Congestive Heart Failure M Chadi Alraies Thursday, January 3, 2008

Essentials of Diagnosis LV failure: LV failure: Exertional dyspnea, Exertional dyspnea, cough, cough, fatigue, fatigue, orthopnea, orthopnea, PND, PND, cardiac enlargement, cardiac enlargement, rales, rales, gallop rhythm, gallop rhythm, pulmonary venous congestion. pulmonary venous congestion. RV failure: RV failure: Elevated venous pressure, Elevated venous pressure, hepatomegaly, hepatomegaly, dependent edema; dependent edema;

Types Systolic heart failure Systolic heart failure Diastolic heart failure Diastolic heart failure High output heart failure High output heart failure Thyrotoxicosis, Thyrotoxicosis, Severe anemia, Severe anemia, Arteriovenous shunting (including dialysis fistulas), Arteriovenous shunting (including dialysis fistulas), Paget's disease of bone, Paget's disease of bone, Thiamine deficiency (wet beriberi). Thiamine deficiency (wet beriberi).

Pathophysiology 1. Contractile state of the myocardium, 2. Preload of the ventricle 3. Afterload applied to the ventricles 4. Heart rate.

Cardiac contractility (pump) ‏ Coronary artery disease (infarction) ‏ Muscle: Hypertrophy Restrictive cardiomyopathy Myocardial toxins (medications, cocaine, ETOH) ‏ Myocarditis Idiopathic dilated cardiomyopathy

Increased preload LV LV Mitral regurgitation Mitral regurgitation Aortic regurgitation Aortic regurgitation RV RV ASD ASD VSA VSA Post infarction interventricular perforation Post infarction interventricular perforation

Increased afterload LV LV Aortic stenosis Aortic stenosis HTN HTN HOCM HOCM RV RV Pulmonary HTN Pulmonary HTN Pulmonic valve stenosis Pulmonic valve stenosis Left heat failure Left heat failure

Conduction system Bradycardia Bradycardia Tachycardia Tachycardia

Pathophysiology 1. Decreased stroke volume 2. Raised end-diastolic volume and pressure 3. Ventricular dilation will occur. 4. Chronic elevation of diastolic pressures. 5. Increased capillary pressure. 6. Transudation of fluid with resulting pulmonary or systemic edema. 7. Activation of neural and humoral systems. 8. Increased activity of the sympathetic nervous system. 9. Increased myocardial contractility, heart rate, and venous tone. 10. Increased peripheral vascular resistance. 11. Increased LV afterload, so that excessive sympathetic activity may further depress cardiac function.

The renin–angiotensin–aldosterone system 1. Reduction of renal blood flow and glomerular filtration rate. 2. The renin–angiotensin–aldosterone system is activated. 3. Increase in peripheral vascular resistance. 4. Increase in sodium and water retention.

Remodeling Left ventricular dysfunction is a progressive process. Left ventricular dysfunction is a progressive process. Remodeling occurs in association with homeostatic attempts to decrease wall stress through increases in wall thickness. Remodeling occurs in association with homeostatic attempts to decrease wall stress through increases in wall thickness. This ultimately results in a change in the geometry of the left ventricle such that: This ultimately results in a change in the geometry of the left ventricle such that: The chamber dilates, The chamber dilates, hypertrophies, hypertrophies, Becomes more spherical. Becomes more spherical. It precedes the development of symptoms, by months or even years. It precedes the development of symptoms, by months or even years. The process of remodeling continues after the appearance of symptoms and may contribute importantly to worsening of symptoms despite treatment. The process of remodeling continues after the appearance of symptoms and may contribute importantly to worsening of symptoms despite treatment.

Causes Ischemic cardiomyopathy Ischemic cardiomyopathy HTN HTN DCM: DCM: ETOH ETOH Myocarditis (HIV) ‏ Myocarditis (HIV) ‏ Idiopathic Idiopathic Cardiotoxins Cardiotoxins Infiltrative cardiomyopathy (sarcoidosis, Amyloidosis, hemochromatosis) ‏ Infiltrative cardiomyopathy (sarcoidosis, Amyloidosis, hemochromatosis) ‏ Valvular hear disease. Valvular hear disease.

Stages of HF

Stages of Heart Failure and Treatment Options for Systolic Heart Failure.

Symptoms LV failure: LV failure: Exertional dyspnea, Exertional dyspnea, Cough, Cough, Fatigue, Fatigue, Orthopnea Orthopnea PND PND Nocturia Nocturia RV failure: RV failure: RUQ pain RUQ pain Loss of appetite Loss of appetite Nausea Nausea Dependent edema Dependent edema

Exacerbations 1. Patient noncompliance 2. Excessive salt and fluid intake 3. Arrhythmias 4. Excessive activity 5. Pulmonary emboli 6. Intercurrent infection 7. Progression of the underlying disease.

New York Heart Association classification I II II III III IV IV Has major limitations: Has major limitations: Patient reports are highly subjective Patient reports are highly subjective Symptoms vary from day to day. Symptoms vary from day to day. Insufficiently sensitive to be useful in predicting outcomes or assessing the results of treatment. Insufficiently sensitive to be useful in predicting outcomes or assessing the results of treatment.

Signs dyspneic dyspneic cachectic or cyanotic cachectic or cyanotic cold extremities and diaphoresis cold extremities and diaphoresis jugular venous jugular venous S3 & S4 gallop S3 & S4 gallop hyperthyroidism and hypothyroidism hyperthyroidism and hypothyroidism crackles at the lung bases crackles at the lung bases Expiratory wheezing and rhonchi Expiratory wheezing and rhonchi bibasilar dullness to percussion bibasilar dullness to percussion hepatic enlargement—tender or nontender hepatic enlargement—tender or nontender Ascites Ascites Peripheral pitting edema Peripheral pitting edema

Lab anemia anemia renal insufficiency renal insufficiency hypokalemia hypokalemia Hyperkalemia Hyperkalemia Hyponatremia Hyponatremia Thyroid function Thyroid function

Brain natriuretic peptide A mean of identifying patients with elevated left ventricular filling pressures. The assessment of this peptide cannot reliably distinguish patients with systolic from those with diastolic dysfunction. Aids in differentiating dyspnea due to HF from dyspnea due to other causes in an emergency setting. The role of brain natriuretic peptide measurement in the identification and management of patients with symptomatic or asymptomatic left ventricular dysfunction remains to be fully clarified.

EKG EKG CXR CXR Echocardiogram Echocardiogram Size and function of both ventricles and atria. Size and function of both ventricles and atria. Pericardial effusion. Pericardial effusion. Valvular abnormalities Valvular abnormalities Intracardiac shunts Intracardiac shunts Segmental wall motion abnormalities (old MI) ‏ Segmental wall motion abnormalities (old MI) ‏ Dilated cardiomyopathy Dilated cardiomyopathy

CARDIAC CATHETERIZATION The combination of: The combination of: Angina Angina Noninvasive evidence of significant myocardial ischemia. Noninvasive evidence of significant myocardial ischemia. Symptomatic heart failure. Symptomatic heart failure.

Treatment

Primary Targets of Treatment in Heart Failure

Pharmacologic Treatment CORRECTION OF REVERSIBLE CAUSES: CORRECTION OF REVERSIBLE CAUSES: Valvular lesions Myocardial ischemia Uncontrolled hypertension Arrhythmias Alcohol- or drug-induced myocardial depression Stop Calcium channel blockers, antiarrhythmic drugs, and NSAID’s

Diuretic therapy

Thiazides Hydrochlorothiazide, metolazone, chlorthalidone. Hydrochlorothiazide, metolazone, chlorthalidone. Block sodium reabsorption in the cortical diluting segment at the terminal portion of the loop of Henle and in the proximal portion of the distal convoluted tubule Block sodium reabsorption in the cortical diluting segment at the terminal portion of the loop of Henle and in the proximal portion of the distal convoluted tubule Thiazides are ineffective when the GFR falls below 30–40 mL/min. Thiazides are ineffective when the GFR falls below 30–40 mL/min.

Loop diuretics Furosemide, bumetanide and torsemide. Furosemide, bumetanide and torsemide. Rapid onset and a relatively short duration of action Rapid onset and a relatively short duration of action Two or more doses are preferable to a single larger dose. Two or more doses are preferable to a single larger dose. Inhibit chloride reabsorption in the ascending limb of the loop of Henle, which results in natriuresis, kaliuresis, and metabolic alkalosis. Inhibit chloride reabsorption in the ascending limb of the loop of Henle, which results in natriuresis, kaliuresis, and metabolic alkalosis.

Potassium sparing diurestics Spironolactone, triamterene, and amiloride Spironolactone, triamterene, and amiloride Spironolactone is a specific inhibitor of aldosterone. Spironolactone is a specific inhibitor of aldosterone.

INHIBITORS OF THE RENIN–ANGIOTENSIN– ALDOSTERONE SYSTEM

Why ACEI? Decrease angiotensin II. Decrease angiotensin II. Vasodilation. Vasodilation. Decreasing sodium retention by reducing aldosterone. Decreasing sodium retention by reducing aldosterone. Increase bradykinin levels, stimulate the synthesis of prostaglandins and nitric oxide. Increase bradykinin levels, stimulate the synthesis of prostaglandins and nitric oxide.

Why ACEI? Reduce mortality by approximately 20% Reduce mortality by approximately 20% Prevent hospitalizations Prevent hospitalizations Increase exercise tolerance Increase exercise tolerance Reduce symptoms. Reduce symptoms. Indicated for the management of patients with reduced EFs without symptoms. Indicated for the management of patients with reduced EFs without symptoms.

Dosing ACEI ACE inhibitors should be titrated over a period of 1–3 months. ACE inhibitors should be titrated over a period of 1–3 months. Cr. 3 and K 5.5 acceptable. Cr. 3 and K 5.5 acceptable. Renal dysfunction is more frequent in: Renal dysfunction is more frequent in: Diabetics, Diabetics, Older patients, Older patients, Low systolic pressures Low systolic pressures

ARB’s Candesartan or valsartan, provide important benefits as an alternative, and in addition, to ACE inhibitors in chronic heart failure. Candesartan or valsartan, provide important benefits as an alternative, and in addition, to ACE inhibitors in chronic heart failure. No effect on bradykinin, prostaglandins, and nitric oxide. No effect on bradykinin, prostaglandins, and nitric oxide.

Spironolactone Aldosterone mediates: Aldosterone mediates: Myocardial remodeling and fibrosis. Myocardial remodeling and fibrosis. Sodium retention. Sodium retention. Potassium loss. Potassium loss. spironolactone should be considered as a neurohormonal antagonist. spironolactone should be considered as a neurohormonal antagonist. Monitor potassium level after 1 and 4 weeks of therapy. Monitor potassium level after 1 and 4 weeks of therapy.

BB

BB chronic elevations of catecholamines and sympathetic nervous system activity cause progressive myocardial damage, leading to worsening LV function and dilation. chronic elevations of catecholamines and sympathetic nervous system activity cause progressive myocardial damage, leading to worsening LV function and dilation. stable patients (defined as having no recent deterioration or evidence of volume overload) with mild, moderate, and even severe heart failure should be treated with a -blocker unless there is a noncardiac contraindication. stable patients (defined as having no recent deterioration or evidence of volume overload) with mild, moderate, and even severe heart failure should be treated with a -blocker unless there is a noncardiac contraindication.

BB Ensure that they were free of fluid retention at the time of initiation. Ensure that they were free of fluid retention at the time of initiation. Initiation must be done gradually. Initiation must be done gradually.

BB Start low and go slow

How to monitor BB? Patients should be instructed to monitor their weights at home. Patients should be instructed to monitor their weights at home. report any increase or change in symptoms immediately. report any increase or change in symptoms immediately. If heart failure worsens, this can usually be managed by increasing diuretic doses and delaying further increases. If heart failure worsens, this can usually be managed by increasing diuretic doses and delaying further increases. Carvedilol, because of its -blocking activity, may cause dizziness or hypotension. This can usually be managed by reducing the doses of other vasodilators and by slowing the pace of dose increases. Carvedilol, because of its -blocking activity, may cause dizziness or hypotension. This can usually be managed by reducing the doses of other vasodilators and by slowing the pace of dose increases.

DIGITALIS GLYCOSIDES The only orally active positive inotropic agents. The only orally active positive inotropic agents. Lack the benefits of the neurohormonal antagonists. Lack the benefits of the neurohormonal antagonists. Efficacy in reducing the symptoms of heart failure has been established. Efficacy in reducing the symptoms of heart failure has been established. Digoxin should be used for patients who remain symptomatic when taking diuretics and ACE inhibitors as well as for patients with heart failure who are in atrial fibrillation and require rate control. Digoxin should be used for patients who remain symptomatic when taking diuretics and ACE inhibitors as well as for patients with heart failure who are in atrial fibrillation and require rate control.

Vasodilators

Nitrates and Hydralazine Use this combination in addition to other effective therapies in African Americans with severe heart failure. Use this combination in addition to other effective therapies in African Americans with severe heart failure. A-HeFT trial. A-HeFT trial.

IV Nitrates Used primarily for acute or severely decompensated chronic heart failure, especially when accompanied by hypertension or myocardial ischemia. Used primarily for acute or severely decompensated chronic heart failure, especially when accompanied by hypertension or myocardial ischemia.

Nesiritide Recombinant form of human brain natriuretic peptide, is a potent vasodilator that reduces ventricular filling pressures and improves cardiac output. Recombinant form of human brain natriuretic peptide, is a potent vasodilator that reduces ventricular filling pressures and improves cardiac output.

POSITIVE INOTROPIC AGENTS Dobutamine and milrinone. Dobutamine and milrinone. The role is limited to: The role is limited to: Patients with symptoms and signs of low CO. Patients with symptoms and signs of low CO. No response to intravenous diuretics. No response to intravenous diuretics. Maintain patients who are awaiting cardiac transplantation. Maintain patients who are awaiting cardiac transplantation. No benefit in terms of survival, decreasing length of admission, or preventing readmission—and significantly increased rates of sustained hypotension and atrial fibrillation. No benefit in terms of survival, decreasing length of admission, or preventing readmission—and significantly increased rates of sustained hypotension and atrial fibrillation.

CALCIUM CHANNEL BLOCKERS agents should be avoided unless they are being utilized to treat associated angina or hypertension, and for these indications amlodipine is the drug of choice. agents should be avoided unless they are being utilized to treat associated angina or hypertension, and for these indications amlodipine is the drug of choice.

IMPLANTABLE CARDIOVERTER DEFIBRILLATORS Patients with… Patients with… Chronic heart failure and Chronic heart failure and Ischemic or nonischemic cardiomyopathy with an EF 35%. Ischemic or nonischemic cardiomyopathy with an EF 35%. SCD-HeFT trial. SCD-HeFT trial.

BIVENTRICULAR PACING (RESYNCHRONIZATION) ‏ Patient criteria: Patient criteria: 1. NYHA class III or IV heart failure, 2. EF of 35%, and 3. QRS duration 120 milliseconds.

CARDIAC TRANSPLANTATION 1-year survival rates exceeding 80–90% 1-year survival rates exceeding 80–90%

Primary Targets of Treatment in Heart Failure

References CMDT 2007 CMDT 2007 ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary THANK YOU