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HEART FAILURE.

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Presentation on theme: "HEART FAILURE."— Presentation transcript:

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

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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

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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


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