heart failure tutorial

7/28/2019 Heart Failure Tutorial

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Departemen Kardiologi FK USURSUP. H. Adam Malik

Medan

HEART FAILURE

Dr. Ali Nafiah Nst, SpJP


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Definition

Heart failure is defined as the inability of the

heart to pump blood forward at a sufficient

rate to meet the metabolic demands of thebody (forward failure), or the ability to do so

only if the cardiac filling pressures are

abnormally high (backward failure), or both.


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Pathophysiology


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Frank-Starling Law


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loss of fibers or contractility

reduced cardiac output

reduced renal

perfusion

increased

sympathetic

tone

arteriolar

constriction

increased

resistance

cardiac

hypertrophy

increased renin

secretion

increased

heart rate

incomplete

diastolic

filling

Na+, H2O

retention

increased capillary

hydrostatic pressure

edema

venous

congestion

increasedfilling pressure

cardiac

dilatation

arrhythmia


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PULMONARY CIRCULATION

Blood flows from the right ventricle throughthe pulmonary artery

Blood reaches the capillaries surrounding

alveoli where gas exchange occursOxygenated blood returns by pulmonary

veins to the left ventricle where it is

pumped into systemic circulation


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LV BACKWARD EFFECTS

Decreased emptying of the left ventricle

Increased volume and end-diastolicpressure in the left ventricle

Increased volume (pressure) in the left

atrium

Increased volume in pulmonary veins


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Increased volume in pulmonary capillary bed= increased hydrostatic pressure

Transudation of fluid from capillaries to alveoli

Rapid filling of alveolar spaces

Pulmonary edema

LV BACKWARD EFFECTS cont


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LV FORWARD EFFECTS

Decreased cardiac output

Decreased perfusion of tissues of body

Decreased blood flow to kidneys and glands

Increased reabsorption of sodium and water

and vasoconstriction


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Increased secretion of sodium and

water-retaining hormones

Increased extracellular fluid volume

Increased total blood volume and

increased systemic blood pressure

LV FORWARD EFFECTS cont


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RV BACKWARD EFFECTS

Decreased emptying of the right ventricle

Increased volume and end-diastolic pressure

in the right ventricle

Increased volume (pressure) in right atrium

Increased volume and pressure in the great

veins


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RV Forward Effects

Decreased volume from the RV to the

lungs

Decreased return to the left atrium and

subsequent decreased cardiac output

All the forward effects of left heart failure


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Causes o f lef t ven tr icu lar failure

Volume over load: Regurgitate valveHigh output status

Pressure over load: Systemic hypertensionOutflow obstruction

Loss of musc les : Post MI, Chronic ischemiaConnective tissue diseases

Infection, Poisons(alcohol,cobalt,Doxorubicin)

Rest r icted Fi ll ing : Pericardial diseases, Restrictivecardiomyopathy, tachyarrhythmia


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Diagnosis


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IDENTIFICATIONS OF HF PATIENTS

With a Syndrome of Decrease Exercise

Tolerance

With a Syndrome of Fluid Retention With No Symptoms or Symptoms of Another

Cardiac or Non Cardiac Disorder

(MI, Arrythmias, Pulmonary or SystemicThromboembolic Events)


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SYMPTOMS AND SIGN

Breathlessness, Ankle Swelling, Fatique

Characteristic Symptoms

Peripheral Oedema, JVP , Hepatomegaly

Signs of Congestion of Systemic Veins

S3 , Pulmonary Rales , Cardiac Murmur


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Fram ingham Criter ia

Major Criteria:

PND

JVD

Rales

Cardiomegaly

Acute Pulmonary Edema

S3 Gallop Positive hepatic Jugular reflex

venous pressure > 16 cm H2O


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Minor Criteria:

Extremitas edema

Night cough

Dyspnea on exertion Hepatomegaly

Pleural effusion

vital capacity by 1/3 of normal

Tachycardia

Weight loss 4.5 kg over 5 days management

Fram ingham Criter ia


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Precipitating Factors

Increased metabolic demand

Increased circulating volume

Condition that increased afterload

Condition that impaired contractility

Failure to take prescribe medication

Arrhytmia


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E C G

A low Predictive Value

LAH and LVH maybe Associated wit LV

Dysfunction Anterior Q-wave and LBBB a good predictors

of EF

Detecting Arrhytmias


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CHEST X-RAY

A Part of Initial Diagnosis of HF

Cardiomegaly, Pulmonary Congestion

Relationship Between Radiological Signs and

Haemodynamic Findings may Depend on the

Duration and Severity HF


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HAEMATOLOGY & BIOCHEMISTRY

A Part of Routine Diagnostic

Hb, Leucocyte, Platelets Electrolytes, Creatinine, Glucose, Hepatic Enzyme,

Urinalysis

TSH, C-RP, Uric Acid

ECHOCARDIOGRAPHY

The Preferred Methods

Helpful in Determining the etiology

Follow Up of Patients Heart Failure


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PULMONARY FUNCTIONS

A Little Value in Diagnosis Heart Failure

Usefull in Excluding Respiratory Diseases

EXERCISE TESTING

Focused on Functional, Treatment Assessment andPrognostic


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STRESS ECHOCARDIOGRAPHY

For Detecting Ischaemia

Viability Study

NUCLEAR CARDIOLOGY

Not Recommended as a Routine Use

CMR( CARDIAC MAGNETIC RESONANCE IMAGING)

Recommenmded if Other Imaging Techniques not

Provided Diagnostic Answer


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INVASIVE INVESTIGATION

Elucidating the Cause and Prognostic Informations

Coronary Angiography :

in CADs Patients

Haemodynamic Monitoring :

To Assess Diagnostic and Treatment of HF

Endomyocardial Biopsy :

in Patients with Unexplained HF


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NATRIURETIC PEPTIDES

Cardiac Function (LV Function )

Plasma Natriuretic Peptide Concentration

(Diagnostic Blood Use for HF)

Natriuretic Peptide :

Greatest Risk of CV Events

Natriuretic Peptide :

Improve Outcome in Patients with

Treatment

Identify Pts. With Asymptomatic LV

Dysfunction (MI, CAD)


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Suspected Heart Failure Because

of symptoms and signs

Assess Presence of Cardiac Disease by ECG, X-Rayor NatriureticPeptides (Where Available)

Imaging by Echocardiography (NuclearAngiography or MRI Where Available)

Assess Etiology, Degree, PrecipitatingFactors and Type of Cardiac Dysfunction

Tests Abnormal

Tests Abnormal

Choose Therapy

ALGORITHM FOR THE DIAGNOSIS OF THE HF

If NormalHeart Failure

Unlikely

Additional Diagnosis TestsWhere Appropriate (e.g.Coronary Angiography)

If NormalHeart Failure

Unlikely

(ESC, 2001)


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Aims of treatment

1. Preventiona) Prevention and/or controlling of diseases leading

to cardiac dysfunction and heart failure

b) Prevention of progression to heart failure once

cardiac dysfunction is established2. Morbidity

Maintenance or improvement in quality of life

3. Mortality

Increased duration of life

Guidelines for the diagnosis and treatment of chronic heart failure

European Heart Journal (2001) 22, 1527-1560


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Treatment opt ion s

Non-pharmacological management

General advice and measures

Exercise and exercise training

Pharmacological therapy

Angiotensin-converting enzyme (ACE) inhibitors

Diuretics

Beta-adrenoceptor antagonists

Aldosterone receptor antagonists

Angiotensin receptor antagonists

Cardiac glycosides Vasodilator agents (nitrates/hydralazine)

Positive inotropic agents

Anticoagulation

Antiarrhythmic agents

Oxygen

Devices and surgery Revascularization (catheter interventions and surgery), other forms of surgery

Pacemakers

Implantable cardioverter defibrillators (ICD)

Heart transplantation, ventricular assist devices, artificial heart

Ultrafiltration, haemodialysis

Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560


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Pharmacological therapy


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Angiotens in-Conver t ing Enzyme Inh ib i tors

Recommended as first-line therapy.

Should be uptitrated to the dosages shown to beeffective in the large, controlled trials, and nottitrated based on symptomatic improvement.

Moderate renal insufficiency and a relatively low bloodpressure (serum creatinine 250 mol.l-1 and systolicBP 90 mmHg) are not contraindications.

Absolute contraindications: bilateral renal arterystenosis and angioedema.




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Diuret ics

Essential for symptomatic treatment when

fluid overload is present and manifest.

Always be administered in combination

with ACE inhibitors if possible.




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-Blocker

Has been traditionally contraindicated in pts withCHF

Now they are the main stay in treatment on CHF

& may be the only medication that shows

substantial improvement in LV function

In addition to improved LV function multiple

studies show improved survival

Contraindication: decompensated HF,Bradicardia/ AV Block, Asma bronchiale




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Recommended in advanced HF (NYHA III-IV),

in addition to ACE inhibition and diuretics to

improve survival and morbidity

Aldosterone Receptor Antagonists - Spironolactone




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ARBs could be considered in patients who donot tolerateACE inhibitors for symptomatictreatment.

It is unclear whether ARBs are as effective asACE inhibitors for mortality reduction.

In combination with ACE inhibition, ARBs mayimprove heart failure symptoms and reducehospitalizations for worsening heart failure.

Angiotensin II Receptor Antagonists




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indicated in atrial fibrillation and any degree ofsymptomatic heart failure.

A combination of digoxin and beta-blockade

appears superior than either agent alone.

In sinus rhythm, digoxin is recommended toimprove the clinical status of patients with

persisting heart failure despite ACE inhibitor anddiuretic treatment.

Cardiac Glycosides




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No specific role for vasodilators in the treatment of HF

Used as adjunctive therapy for angina or concomitanthypertension.

In case of intolerance to ACE inhibitors ARBs are

preferred to the combination hydralazinenitrates.

HYDRALAZINE-ISOSORBIDE DINITRATE

Hydralazine (up to 300 mg) in combination with ISDN (up to 160

mg) without ACE inhibition may have some beneficial effect on

mortality, but not on hospitalization for HF. Nitrates may be used for the treatment ofconcomitant angina or

relief ofacute dyspnoea.

Vasodilator Agents In Chronic Heart Failure




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Commonly used to limit severe episodes ofHF or as a bridge to heart transplantationin end-stage HF.

Repeated or prolonged treatment with oralinotropic agents increases mortality.

Currently, insuffcient data are available to

recommend dopaminergic agents for heartfailure treatment.

Positive Inotropic Therapy




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Recommendation

1. All pts with HF and AF should be treated with

warfarin unless contraindicated.

2. Patients with LVEF 35% or less.

Anticoagulation

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left

Ventricular Systolic Dysfunction - Pharmacological Approaches 2000


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Antiplatelet Drugs

Recommendation

There is insufficient evidence concerning thepotential negative therapeutic interaction

betweenASA and ACE inhibitors.

Antiplatelet agent for pts with HF who haveunderlyingCAD.

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left

Ventricular Systolic Dysfunction - Pharmacological Approaches 2000

i h h i


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No indication for the use of antiarrhythmic agents in HF

Indications for antiarrhythmic drug therapy include AF(rarely flutter), non-sustained or sustained VT.

CLASS I ANTIARRHYTHMICS

should be avoided CLASS II ANTIARRHYTHMICS

Beta-blockers reduce sudden death in heart failure

CLASS III ANTIARRHYTHMICS

Amiodarone is the only antiarrhythmic drug withoutclinically relevant negative inotropic effects.

Antiarrhythmics




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Classification of HF

Activity Levels (NYHA Classification)

I asymptomatic at rest

symptoms with heavy exercise

II asymptomatic at restsymptoms with moderate exercise

III asymptomatic at rest

symptoms with activities of daily living

IV symptoms at rest

Exercise testing and O2 consumption


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ACC/AHA A New Approach To The Classification of HF

Stage Descriptions Examples

A Patient who is at high risk fordeveloping HF but has no

structural disorderof the heart.

Hypertension; CAD; DM;rheumatic fever; cardiomyopathy.

B Patient with a structural disorder

of the heart but who has never

developed symptoms of HF.

LV hypertrophy or fibrosis;

LV dilatation; asymptomatic VHD;

MI.

C patient with past or current

symptoms of HF associated with

underlying structural heart

disease.

Dyspnea or fatigue ec LV systolic

dysfunction; asymptomatic

patients with HF.

D Patient with end-stage disease Frequently hospitalized pts ; pts

awaiting heart transplantation etc

ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001

Stages in The Evolution of HF and Recommended Therapy by Stage


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Stage A Stage B Stage C Stage D

Pts with :

Hypertension

CAD

DM

Cardiotoxins

FHx CM

THERAPY Treat Hypertension

Stop smoking

Treat lipid disorders

Encourage regularexercise

Stop alcohol

& drug use

ACE inhibition

Pts with :

Previous MI

LV systolic

dysfunction

Asymptomatic

Valvular disease

THERAPY All measures under

stage A

ACE inhibitor

Beta-blockers


stage A

Drugs for routine use:

diuretic ACE inhibitor

Beta-blockers

digitalis


stage A,B and C

Mechanical assist

device Heart transplantation

Continuous IV

inotrphic infusions for

palliation

Pts who have

marked symptoms

at rest despite

maximal medical

therapy.

Pts with :

Struct. HD

Shortness of

breath and fatigue,

reduce exercise

tolerance

Struct.

Heart

Disease

Develop

Symp.of

HF

Refract.

Symp.of

HF at rest

Stages in The Evolution of HF and Recommended Therapy by Stage

ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001


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Chronic Heart FailureChoice ofPharmacological Therapy

LV systolic dysfunction ACE inhibitor Diuretic Beta-blockerAldosterone

Antagonist

Asymptomatic LV

dysfunctionIndicated Not indicated Post MI Not indicated

Symptomatic HF (NYHA II) Indicated Indicated ifFluid retention

Indicated Not indicated

Worsening HF (NYHA III-IV) IndicatedIndicated

comb. diuretic

IndicatedIndicated

End-stage HF (NYHA IV) Indicated Indicatedcomb. diuretic

Indicated Indicated



A

Chronic Heart Failure Choice of


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Chronic Heart Failure Choice ofPharmacological Therapy

LV systolic dysfunction

Angiotensin

II receptorantagonists

Cardiac glycosides

Vasodilator

(hydralazine/

isosorbidedinitrate)

Potassium -sparing

diuretic

Asymptomatic LV

dysfunctionNot indicated With AF Not indicated Not indicated

Symptomatic HF (NYHA II)

If ACE inhibitors

are not tolerated

and not on beta-blockade

(a) when AF

(b) when improved

from more severe

HF in sinus

rhythm

If ACE inhibitors

and angiotensin

II antagonists

are not

tolerated

If persisting

hypokalaemia

Worsening HF (NYHA III-IV)

If ACE inhibitors

are not tolerated

and not on beta-

blockade

indicated

If ACE inhibitors

and angiotensin

II antagonists

are not

tolerated

If persisting

hypokalaemia

End-stage HF (NYHA IV)If ACE inhibitors

are not tolerated

and not on beta-

blockade

indicated

If ACE inhibitorsand angiotensin

II antagonists

are not

tolerated

If persisting

hypokalaemia



B


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Intervention


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Pts with heart failure ofischaemic origin revascularization

symtomatic improvement.

A strong negative correlation of operative mortality and LVEF,

a low LVEF (


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Algorithm for Management HF

Conclusion


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Conclusion

DIAGNOSIS OF HEART FAILURE

Clinical Signs and Symptoms

Echocardiography (LVEF) The Preferred

Method

Natriuretic Peptide Helpful in The Diagnosis

Process

Additional Test Should be PerfomedWhere Diagnosis Doubt Persist

Conclusion


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Conclusion

Management of HF must be starting fromtheearlier stage (AHA/ACC stage A).

Treatment at each stage can reduce

morbidity and mortality.

Before initiatingtherapy :

Established the correct diagnose. Consider management outline.


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Thank YoU

PREVENTION

IS BETTER THANTREATMENT

NO MATTER WHAT,

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