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HEART FAILURE AND BREATHLESSNESS IN END STAGE CARE Dr K Ranjadayalan, Consultant Cardiologist BMI The London Independent Hospital Newham University Hospital A Breathless patient 57 yr old Male P/C Effort Dyspnoea for 6 weeks Bilateral leg swelling v P/H H/T for 4 years S/H - Non smoker, moderate alcohol intake A Breathless Patient O/E No “JACC”, bilateral pitting oedema CVS o o o o Pulse-110/min, BP I 145/96, Raised JVP Normal heart sounds Increased respiratory rate Scattered wheeze RHC tenderness with hepatomegaly v Investigations ? In the community Cause of breathlessness – o ? Cardiac (Heart Failure) o ? Respiratory Most likely Cause of his breathlessness is: 1. 2. 3. 4. 5. Left Heart failure Late onset bronchial asthma Chest infection Right Heart failure v Congestive Heart failure **Please vote on the tablets provided Heart Failure Definition Different types of HF Pathophysiology of HF Causes of HF When to suspect HF Investigations & management of HF v Natural History of Heart Failure Mechanism of Death Sudden Death 40% 100% Worsened HF Other Survival Progression v Annual Mortality 0% < 5% 10% Asymptomatic Mild 20 - 30 % Moderate 30 - 80% Severe Left Ventricular Dysfunction and Symptoms 40% 20% Definition of HF A clinical syndrome due to failure of the heart to maintain adequate cardiac output (blood flow) due to a structural or functional defect of the heart. Structural defect - Common o Ventricular Dysfunction or Valve malfunction v Structural defect - Uncommon o Abnormal shunts or Pericardial disease What happens when the Cardiac output drops? Body Activation of Neurohormonal system Diversion of blood flow to brain Heart Increase in intracardiacv pressures Dilatation or hypertrophy of ventricles Dilatation of atria Fibrosis, Hypertrophy & apoptosis Neurohormonal activation in HF 1. Sympathetic activation Vasoconstriction (Afterload) Sinus tachycardia (Preload) 2. Renin Angiotensin Aldosterone system Vasoconstriction (Afterload) v salt & water retention (Preload) Preload - volume of blood in the LV immediately before systole Afterload - resistance to blood flow in arteries Why ? Cardiac Output = Stroke Volume (SV) X Heart Rate (HR) Blood Pressure = Cardiac Output X Peripheral Resistance (PR) SV - Increase in fluid retention, Sympathetic activation HR - Sympathetic activationv PR – Vasoconstriction - Angiotensin 11 & sympathetic activation Neurohormonal activation in HF 3. Natriuretic peptides Atrial natriuretic peptides ( ANP) Secreted from atria Brain natriuretic peptides ( BNP) v (cardiac) Secreted from ventricles Diuresis, vasodilatation (by reducing angiotensin, aldosterone, & endothelin) Types of Heart failure *Left heart failure – Acute or Chronic Right heart failure – Acute or Chronic Congestive heart failure – Chronic v * Functionally - Systolic or Diastolic Causes of Left Heart Failure (Acute or Chronic) 1.. Coronary artery disease 2. Hypertension 3. Valvular disease (congenital or acquired) v 4. Cardiomyopathy – HCM, DCM, RCM, AF induced CM Hypertension to HF Obesity Diabetes IGT LVH Diastolic Dysfunction HTN CHF CAD Smoking Lipids Diabetes MI Systolic Dysfunction v Overt HF Normal LV Structure and Function LV Remodeling Subclinical LV Dysfunction Adapted with permission from: Vasan RS, Levy D. Arch Intern Med. 1996;156:1790. Causes of Dilated Cardiomyopathy 1. 2. 3. 4. 5. 6. 7. 8. Alcohol, cocaine Connective tissue diseases Drugs - Herceptin, Antidepressant Endocrine causes – Thyroid, acromegaly, diabetes Familial – 10 to 20% v Infiltration – Sarcoid, Fe deposits Infection – viral Pregnancy Causes of Right Heart Failure (Chronic) 1. Left Heart Failure - CCF 2. Chronic Lung disease – Cor Pulmonale 3. Recurrent Pulmonary embolism v 4. Congenital Heart Disease 5. Idiopathic Pulmonary H/T When to suspect HF ? v Left heart failure • Breathlessness on exertion • Fatigue • Paroxysmal nocturnal dyspnoea -2am v Orthopnoea (indicative of fluid overload) Cough & wheezing (Cardiac) Signs of Left heart failure (1) Increased respiratory rate Increased heart rate (Sinus or atrial fib or flutter) Sweating Cyanosis Cold extremities BP- High, low, normal v Signs of Left heart failure (2) Cardiomegaly – Displaced apex Third heart sound Mitral or Aortic murmur Crackles v Wheeze Pleural effusion – bilateral or unilateral Symptoms of Right heart failure Dyspnoea Peripheral oedema Abdominal distension v GI symptoms- Nausea, vomiting, loss of appetite Signs of Right heart failure Raised JVP Parasternal heave – RV enlargement Murmur, third heart sound Hepatomegaly with signs ofv liver dysfunction Leg or sacral oedema Ascites Basal crackles – specific for fluid overload-High PCWP Clear lung fields tell you veryv little about the fluid status in heart failure Examination of the neck veins is the best physical exam technique for determining the fluid status in heart failure Investigations of Heart Failure (Chronic) ECG Brain Natriuretic Peptides –BNP or NTpro BNP CXR Echocardiography Blood tests v Angiography – Non invasive or invasive Cardiac MRI – Ischaemic or Nonischaemic Myocardial biopsy ESC Guidelines for Heart Failure Diagnosis Suspected Heart Failure because of symptoms & signs Assess presence of cardiac disease by ECG, X-ray or BNP (where available) Normal Heart Failure unlikely Test abnormal Imaging by echocardiographyv Normal Heart Failure unlikely Test abnormal Assess aetiology, degree, precipitating factors & type of cardiac dysfunction Additional diagnostic tests Where appropriate (e.g. coronary angiography) Choose therapy Eur Heart Journal (2001)22, 1527-1560 Breathless patient 1 v Breathless patient 2 v Role of Echocardiography in HF Gold standard investigation Differentiates Systolic and diastolic dysfunction Quantifies Systolic dysfunction - LVEF v Quantifies Diastolic dysfunction – Grade 1 to 4 Identifies the cause of heart failure Treatment of Heart failure (Chronic) Non pharmacological Pharmacological Surgical v Device therapy Transplant Non pharmacological Avoid alcohol, smoking & stress Bed rest during acute exacerbations Counseling Diet low in salt Exercise Fluid restriction v How Do We Make Heart Failure Patients (LVSD) Live Longer? Angiotensin II (Renin-Angiotensin Aldosterone System [RAAS] Norepinephrine (Sympathetic Nervous System [SNS]) -Blockade RAAS Inhibition v Disease Progression Devices How do we make Heart Failure patients Feel Better & Live longer? Diuretics – Furosemide, metolazone RASS Inhibition – ACEI or ARBs, Anti Aldosterone v Beta blockers – Bisoprolol, Carvedilol, Metoprolol, Nebivolol Beta blocker in HF • Indicated for symptomatic & asymptomatic LVSD • Start low and go slow v • Aim for heart rate 55 to 60/min • Benefit more in sinus rhythm than in AF patients Benefits of Beta blocker in HF • Reduce SCD and total death • Improve LV size and Function v • Reduce onset of AF and VT • Meta analysis of 19,000 patients Spironolactone in HF • Aldosterone antagonist spironolactone at low dose (12.5 mg to 25 mg once daily) should be considered for NYHA Class 11 or IV Heart failure • Serum potassium concentration should be monitored after the first week and at regular intervals thereafter and after any change in dose of spironolactone v • For spironolactone intolerant patients or young males consider Eplerenone • Avoid in significant renal dysfunction Digoxin in HF • No prognostic benefit • Cardiac tonic – reduce symptoms and admissions v • Can be used for rate control of AF if rhythm control not possible Device therapy in HF 1. ICD v 2. Biventricular pacing- CRT Why ICD ? Sudden cardiac arrest is 6 to 9 times more likely in HF than in the general population Sudden death is caused most commonly by VT or VF in patients with LV dysfunction v 90% of patients do not survive their first cardiac arrest Indications for ICD Impaired LV with sustained or non sustained VT Resuscitated VF/VT arrests not due to reversible cause v Patients with Previous MI , LVEF<35%,QRS >120 3. LVAD v 4.Heart transplant Summary Heart failure is common and the prevalence is increasing The main cause of systolic HF is CAD & Diastolic HF- H/T The burden of HF is the disabling symptoms, activity limitation, arrhythmias, frequent hospitalisations and high mortality Pharmacological treatment and device therapy have been shown to improve the outcome v in systolic but not diastolic HF Patients with advanced Heart failure and their families should be offered supportive care