Heart Failure Dr Nidhi Bhargava

Cardiac Failure  Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.(AHA/ACC HF guidelines 2001)

 Economic burden % of all healthcare costs and 60-75% of these costs relate to hospital burden  NYHA classes  1-1V  All class HF mortality- 50% in 5 years  NYHA Class 1V- 1 year survival -50%

 NYHA (New York Heart Association Classification)  Class 1 Cardiac disease but no limitation in ordinary physical activity, e.g. no SOB when walking, climbing stairs etc.  Class 2 Mild symptoms ( mild SOB and or angina) and slight limitation during ordinary activity  Class 3 Marked limitation in activity due to symptoms, even during less than ordinary activity, e.g. walking short distances ( m) Comfortable only at rest.  Class 4 Severe Limitations. Experiences symptoms even at rest. Mostly bedbound patients

 Causes of death  40% Sudden  50% pump failure  30-40% are in NYHA class V  Rehospitalisation rates  2% at 2 days  20% at 1 month  50% at 6 months

Causes 1. Myocardial Dysfunction (IHD, DCM) 2. Volume overload (AR, MR) 3. Obstruction (AS, MS, HOCM) 4. Diastolic Dysfunction (Constriction) 5. Mechanical Problems (LV aneurysm) 6. Rhythm Disturbance (AF) 7. High Output (anaemia, shunts, thyrotoxicosis) 8. IHD and HT-most common disease processes often in combination causing myocardial damage

Pathophysiology  Large MI CO BP Compensatory Mechanisms Neuroendocrine activation Renin angiotensin  Aldosterone

Pathophysiology Neuroendocrine Activation- Increased HR and contractility Aldosterone System-Na retention and hence water retention Renin angiotensin system- vasoconstriction

Pathophysiology  An increase in LVED volume  Starling’s law- increased LVED volume and hence increased stroke volume  Hence increased stress on the left ventricular wall- further thinning of the infarcted wall and expansion of infarcted region  The normal wall can compensate for the rest of infarcted area- compensatory mechanism otherwise LV dilatation and LVSD-worse than original infarct

Signs and Symptoms of Heart failure  ESC guidelines  Essential features-SOB, ankle swelling, objective evidence of cardiac dysfunction at rest using echo  Non essential features- Response to treatment directed at HF (if diagnosis in doubt)

Symptoms 1. Exertional Dyspnoea 2. Orthopnoea 3. PND 4. Ankle swelling 5. Anorexia and wt loss 6. Cold peripheries 7. Tiredness

Signs  Tachycardia  Hypotension  Raised JVP  3 rd heart sound  PSM of MR  Basal crackles  Ankle oedema

Investigations  ECG- If normal chances of LVSD are very low (<5%)- LBBB, Q waves, non specific ST/T waves changes  CXR- cardiomegaly, Pulmonary oedema  BNP- elevated in both systolic and diastolic dysfunction, results affected by obesity, diuretics and ACEi,  blockers, spironolactone-all decerase the levels. LVH, ischaemia and tachycardia, PE, eGFR < 60, COPD, sepsis will increase the levels  Echo-confirmatory test- systolic dysfunction/any valvular disease/ischaemic aetiology or regional wall motion abnormality/diastolic dysfunction  Nuclear imaging  Stress echocardiography  Cardiac catheterisation  Lung function tests

Treatment  Acute HF  Sit up, high dose O2, i/v diamorphine, i/v GTN, intubation  Treat intercurrent infection  Systolic BP<80 –poor prognosis  Ionotropes to increase BP and help orgn perfusion

Treatment  Chronic HF  Non pharmacological- restrict salt and fluid intake, encourage exercise, decrease or abstain from alcohol  Flu vaccination  Tight BP control  Loop diuretcis-frusemide 40-80mgs or bumetanide 1-2mgs

Non Coronary Interventions  Pacing- broad QRS+ LBBB  Defibrillators-ventricular arrhythmias  Valvular surgery-Mitral valve repair  Heart Transplant- otherwise fit individuals  Left ventricular assist devices- as a bridge to transplantation

Treatment  ACEi – improve prognosis and symptoms, optimise dose, slow titration every 2 weeks with UEs monitoring  ARBs- role not confirmed (to be used if unable to tolerate ACEi)  Hydralazines and nitrates- improve diagnosis and prognosis (consensus study), first line or 2 nd line (NYHA 111-1V), Africo carribean population   blockers- Improve prognosis and symptoms. Assess HR and BP at each titration, use those licensed for HF (even in pts with COPD)  Spironolactone- NYHA 111-1V, monitor K levels and eGFR  Ivabradine- in pts with NYHA class 2-4 stable CHF with systolic dysfunction, in sinus rhythm, HR ≥ 75/min and given in combination with other HF treatment or when beta blocker is contraindicated, LVEF ≤ 35% aftre stabilisation with other treatement for at least 4 weeks.

Treatment  Rehabilatation- supervised group exercises- rehab programme  Psychological and educational support-role of community heart failure nurses

CRT (cardiac resynchronisation therapy)  Moderate to severe LVSD  NYHA 111-1V  No revascularisation or surgery strategy  Stable and optimal medical regime  QRS ≥ 130ms  EF≤ 35%  LVED dimension ≥ 55mm

Case 1  73 years old female  Recent onset of orthopnoea  PMH-HT diagnosed 3 years ago  Medication-atenolol  o/e- b/l basal crepts  ? Suspected diagnosis  Tests needed to confirm diagnosis  Treatment

Case 2  71 years old male  P/C- breathlessness and fatigue, gradually worsening  PMH- Type 1 DM, angina  o/e- irregular pulse (possibly AF), low volume  ? Heart failure  Tests for confirmation

Case 3  68 years old female  P/C- exertional breathlessness, ankle swelling, cough  PMH- Type 2 DM  o/e- ankle oedema, high BP and 2cms hepatomegaly  ? Heart failure  Tests  Treatment

Case 4  80 years old female  P/C- fatigue, weight loss, feels stomach always bloated  PMH-chronic bronchitis  o/e- raised JVP, PSM in the lower sternal edge, 3 rd HS, ascites  ? Heart failure  Tests

Case 5  62 years old male  P/C- breathlessness and orthopnoea  PMH-COPD  o/e- b/l basal crepitations and tachycardia  ? Exacerbation of COPD or possible heart failure  Tests

Case 6  65 years old female of Africo-Caribbean ethinicity  P/C- 3/52 of exertional breathlessness  PMH- Hypertension and obesity  o/e- b/l basal crepitations, laterally displaced apical impulse  ? Heart failure  Tests  Treatment  After 6 months pt presents again with worsening breathlessness  Treatment  Pt returns after 4 months with breathlessness at rest

Case 7  57 years old male smoker  P/C- 3/52 cough  PMH- LVSD  Current medication-Bisoprolol 10mgs and Ramipril 7.5mgs  o/e- chest clear, no signs of fluid overload  CXR normal, renal function normal  Review the previous diagnosis of heart failure  Repeat BNP

Case 8  64 years olf female  P/C- 2/7 breathlessness  PMH- HT, STEMI 8/7 treated with PCI  Medications- aspirin 75mgs, clopidogrel 75mgs, atenolol 25mgs, Ramipril 3.75mgs  o/e- b/l crepts in lower 1/3 of lungs, raised JVP, 3 rd HS, normal Ues  Suspected HF secondary to MI  Treatment

Case 8 continued…  Echo- moderately severe systolic dysfunction  Aldosterone antagonist licensed for HF following MI  Eplerenone 25mgs – monitor UE and K levels  Change atenolol to Bisoprolol 1.25mgs  Titrate Bisoprolol once signs of congestion cleared