1. HEART FAILURE

2. Definition
Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The syndrome of heart failure is characterized by symptoms such as breathlessness and fatigue, and signs such as fluid retention (Hurst, 2008).
Heart failure is a syndrome in which the patient should have the following feature: symptom of HF, typically shortness of breath at rest or during exertion, and/or fatigue; sign of fluid retention such as pulmonary congestion or ankle swelling; and objective evidence of an abnormality of the structure or function of the heart at rest (ESC Guidelines, 2008).

3. Other Definitions
Congestive Heart Failure : similar to the above but with features of circulatory congestion (fluid retention) such as jugular venous distension, rales, peripheral edema, and ascites. Adjectives such as chronic, overt, treated, untreated, undulating, worsening and compensated can precede the phrase (Hurst, 2008).
Noncardiac Circulatory Failure : a syndrome that is clinically indistinguishable from congestive heart failure where there is no reason to ascribe the condition to structural heart disease. There must be a noncardiac cause such as acute renal failure. This entity includes so-called high output heart failure; a better terminology is circulatory failure because in these conditions the heart is usually not abnormal (Hurst, 2008).

4. Systolic Heart Failure : a clinical syndrome with classic symptoms of breathlessness, fatigue, and exercise intolerance whereby the dominant cardiac feature is a large, dilated heart and impaired systolic performance. There may or may not be concomitant valvular disease (Hurst, 2008).
Diastolic Heart Failure : this term is used when the ejection fraction at rest is normal or near normal. An alternative phrase is preserved ejection fraction. The features of heart failure are present, and the heart is small or normal in size. There is often left ventricular (LV) hypertrophy and impaired filling of the heart caused by altered LV stiffness or other evidence of diastolic dysfunction. Severe systemic hypertension and/or valvular disease such as mitral regurgitation can be present. This form of heart failure can coexist with systolic heart failure, particularly on exercise (Hurst, 2008). 

5. Right-Sided Heart Failure : a clinical syndrome characterized by tissue congestion including jugular venous distention, peripheral edema, ascites, and abdominal organ engorgement. There is marked impairment of right ventricular systolic performance, usually with right ventricular dilatation and severe tricuspid regurgitation. There are multiple causes of this syndrome, including severe left-sided heart failure (the commonest cause), severe lung disease with chronic hypoxemia and pulmonary hypertension (cor pulmonale), right ventricular myocardial infarction, primary pulmonary hypertension and congenital abnormalities of the heart (Hurst, 2008). 
Left-Sided Heart Failure : a clinical syndrome where the dominant feature is fluid congestion in the lung (pulmonary edema) rather than in the systemic circulation (Hurst, 2008).

6. Epidemiology
Europe
The prevalence of symptomatic HF range from 0.4-2%.
10 million HF pts in 900 million total population
USA
Nearly 5 million HF pts.
± 500,000 pts are HF for the 1st time each year.
Last 10 years  number of hospitalizations has increased.
Nearly 300,000 patients die of HF each year.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22,
ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart Failure in the Adult 2001

7. Stable, worsening or decompensated
Classification of HF
New Onset
First presentation
Acute or slow onset
Transient
Recurrent or episodic
Chronic
Persistent
Stable, worsening or decompensated
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

8. Classification of Heart Failure: ACC/AHA Stage vs NYHA Class
Slide ID: 7753
The American College of Cardiology/American Heart Association (ACC/AHA) writing committee decided to take a new approach to the classification of heart failure – one that emphasized the evolution and progression of the disease. Only Stages C and D qualify for the traditional clinical diagnosis of heart failure. This classification is intended to complement, but not replace, the New York Heart Association (NYHA) Functional Classification.
ACC/AHA Heart Failure Stage
Stage A: patients who are at high risk for developing heart failure but have no structural disorder of the heart.
Stage B: patients with structural disorders of the heart who have never had symptoms of heart failure.
Stage C: patients with past or current symptoms of heart failure associated with underlying structural heart disease.
Stage D: patients with end-stage disease who require specialized treatment strategies such as mechanical circulatory support, continuous IV inotrope infusions, cardiac transplantation, or hospice care.
NYHA Functional Classification
Assigns patients to 1 of 4 functional classes depending on the degree of effort needed to elicit symptoms. Patients with very low LV ejection fractions may be asymptomatic, whereas patients with preserved LV systolic function may have many symptoms. The apparent discordance between severity of systolic dysfunction and the degree of functional impairment is not well understood.
Class I: symptoms of heart failure only at levels that would limit normal individuals (asymptomatic).
Class II: symptoms of heart failure on ordinary exertion.
Class III: symptoms of heart failure on less-than-ordinary exertion.
Class IV: symptoms of heart failure at rest.
References
Hunt SA et al. J Am Coll Cardiol. 2001;38:
Farrell MH et al. JAMA. 2002;287:

9. Killip classification
Stage 1: No Heart Failure
no clinical sign of cardiac decompensation
Stage 2: Heart Failure
S3 gallop, pulmonary venous hypertension, wet rales in the lower half of the lung field
Stage 3: Severe Heart Failure
rales throughout the lung field
Stage 4: Cardiogenic Shock
hypotension (SBP < 90 mmHg), peripheral vasoconstriction (oliguria, cyanosis, sweating)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

10. Forrester classification
Normal perfusion and PCWP
Poor perfusion and low PCWP (hypovolaemic)
Near normal perfusion and high PCWP (pulmonary oedema)
Poor perfusion and high PCWP (cardiogenic shock)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

11. ACC/AHA CLASSIFICATION FORRESTER CLASSIFICATION
NYHA CLASSIFICATION
FORRESTER CLASSIFICATION

12. Aetiology Coronary Artery Disease Valvular Heart Disease Hypertension
Cardiomyopathies (HCM, DCM, RCM)
Drugs (β blockers, CCB, Antiarrhythmic)
Toxins (Alcohol, Cocaine, Mercury, Cobalt)
Endocrine (DM, Hypo/hyperthyroid, Cushing)
Nutritional (Def. thiamine, selenium, obesity)
Infiltrative (Sarcoidosis, amyloidosis)
Others (Chagas, HIV, Peripartum, ESRD)

13. Cardiac Output Heart Rate Stroke Volume Contractility Preload
Afterload
Heart Rate
Stroke Volume
Cardiac Output

14. Preload: the ventricular wall tension at the end of diastole.
Afterload: the ventricular wall tension during contraction.
Contractility: property of heart muscle that accounts for changes in the strength of contraction, independent of preload and afterload.
Stroke volume: volume of blood ejected from ventricle during systole. (SV = EDV – ESV)
Ejection fraction (EF) = SV : EDV
Cardiac output: volume of blood ejected from ventricle per minute. (CO = SV x HR)

15. Patophysiology

16. Neurohormonal Mechanism in HF

17. Role of Sympathetic System in HF

18. Role of RAAS in HF

19. Role of Other Hormones Anti Diuretic Hormone/Vasopressin Endothelin
Increased intravascular volume
Vasoconstriction
Endothelin
Potent vasoconstrictor
Natriuretic peptides
Atrial and B-type
Excretion natrium and water
Vasodilatation
Inhibit secretion of renin
Antagonism of Angiotensn II, aldosterone and ADH

21. Symptoms Major symptoms Minor symptoms Dyspnea Orthopnea Weight loss
Paroxysmal nocturnal dyspnea
Ankle edema
Pulmonary edema
Fatigue
Exercise intolerance
Cachexia
Weight loss
Cough
Nocturia
Palpitations
Peripheral cyanosis
Depression

22. Physical Findings Major symptoms Minor symptoms Tachycardia
Elevated venous pressure
Positive hepatojugular reflux
Pulmonary rales
Tachypnea
Third heart sound
Hepatomegaly
Ankle edema
Ascites
Pleural effusion
Mitral regurgitation
Cardiomegaly
Splenomegaly
Hypotension
Pulsus alternans
Extrasystole
Atrial fibrillation
Weight loss

23. Diagnostic Studies Routine laboratory testing
Blood count, CRP, BNP, creatinine, electrolytes, CK, troponin, liver function tests, TSH, urine analysis
Chest x-ray
Yes
Electrocardiography
Echocardiography
Holter monitoring
No, unless symptoms of an arrhythmia
Exercise testing
Yes (VO2max)
Radionuclide angiography
No, unless EF during exercise indicated
Computed tomography scanning
No; special indication (coronary calcifications, coronary anatomy)
Magnetic resonance imaging
No; special indication (late enhancement, myocardial perfusion, myocardial tagging)
Coronary angiography
Selected patients with suspected CAD
Follow-up
Clinical examination, electrolyte and BNP levels; electrocardiography and echocardiography, when indicated

24. ECG Heart rate Rhythm Conduction Ischaemic Infarction Hypertrophy BBB
Prolonged QT interval
Perimyocarditis

25. Chest X-ray Should be perform as soon as possible Cardiomegaly
Congestion
Effusion
Infiltrates
Limitations of a supine film should be noted

26. Laboratory test Blood count Electrolyte (Na, K) Urea, creatinine
Glucose
Albumin
Hepatic enzymes
INR
Cardiac markers
Natriuretic peptides (BNP & NT-pro BNP)

27. Arterial blood gas analysis
Assessment of oxygenation (pO2)
Respiratory function (pCO2)
Acid-base balance (pH)
Should be assessed in severe respiratory distress

28. Echocardiography General findings: Size and shape of the ventricle
LV ejection fraction (LVEF)
Regional wall motion; synchronicity of ventricular contraction
LV remodeling (concentric versus eccentric)
LV or RV hypertrophy (DD—hypertension, COPD, valve disease)
Morphology and severity of valve lesions
Mitral inflow and aortic outflow properties; RV pressure gradient
Output state (low or high)

29. Echocardiography (cont.)
Systolic dysfunction:
Reduced LVEF (<45%)
Enlarged left ventricle
Thin LV wall
Eccentric LV remodeling
Mild or moderate mitral regurgitation
Pulmonary hypertension
Reduced mitral filling
Signs of increased filling pressure

30. Echocardiography (cont.)
Diastolic dysfunction:
Normal LVEF (≥45%-50%)
Normal LV size
Thick LV wall, dilated atria
Concentric LV remodeling
No or minimal mitral regurgitation
Pulmonary hypertension
Abnormal mitral filling pattern
Signs of increased filling pressure

31. Cardiac Magnetic Resonance Imaging
Dark blood imaging
Wall thickness, morphology of the myocardium, tumor masses
Bright blood imaging
Wall thickness, geometry of the ventricle
Myocardial tagging
Cardiac rotation, shear motion, torsion, myocardial twist
Phase contrast imaging
Blood flow velocity, cardiac output, pressure gradients
Contrast enhancement
Myocardial fibrosis, ischemic zone, infarct size
MR coronary angiography
Coronary anatomy, coronary plaques
Stress imaging
Wall motion abnormalities, recruitable stroke work, ischemic territory
Perfusion and diffusion imaging
Perfusion abnormalities, territory, ischemic zone
Spectroscopy
Viability, energy-rich phosphosphate

32. Indications for Coronary Angiography
Heart failure patients with angina
Patients with prior myocardial infarction or known coronary artery disease
Patients (younger than 65 yr) with unexplained heart failure
Positive exercise test in patients with cardiovascular risk factors
Heart failure patients with positive scintigraphy, stress echocardiography, or positron emission tomography results
Heart failure patients with severely dyskinetic myocardium

33. Prognosis Aetiologies Age Co-morbidities Progression Outcomes
Difficult to predict
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

34. Condition associated with a poor prognosis in HF
Advanced age
Ischaemic aetiology
Resuscitated sudden death
Poor compliance
Renal dysfunction
Diabetes
Anaemia
COPD
Depression
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

35. Management Non Pharmacological: Self care management
Symptom recognition
Weight monitoring
Diet and nutrition
Fluid intake (restriction of L/d)
Alcohol (limited g/d)
Smoking cessation
Immunization (pneumococcal and influenza)
Activity and exercise training
Sexual activity
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

36. Pharmacological Objective Prognosis Reduce mortality Morbidity
Relieve symptom and sign
Improve quality of life
Eliminate oedema
Reduce fatigue and dyspnea
Reduce need hospitalization
Prevention
Occurrence myocardial damage
Progression myocardial damage
Remodelling myocardium
Reoccurence symptom
Hospitalization
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

37. Treatment Normal Asymptomatic LV dysfunction EF <40%
Symptomatic CHF
NYHA II
ACEI
Symptomatic CHF
NYHA - III
Diuretics mild
Neurohormonal inhibitors
Digoxin?
Symptomatic CHF
NYHA - IV
Loop diuretics
Treatment of Heart Failure.
Treatment scheme according to the degree of heart failure
Patients with asymptomatic ventricular dysfunction should receive ACEI when the LVEF is significantly reduced, and clearly if it is less than 35%. In the presence of symptoms of heart failure, diuretics or neurohormonal inhibitors should be added. The use of digoxin remains controversial.
In more advanced stages, in the presence of poorly controlled symptoms, newer drugs can be tried, reserving the inotropes for patients whose symptoms are uncontrollable with other medications.
In any case, secondary prevention and assisting the patients in adapting to their limitations should remain in mind.
Inotropes
Specialized therapy
Transplant
Secondary prevention
Modification of physical activity

38. ACEI
Unless contraindicated or not tolerated, ACEI should be used in all patients with symptomatic HF and LVEF ≤ 40%.
Class I, level A
Contraindications:
- history of angioedema
- bilateral renal artery stenosis
- serum potassium > 5.0 mmol/L
- serum creatinine > 2.5 mg/dL
- severe aortic stenosis
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

39. β blocker
Unless contraindicated or not tolerated, β blocker should be used in all patients with symptomatic HF and LVEF ≤ 40%.
Class I, level A
Contraindications:
- asthma (COPD is not a contraindication)
- second or third degree AV block (without PPM)
- sick sinus syndrome (without PPM)
- sinus bradycardia
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

40. Potential adverse effect β blocker
Asymptomatic hypotension
Doesn’t require intervention
Symptomatic hypotension
Often improve with time. Consider reducing dose of other hypotensive agents (except ACEI/ARB)
Worsening HF
Increase dose of diuretic (temporary) and continue β blocker (lower dose) if possible
Excessive bradycardia
Record ECG to exclude heart block. Stop digitalis if administered. Dose of β blocker may need to be reduced or discontinued
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

41. Aldosterone antagonist
Unless contraindicated or not tolerated, low dose of aldosterone antagonist should be considered in all patients with severe symptomatic HF and LVEF ≤ 35%.
Class I, level B
Contraindications:
- serum potassium > 5.0 mmol/L
- serum creatinine > 2.5 mg/dL
- concomitant potassium sparing diuretic or supplement
- combination of ACEI and ARB
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

42. ARB
Unless contraindicated or not tolerated, ARB is recommended in patients with HF and a LVEF ≤ 40% who remain symptomatic despite optimal ACEI and β blocker.
Class I, level A
ARB is recommended as an alternative in patients intolerant of an ACEI.
Class I, level B
Contraindications:
- bilateral renal artery stenosis
- serum potassium > 5.0 mmol/L
- serum creatinine > 2.5 mg/dL
- severe aortic stenosis
- patients with ACEI and Aldosterone antagonist
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

43. ARB (cont.)
ARBs are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI intolerant.
Class I, level A
ARBs are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications.
Class IIa, level A
The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy.
Class IIb, level B
ACCF/AHA Guidelines for the diagnosis and management heart failure in adults.
Journal of the american heart association

45. Hydralazine and ISDN
In symptomatic patients with LVEF ≤ 40%, combination of H-ISDN may be used as alternative if there is intolerance to both ACEI and ARB.
Class IIa, level B
Contraindications:
- symptomatic hypotension
- lupus syndrome
- severe renal failure
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

46. Hydralazine and ISDN (cont.)
The combination of hydralazine and nitrates is recommended to improve outcomes for patients with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics.
Class I, level B
The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACE inhibitor and beta blocker for symptomatic HF and who have persistent symptoms.
Class IIa, level B
A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency.
Class IIb, level C
ACCF/AHA Guidelines for the diagnosis and management heart failure in adults.
Journal of the american heart association

47. Digoxin
In patients wih symptomatic HF and AF, digoxin may be used to slow a rapid ventricular rate.
Class I, level C
Contraindications:
- second or third degree AV block (without PPM)
- sick sinus syndrome
- pre-excitation syndrome
- digoxin intolerance
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

48. Diuretics
Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion.
Class I, level B
Consider:
- hypokalaemia / hypomagnesaemia / hyponatraemia
- hyperuricaemia / gout
- hypovolaemia / dehydration
- renal failure
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

49. Others Anticoagulants (vitamin K antagonist) Antiplatelet agents
HMG CoA reductase inhibitors (statins)
Devices and surgery
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

50. Acute Heart Failure AHF may present with one or several clinical
Rapid onset of symptoms and signs secondary to abnormal cardiac function
Can present as new onset and without previously known cardiac dysfunction or ADHF
Often life threatening and requires urgent treatment
AHF may present with one or several clinical
conditions:
Worsening or Decompensated Chronic Heart Failure
Hypertensive Heart Failure
Pulmonary Oedema
Cardiogenic Shock
Isolated Right HF
ACS and HF

51. Clinical classifications
Tissue perfusion
Dry and warm
Wet and warm
Dry and cold
Wet and cold
Pulmonary congestion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

52. Causes and precipitating factors
Ischaemic heart disease
Acute coronary syndrome
Mechanical complications of acute MI
RV infarction
Valvular
Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection
Myopathies
Postpartum cardiomyopathy
Acute myocarditis

53. Hypertension/arrhythmias Circulatory failure
Septicaemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism
Decompensation of pre-existing CHF
Volume overload
Infection
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug and alcohol abuse

54. Diagnostic of Acute Heart Failure
Based on presenting symptoms and clinical findings
History
Physical examination
ECG
Chest X-ray
Echocardiography
Laboratory (BGA, etc)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

55. Monitoring Non invasive: Invasive: Vital Sign Oxygenation Urine output
ECG
Invasive:
Arterial line (haemodynamic unstable)
Central venous lines
Pulmonary artery catheter
Coronary angiography

56. Goals of treatment Immediate (ED/ICU/ICCU) Improved symptom
Restore oxygenation and improve organ perfusion
Limit cardiac/renal damage
Minimize ICU length of stay
Intermediate (hospital)
Stabilize patient & optimize treatment strategy
Initiate appropriate pharmacology therapy
Consider device therapy
Minimize hospital length of stay
Long term and pre discharge management
Plan follow up strategy
Education
Prevention
Quality of life

57. Management Immediate symptomatic treatment
Patient distressed or in pain >> analgesia, sedation
Pulmonary congestion >> diuretic, vasodilator
Arterial oxygen saturation < 95% >> increase FiO2, consider CPAP, NIPPV, mechanical ventilation
Heart rate and rhythm disorder >> pacing, antiarrhythmics, electroversion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

58. Oxygen
As early as possible in hypoxaemic patients to achieve O2 saturation ≥ 95% (> 90% in COPD).
Class I, level C
NIV with PEEP as soon as possible in every patient with acute cardiogenic pulmonary oedema
Contraindication:
- unconscious patients
- anxiety
- immediate need ET intubation
- severe obstructive airway disease
- severe Right HF
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

59. Morphine
Morphine should be considered in the early stage of severe AHF with restlessness, dyspnoea, anxiety, chest pain.
Respiration should be monitored
Caution: hypotension, bradycardia, advanced AV block, CO2 retention
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

60. Loop diuretics
Diuretics are recommended in AHF patients with congestion and volume overload.
Class I, level B
Adverse effect:
- hypokalaemia, hyponatraemia
- hyperuricaemia
- hypovolaemia and dehydration
- neurohormonal activation
- may increase hypotension following ACEI/ARB therapy
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

61. Vasodilators
Vasodilators are recommended at an early stage for AHF without hypotension or serious obstructive valvular disease.
Class I, level B
Adverse effect:
- headache (nitrat)
- tachyphylaxis (nitrat)
- hypotension (NTG or nesiritide infusion)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

62. Inotropic agents
Inotropic agents should be considered in low output states, in the presence of hypoperfusion or congestion.
Dobutamine (class IIa, level B)
Dopamine (class IIb, level C)
Milrinone and enoximone (class IIb,level B)
Levosimendan (class IIa, level B)
Norepinephrine (class IIb, level C)
Cardiac glycoside (class IIb, level C)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

63. Thank You