HEART FAILURE HEART FAILURE DEFINITION: A clinical syndrome DEFINITION: A clinical syndrome characterized by systemic perfusion characterized by systemic perfusion inadequate to meet the body’s metabolic inadequate to meet the body’s metabolic demands as a result of impaired cardiac demands as a result of impaired cardiac pump function pump function
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
HEART FAILUREHEART FAILURE
DEFINITION: A clinical syndrome DEFINITION: A clinical syndrome characterized by systemic perfusion characterized by systemic perfusion
inadequate to meet the body’s metabolic inadequate to meet the body’s metabolic demands as a result of impaired cardiac demands as a result of impaired cardiac
pump functionpump function
HEART FAILUREHEART FAILUREACC/AHAACC/AHA
• A COMPLEX CLINICAL SYNDROME THAT CAN RESULT FROM ANY STRUCTURAL OR FUNCTIONAL CARDIA DISORDER THAT IMPAIRS THE ABILITY OF THE VENTRICLE TO FILL OR EJECT BLOOD.
HAERT FAILUREHAERT FAILURE
• SYTOLIC HEART FAILURE ( 60% ):
REDUCED CARDIAC CONTRACTILITY AS IN CORONARY ARTERY DISEASE WITH MI OR CHRONIC ISCHEMIA, DILATED CARDIOMYOPATHY, VALVULAR HEART DISEASE, HYPERTENSIVE HEART DISEASE,TOXIN INDUCED CARDIOMYOPATHY ( DOXORUBICIN, HERCEPTIN, ALCOHOL) AND CONGENITAL HEART DISEASE.
DIASTOLIC HEART FAILUREDIASTOLIC HEART FAILURE
• IMPAIRED CARDIAC RELAXATION AND ABNORMAL VENTRICULAR FILLING
AS IN CHRONIC HT,IHD, RESTRICTIVE INFILTRATIVE AND HYPERTRPHIC CARDIOMYOPATHIES.
INADEQUATE RV FILLING FROM PERICARDIAL CONSTRICTION OR TAMPONADE
RIGHT VENTRICULAR SYSTOLIC DYSFUNCTIONRIGHT VENTRICULAR SYSTOLIC DYSFUNCTION
* CONSEQUNCE OF LV DYSFUNCTION.• OTHER CAUSES:VIZ. RV INFARCTION,
PAH,CHRONIC SEVERE TR, ARRHYTHMOGENIC RV DYSPLACIA
HIGH OUT PUT FAILUREHIGH OUT PUT FAILURE
• THYROTOXICOSIS.
• ARTRIOVENOUS FISTULAE
• PREGNANCY
• SEVERE ANEMIA
CLASSIFICATION OF HF( ACC/AHA)CLASSIFICATION OF HF( ACC/AHA)BASED ON STRUCTURAL ABNORMALITY OR BY SYMPTOMSBASED ON STRUCTURAL ABNORMALITY OR BY SYMPTOMS
Prevalence and Prevalence and magnitude of the problemmagnitude of the problem
• >5 million affected with HF in USA( 2% of population: 6-10% > 65 years age)
• 550,000 diagnosed each year
• Annual mortality 5 to 20 %
• 12.15 million office visits and 6.5 million hospital admission days.
• Total direct and indirect cost 27.9 billion US $ & Annual cost of drugs 2.9 Billion $.
NATURAL HISTORY OF HFNATURAL HISTORY OF HF
• PROGRESSIVE PUMP FAILURE AND DEATH• SCD 50%• END ORGAN FAILURE INDICATORS OF POOR PROGNOSIS: RENAL DYSFUNCTION,VALVULAR
REGURGITATION, VENTRICULAR ARRHYTHMIAS, HIGH NYHA CLASS, LOW EF, HIGH BNP AND CATECHOLAMINE LEVEL, LOW SODIUM, MARKED LV DILATATION, CACHEXIA AND COMBINED SYSTOLIC AND DIASTOLIC DYSFUNCTION.
PATHOPHYSIOLOGYPATHOPHYSIOLOGY LV DYSFUNCTION LV DYSFUNCTION * * LOW C.OLOW C.O * ELEVATED PA PRESSURES* ELEVATED PA PRESSURES * PULMONARY CONGESTION* PULMONARY CONGESTION * ACTIVATION OF NEUROHORMONAL PATHWAS TO INCREASE BLOOD * ACTIVATION OF NEUROHORMONAL PATHWAS TO INCREASE BLOOD
VOLUMEVOLUME * ENHANCED SYMPATHETIC ACTIVITY AND INREASED HR * ENHANCED SYMPATHETIC ACTIVITY AND INREASED HR
&CONTRACTILITY AND CATECHOLAMINE INDUCED &CONTRACTILITY AND CATECHOLAMINE INDUCED VASOCONSTRICTION OF VASCULAR BEDSVASOCONSTRICTION OF VASCULAR BEDS * RENIN SECRETION FROM JUXTAGLOMERULAR APPARATUS* RENIN SECRETION FROM JUXTAGLOMERULAR APPARATUS
CONSEQUENCES OF CONSEQUENCES OF COMPENSATORY MECHANISMS COMPENSATORY MECHANISMS
CATECHOLAMINES AGGRAVATE ISCHEMIA, CATECHOLAMINES AGGRAVATE ISCHEMIA, ARRHYTHMIA, INDUCE CARDIAC ARRHYTHMIA, INDUCE CARDIAC REMODELLING AND TOXIC TO MYOCYTES.REMODELLING AND TOXIC TO MYOCYTES.
• Cardiac catheterisation:Coronary angiography.• MRI in arrhythmogenic RV dysplasia, myocardial
viability assessment and infiltrative cardiomyopathy.
Echocardiography in HFEchocardiography in HF Plays major role in diagnosis of HF with preserved EF or Plays major role in diagnosis of HF with preserved EF or
Tissue Doppler imaging in assessment of diastolic Tissue Doppler imaging in assessment of diastolic dysfunction and in inter & intraventricular dyssynchrony dysfunction and in inter & intraventricular dyssynchrony
2 dimensional speckle tracking echo2 dimensional speckle tracking echo Calculation of myocardial velocities and deformation Calculation of myocardial velocities and deformation
parameters such as strain and strain rate.parameters such as strain and strain rate.
chokkanathapuram g venkitachalam, 05/10/2010
MRIMRI
• MRI and CT scan MRI accurate in assessment of LV and RV volumes,
Diagnosis of heart failure.Diagnosis of heart failure.BNP level correlates well with NYHA BNP level correlates well with NYHA
symptomatic class.symptomatic class.Useful in assessing response to therapyUseful in assessing response to therapyHelpful in discharge timing.Helpful in discharge timing.Useful in prognostication. Useful in prognostication.
HEART FAILURE HEART FAILURE MANAGEMENTMANAGEMENTIdentification of precipitatingIdentification of precipitating factorsfactors
ACC/AHA stage ACC/AHA stage
CLASSIFICATION OF HF( ACC/AHA)CLASSIFICATION OF HF( ACC/AHA)BASED ON STRUCTURAL ABNORMALITY OR BY SYMPTOMSBASED ON STRUCTURAL ABNORMALITY OR BY SYMPTOMS
Management of HFManagement of HF
Modification of Life style-Cardiac Rehabilitation• 2 g sodium diet.• Weight monitoring daily• 2-L fluid restriction• Avoid cardiotoxic agents including alcohol and
ACEIACEI Essential unless contraindicated.Essential unless contraindicated. Use regardless of EF esp. in DM &HT.Use regardless of EF esp. in DM &HT. Vasodilatation and neurohormonal modulation Vasodilatation and neurohormonal modulation
improves mortality, symptoms, effort tolerance, improves mortality, symptoms, effort tolerance, LVEF & visits to hospital.LVEF & visits to hospital.
Use maximum tolerated dose.Use maximum tolerated dose. 20 % intolerant.20 % intolerant. Problem: Angioedema and worsening of renal Problem: Angioedema and worsening of renal
function. function.
ARB AND RENIN INHIBITORARB AND RENIN INHIBITOR ARB no superior to ACEI in improving mortality.ARB no superior to ACEI in improving mortality. Improve morbidity when added to ACEIImprove morbidity when added to ACEI Recommended for those intolerant to ACEI.Recommended for those intolerant to ACEI. May have morbidity benefits in diastolic HF.May have morbidity benefits in diastolic HF. Addition of Renin inhibitor Alliskerin to standard Addition of Renin inhibitor Alliskerin to standard
therapy results in lower BNP levelstherapy results in lower BNP levels
Beta Blockers in HFBeta Blockers in HF Carvedilol,Metoprolol succinate and Bisoprolol Carvedilol,Metoprolol succinate and Bisoprolol
shown to improve survival.shown to improve survival. Nebivolol has some advantages over carvedilolNebivolol has some advantages over carvedilol (highly Beta 1 selective& enhances NO (highly Beta 1 selective& enhances NO
bioavailability)bioavailability) ? Benefit due to Antiarrhythmic, anti-ischemic, ? Benefit due to Antiarrhythmic, anti-ischemic,
antiremodelling and antiapototic properties and antiremodelling and antiapototic properties and reduced HR and MV O2.reduced HR and MV O2.
DM, COPD, PVD, euvolumic Class IV not DM, COPD, PVD, euvolumic Class IV not contraindicationscontraindications
Combine with ACEI Combine with ACEI
Digoxin in HFDigoxin in HF
• Neurohormonal modulating agent inhibiting enzyme Na+, K+-ATP ase and improves contractility, reduces CNS sympathetic outflow and inhibits renin release in Kidney.
Reduces rate of hospitalization for HF but not mortality
Esp. useful in AF with HF( Class I , level C)NSR, HF ,EF< 40 % ( Class II A, Level B) • Dose to maintain serum level < 1 ng/ml.
increased intracellular cGMP> vasodilatation.• Hydralazine prevents nitrate tachyphylaxis.Inferior to ACEI in improving survival
but better in improving hemodynamic.
Useful when ACEI/ARB cannot be used (Hyperkalemia or renal failure) . May be
added to ACEI if PAH is present.
Aldosterone antagonistsAldosterone antagonists
• 30 % reduction in mortality and hospitalizations when spironolactone is added to standard therapy for patients with advanced HF(NEJM 341:1999;709-717)
• 15 % reduction in risk in HF with EF<40 %
after MI when treated with eplerenone, a selective aldosterone blocker (EPHESUS study NEJM 348:2003;1309-1321)
Aldosterone blockersAldosterone blockers
• Use in moderate to severe HF and reduced LVEF.
• Prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.
• Avoid if S.Creatinine > 2.5 mg/dl.
• No gynecomastia or menstrual irregularity with eplerenone
IVABRADINEIVABRADINE
• Acts on If ion current and reduces sinus rate : Beneficial in angina 36 % reduction in fatal and non fatal MI ( BEAUTIFUL study ).
Chronic heart failure• In the SHIFT study, ivabradine significantly reduced the risk of the primary
composite endpoint of hospitalization for worsening heart failure or cardiovascular death by 18% (P<0.0001) compared with placebo on top of optimal therapy. These benefits were observed after 3 months of treatment. SHIFT also showed that administration of ivabradine to heart failure patients significantly reduced the risk of death from heart failure by 26% (P=0.014) and hospitalization for heart failure by 26% (P<0.0001). The improvements in outcomes were observed throughout all prespecified subgroups: female and male, with or without beta-blockers at randomization, patients below and over 65 years of age, with heart failure of ischemic or non-ischemic etiology, NYHA class II or class III, IV, with or without diabetes, and with or without hypertension.[8]
I.V ionotropes and vasodilators.I.V ionotropes and vasodilators.
• Dobutamine : Cardiac B1 receptor stimulation to improve contractility in acute hypotensive HF. Long term use only in those with ICD awaiting transplant.
Useful in acute decompensated heart failure• Milrinone: Phosphodiesterase inhibitor: vasodilator: May
improve PAH: useful in those on B-blocker> proarrhythmic.
• NTG Anti ischemic vasodilator.• Nitroprusside : Vasodilator; may provoke ischemia by
steal: Thyocynate accumulation in renal failure.
NesiritideNesiritide
• Nesiritide ( recombinant synthetic BNP) : vasodilation in arteries and veins: promotes diuresis, lowers PAW pressure: useful in “up-front” care of decompensated HF.
No increase in HR or MVO2. No tolerance and not proarrhythmic
No mortality benefit
LEVOSIMENDANLEVOSIMENDAN
• Calcium sensitizer.
• Increases contractility without rise in intracellular Ca.
• Binds to troponin-c of myocytes
• Vasodilatory effect by opening ATP sensitive K channels in vascular SMC
• Decreases preload and after load
LEVOSIMENDANLEVOSIMENDAN
• Total 3500 patients in trials
• Initial BNP reduction
• No reduction in mortality at 6 monthsSuperior to Dopamine in acutely
decompensated HF on B blockerReduces troponin leak after cardiac
surgery when used perioperatively
AQUARETICSAQUARETICSUp regulated Arginine Vasopressin Up regulated Arginine Vasopressin
stimulation represents a maladaptive stimulation represents a maladaptive neurohormonal response in HF.neurohormonal response in HF.
AVP increases blood volume by water AVP increases blood volume by water retention via V2 receptors in collecting retention via V2 receptors in collecting ducts.ducts.
tolerance and symptoms on 6 minute walk test in tolerance and symptoms on 6 minute walk test in Idiopathic PAH and PAH secondary to CHD.Idiopathic PAH and PAH secondary to CHD.
Endothelin receptor blockers Bosentan ( non –Endothelin receptor blockers Bosentan ( non –selective ) and Sitaxentan ( selective ET- A) selective ) and Sitaxentan ( selective ET- A) receptor blocker may be combined with sildenafil receptor blocker may be combined with sildenafil to reduce PA pressure in idiopathic PAH and to reduce PA pressure in idiopathic PAH and shunt dependent PAH with high PVR. shunt dependent PAH with high PVR.
No proven benefit in LV dysfunction.No proven benefit in LV dysfunction.
HF WITH AF/SVTHF WITH AF/SVT
• 10-30 % of HF.
• Decreased atrial support
• Reduced filling time
• Decresed contraction and relaxation
• EmbolismTachycardiomyopathy
• Rate control
Other medical therapiesOther medical therapies
• Aspirin,statin to lower LDL < 70 mg/dL, Amlodipine, warfarin in AF, Thrombii, LV aneurysm, sleep apnoea and anemia management, Thyroid disease management.
Hepatitis C viral infection can cause cardiomyopathy/myocarditis and respond to prednisolone + azathioprine/?Interferon
HIV associated DCM difficult to treat.Zidovudine may induce cardiomyopathy
• ALL HF PATIENTS SHOULD RECEIVE AN ACEI/ARB AND A BETA BLOCKER
• DIURETICS REQUIRED IN MOST PATIENTS TO MANAGE FLUID RETENTION
• DIGOXIN RESERVED FOR THOSE WITH SIGNS AND SYMPTOMS OF HF/ AF
• ALDOSTERONE ANTAGONIST USED FOR CLASS III OR IV HF OR HF POST MI
• ARB OR HYDRALAZINE+NITRATE MAY BE ADDED FOR ADDITIONAL BENIFIT
o We have been able to add some Life to We have been able to add some Life to YearsYears
However, it is doubtful whether we have However, it is doubtful whether we have been successful in adding Years to Life.been successful in adding Years to Life.
DIASTOLIC DYSFUNCTIONDIASTOLIC DYSFUNCTION(Heart failure with preserved LV function)(Heart failure with preserved LV function)
• Cardiac catheterisation:Coronary angiography.• MRI in arrhythmogenic RV dysplasia,myocardial
viability assesment and infiltrative cardiomyopathy.
Echocardiography in HFEchocardiography in HF
• Plays major role in diagnosis of HF with preserved EF or mild LV systolic dysfunction
( LVEF 45-50 %)
• Tissue Doppler imaging in assessment of diastolic dysfunction and in inter & intraventricular dyssynchrony
• 2 dimensional speckle tracking echo Calculation of myocardial velocities and deformation
parameters such as strain and strain rate.
chokkanathapuram g venkitachalam, 05/10/2010
MRI and CT scanMRI and CT scan
• MRI accurate in assesment of LV and RV volumes, global function, regional wall motion, myocardial thickness, thickening , mass, tumours, valves, pericardial disease CHD, ARVD, inflitrative myopathy And myocardial viability.
• MSCT,CT coronary angiogarphy.
Aldosterone blockersAldosterone blockers
• Use in moderate to severe HF and reduced LVEF.
• Prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.
• Avoid if S.Creatinie > 2.5 mg/dl.
• No gynecomastia with eplerenone
Investigations in HFInvestigations in HF
• Metabolic ( Cardiopulmonary ) exercise testing. – Peak VO2 > 25 ml/Kg./ Min normal for middle aged adults. < 14 ml/Kg./Min indicates severe cardiac limitation and poor prognosis.
BNP in HFBNP in HF
• BNP- 32 amino acid polypeptide secreted by ventricles in response to excess stretching of myocytes
• NT ProBNP 76 amino acid polypeptide co secreted and inactive- longer half life
• BNP binds to and activates ANP receptors
- short half life
Biologic actions of BNPBiologic actions of BNP
• Decreases SVR
• Decreases CVP
• Increases natriuresis
• Decreases blood volumePlasma conc. of both BNP and NT-
ProBNP elevated in asymptomatic and symptomatic heart failure
BNP in HFBNP in HF• BNP > 100 pg/ml
Sensitivity 90%; Specificity 76 %• BNP > 50 pg/ml
Sensitivity > 97 %: Specificity 62 %
Grey area 100-500 pg/mlBNP elevated in LVH,Tachycardia, RV overload,
Myocardial ischemia, hypoxemia, renal dysfunction, advanced age, cirrhosis,sepsis and infection.
Decreased in obesity
BNP in HFBNP in HF
• Diagnosis of heart failure.
• BNP level correlates well with NYHA symptomatic class.
• Useful in assessing response to therapy
• Helpful in discharge timing.
• Useful in prognostication.
Other medical therapiesOther medical therapies
• Aspirin,statin to lower LDL < 70 mg/dL, Amlodipine, warfarin in AF, Thrombii, LV anerysm, sleep apnoea and anemia mangement, Thyroid disease management.
AQUAPHERESISAQUAPHERESIS
• Ultrafiltration to remove excess fluid without sodium through a filter.
• Upto 500 ml fluid removed/ hour
• Reduces hospitalizations
• Avoids problems with over diuresis
• No large scale studies
PHOSPHODIESTERASE INHIBITORS AND PHOSPHODIESTERASE INHIBITORS AND ENDOTHELIN RECEPTOR BLOCKERS.ENDOTHELIN RECEPTOR BLOCKERS.
• Sildenafil ( PDE 5 inhibitor), improves effort tolerance and symptoms on 6 minute walk test in Idiopathic PAH and PAH secondary to CHD.
• Endothelin receptor blockers Bosentan ( non –selective ) and Sitaxentan ( selective ET- A) receptor blocker may be combined with sildenaphil to reduce PA pressure in idiopathic PAH and shunt dependent PAH with high PVR.
Definition of heart failureDefinition of heart failureESC GuidelinesESC Guidelines
Heart failure is a clinical syndrome in which patients have the following features:• † Symptoms typical of heart failure (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling) and• † Signs typical of heart failure (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly) and• † Objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration)