32 ECHOCARDIOGRAPHY Assessment of LV systolic function (EF) Assessment of LV diastolic function

33 Natriuretic peptides Plasma concentrations of BNP and NT-proBNP are helpful in the diagnosis in HF A low-normal concentration in an untreated patient makes HF unlikely as the cause of symptoms BNP and NT-proBNP have considerable prognostic potential. Their role in treatment monitoring remains to be determined

34 The value of BNP in HF diagnosis A. Is well established in the general population B. Is well established in persons at risk of heart failure C. Is well established in patients with suggestive symptoms D. Has an overall accuracy of 100% E. Is based on a high negative predictive value

35 The value of BNP in HF diagnosis A. Is well established in the general population B. Is well established in persons at risk of heart failure C. Is well established in patients with suggestive symptoms D. Has an overall accuracy of 100% E. Is based on a high negative predictive value

36 NYHA classification of HF Class I No limitation: ordinary physical exercise does not cause undue fatigue, dyspnea, or palpitations Class II Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations, or dyspnea Class III Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms Class IV Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

37 Heart disease (any) Hypertension Diabetes, Hyperchol. Family Hx Cardiotoxins Asymptomatic LV dysfunction Systolic / Diastolic Marked symptoms at rest despite max. therapy Dyspnea, Fatigue Reduced exercise tolerance Stages in the Evolution of Heart Failure Clinical Characteristics A B C D

38 ACE-i  blockers Treat risk factors Avoid toxics ACE-i in selected p. In selected patients Palliative therapy Mech. Assist device Heart Transplant ACE-i  blockers Diuretics / Digitalis Stages in the Evolution of Heart Failure Treatment A B C D

39 Goals of treatment in CHF Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms

40 Prolong survival ACE inhibitors Beta blockers Spironolactone Angiotensin receptor blockers Implantable cardioverter-defibrillators Prolong survival ACE inhibitors Beta blockers Spironolactone Angiotensin receptor blockers Implantable cardioverter-defibrillators

41 Symptom reduction and improved activity tolerance Exercise training Diuretics ACE inhibitors Digoxin Beta blockers Symptom reduction and improved activity tolerance Exercise training Diuretics ACE inhibitors Digoxin Beta blockers

42 Prevent progression (remodeling) ACE inhibitors Beta blockers Spironolactone Angiotensin receptor blockers Cardiac resynchronization (biventricular pacing) Prevent progression (remodeling) ACE inhibitors Beta blockers Spironolactone Angiotensin receptor blockers Cardiac resynchronization (biventricular pacing)

43 Sodium and fluid restriction Alcohol Weight Smoking Rest and exercise Non-pharmacological management

44 2-2.5 g sodium restriction (about 5-6 g of salt) Fluid restriction (in patients with refractory fluid retention, significant hyponatremia or severely impaired renal function Low fat diet and caloric restriction when indicated Abstention from alcohol or restriction to 1 drink per day Dietary advice

45 Encourage regular activity in all patients Exercise training/cardiac rehabilitation in stable, motivated patients Activity and exercise councelling

46 Symptomatic and psychologic benefits: Aerobic training results in increased exercise capacity (peak oxygen consumption), improved quality of life (questionnaires), reduced sympathetic nervous system activity Possible beneficial effect on prognosis Activity and exercise councelling

47 Treatment Pharmacologic Therapy Treatment Pharmacologic Therapy Diuretics ACE inhibitors Beta Blockers Digitalis Spironolactone Other Diuretics ACE inhibitors Beta Blockers Digitalis Spironolactone Other

48 Approach to the patient with HF Assess LV function (EF < 40%) Assess volume status Fluid retention? ACE inhibitor Beta-blocker Diuretic No Yes Digoxin

49 Digitalis. Indications When no adequate response to When no adequate response to ACE-i + diuretics + beta-blockers ACE-i + diuretics + beta-blockers AHA / ACC Guidelines 2001 AHA / ACC Guidelines 2001 AF, to slow AV conduction AF, to slow AV conduction Dose to mg / day

50 Spironolactone. Indications Recent or current symptoms despite ACE-i, diuretics, dig. and  -blockersRecent or current symptoms despite ACE-i, diuretics, dig. and  -blockers AHA / ACC HF guidelines 2001 Recommended in advanced heart failure (III-IV), in addition to ACE-i and diureticsRecommended in advanced heart failure (III-IV), in addition to ACE-i and diuretics HypokalemiaHypokalemia ESC HF guidelines 2001

51 Candesartan, Eprosartan, Irbesartan Candesartan, Eprosartan, Irbesartan Losartan, Telmisartan, Valsartan Efficacy seems to be equal to ACE-I Efficacy seems to be equal to ACE-I Indicated in patients intolerant to ACE-I Indicated in patients intolerant to ACE-I Can be considered in combination with ACE-I in patients who remain symptomatic Can be considered in combination with ACE-I in patients who remain symptomatic Angiotensin II Receptor Blockers (ARB)

52 Nitrates. Clinical Use CHF with myocardial ischemia Orthopnea and paroxysmal nocturnal dyspnea In acute CHF and pulmonary edema:NTG sl / iv Nitrates + Hydralazine in intolerance to ACE-I (hypotension, renal insufficiency) CHF with myocardial ischemia Orthopnea and paroxysmal nocturnal dyspnea In acute CHF and pulmonary edema:NTG sl / iv Nitrates + Hydralazine in intolerance to ACE-I (hypotension, renal insufficiency)

53 May increase mortality Exception: Digoxin, Levosimendan Use only in refractory CHF NOT for use as chronic therapy May increase mortality Exception: Digoxin, Levosimendan Use only in refractory CHF NOT for use as chronic therapy Positive Inotropic Therapy

54 Inotropes, long term / intermittent Inotropes, long term / intermittent Antiarrhythmics (except amiodarone) Antiarrhythmics (except amiodarone) Calcium antagonists (except amlodipine) Calcium antagonists (except amlodipine) Non-steroidal antiinflammatory drugs (NSAIDS) Non-steroidal antiinflammatory drugs (NSAIDS) Tricyclic antidepressants Tricyclic antidepressants Corticosteroids Corticosteroids Lithium Lithium Drugs to Avoid (may increase symptoms, mortality) ESC HF guidelines 2001

55 1.New neurohormonal modulators 1. New neurohormonal modulators Beta-blockers Beta-blockers Aldosterone receptor antagonists Aldosterone receptor antagonists Angiotensin II receptor antagonists Angiotensin II receptor antagonists Endothelin inhibitors Endothelin inhibitors Vasopresin inhibitors Vasopresin inhibitors Natriuretic Peptides Natriuretic Peptides Endopeptidase inhibitors Endopeptidase inhibitors Vasopeptidase inhibitors Vasopeptidase inhibitors New Drugs (ongoing research)

56 Diastolic Heart Failure Treat as HF with low LVEF Treat as HF with low LVEF Control: Control: Hypertension Hypertension Tachycardia Tachycardia Fluid retention Fluid retention Myocardial ischemia Myocardial ischemia Ongoing research Ongoing research

57 ICD Implantation of an ICD in combination with biventricular pacing may be considered in patients who remain symptomatic with severe heart failure NYHA class III-IV with LVEF≤35% and QRS duration ≥ 120 msec Implantation of an ICD in combination with biventricular pacing may be considered in patients who remain symptomatic with severe heart failure NYHA class III-IV with LVEF≤35% and QRS duration ≥ 120 msec ICD therapy is recommended to improve survival in patients after cardiac arrest or who have sustained ventricular tachycardia ICD therapy is recommended to improve survival in patients after cardiac arrest or who have sustained ventricular tachycardia

58 Heart Transplant. Indications Refractory cardiogenic shock Refractory cardiogenic shock Documented dependence on IV inotropic support to maintain adequate organ perfusion Documented dependence on IV inotropic support to maintain adequate organ perfusion Peak VO2 < 10 ml / kg / min Peak VO2 < 10 ml / kg / min Severe symptoms of ischemia not amenable to revascularization Severe symptoms of ischemia not amenable to revascularization Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities Contraindications: age, severe comorbidity

59 Thank you for attention!


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