Management of Heart Failure
Overview Interactive exercise What colour are your sunglasses? Update on pathophysiology of HF Interactive case study Heart failure with preserved systolic function Discussion Close
Which treatment do you want? A B C time % survival
What colour are your lenses?
Pathophysiology How we think about the failing heart affects our treatment strategies Changes in mechanistic understanding: 1.Cardio-centric view 2.Cardio-renal view 3.Neuro-hormonal view
Cardiocentric view Reduced cardiac output is the “cause” Cardiac compensatory mechanisms –Frank-Starling curve –LV dilatation –LV hypertrophy Problems –Positive inotropes kill! –Still some research on calcium sensitisers etc Benefits –Cardiac resynchronisation
Cardiorenal view Reduced perfusion to the renal arterioles causes salt and fluid retention (RAAS) Aim of treatment is to normalise volume status –Focus on diuretics and fluid balance –Stimulated development of ACEi / ARB’s / Aldosterone antagonists –New developments Direct renin inhibitors –Know the eGFR but …
Neurohormonal view Heart failure is due to chronically activated compensatory mechanisms –Autonomic nervous system –Renin-Angiotensin-Aldosterone system –Role of the peripheries (muscles, arterioles) Stimulated treatments –Beta blockers –ACEi/ARB/aldosterone antagonists –Natriuretic peptides –Exercise
Heart Failure Ventricular contractile dysfunction Sympathoadrena l activation Cardiac output peripheral resistance Renal perfusion Angiotensin II Angiotensin I Renin Salt and water retention Aldosterone vasodilators ACEi Diuretics Aldosterone antagonists ARB Renin inhibitors BB NPs
Case study Jean 76 year old lady Long history of type 2 diabetes (diet controlled) Previous episode of gout “mild” COPD Resistant hypertension for years Drugs –Atenolol 50 –Verapamil 120 bd (but only taking evening) –Aspirin 75 Tried –Felodipine –Bendroflumethiazide –Doxazosin
Presenting complaint Increasing abdominal swelling Increasing breathlessness on exertion Some ankle swelling
Examination Pulse 110 irreg irreg BP 176/94 JVP visible 3 cm Pitting oedema (mild) Distended abdomen but … Heart sounds normal Chest clear
Discuss What do you think is going on? What tests will you request and where? Are you going to start any treatment now? 7 mins
What the GP did ECG in the practice Open access CXR Open access U/S abdomen Bloods –FBC –U&E –LFT –TFT Started frusemide 40 mg od
Results FBC –Hb 9.7 MCV 85 U&E –Cr 120 eGFR 56K 4.5 CXR –Clear lung fields. Enlarged cardiothoracic ratio U/S Abdo –Dilated hepatic veins consistent with heart failure ECG –AF rate 110LBBBQRS duration 150ms
Discuss Is the diagnosis clear? More tests? Referral –Where? –Choose and book? Treatment? 7 minutes
What the GP did Referred to Cardiology at BRI by letter –24th August 2007 Triaged by Cardiology Consultants –One stop clinic –Seen 19th September 2007
One stop clinic Designed to see patients who are likely to need a test and review 7 new patients twice a week Suitable for: –Breathlessness, arrhythmias, murmurs, chest pain and pre-op assessment Patients warned may take all morning! ECG on arrival Letter reviewed and sent for echo prior to being seen
Echo
Discuss Heart Failure treatment AF treatment Follow up 5 minutes
What the Cardiologist did Make the diagnosis –Heart failure with impaired LV systolic function secondary to hypertension –AF Recommend changes in treatment (by GP) –Stop verapamil, atenolol and aspirin –Start bisoprolol, ramipril and warfarin Letter to GP and patient Discharged back to GP Review by Heart Failure nurses for education and monitor uptitration
Discuss Uptitration of drugs –By whom? –Monitoring of renal function What would trigger referral back to secondary care? Anaemia –Investigate? Causes? Treatment? 5 mins
Heart Failure with preserved systolic function % of HF Elevated LV filling pressures Normal ejection fraction on echo –Other supporting signs of heart failure Typical patient –Elderly –Female –Hypertension
Question? What would you have done differently if an open access echo had come back showing: –Good LV systolic function –Mild concentric LVH –Mild mitral regurgitation –Moderate tricuspid regurgitation –Moderate pulmonary hypertension –Probable diastolic dysfunction 2 mins
“Diastolic” Heart Failure Poor response to haemodynamic stress –AF –Tachycardia – BP –Ischaemia Little direct trial evidence –CHARM preserved –SENIORS
Treatment options Control BP Control heart rate (esp in AF) Control congestion Revascularise if driven by ischaemia Be careful not to reduce preload too much
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