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Transcript
9/22/2016 Introduction to Heart Failure Marshall Hyden, MD Objectives Define heart failure Prevalence of heart failure Outcomes of patients with heart failure 1 9/22/2016 Case 55 yo male who presents to clinic with shortness of breath on exertion. Symptoms have been slowly progressing over the past 1 month to where he can now walk only ½ block before stopping due to shortness of breath. Denies chest pain. Is sleeping in a recliner now due to shortness of breath with lying flat. History of coronary artery disease with stent placed to LAD 2 years ago. What is heart failure? Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body's needs for blood and oxygen. Two types of heart failure • Systolic dysfunction – Decrease in ability of the heart to contract and eject blood to the body • Diastolic dysfunction – Inability of the ventricle of the heart to relax to allow blood to enter the heart 2 9/22/2016 Why is it important? • Nearly 6 million Americans are living with heart failure • 1 in 5 will develop heart failure during their lifetime • Mortality at 5 years after diagnosis is about 50% 3 9/22/2016 Risk factors for heart failure • • • • • • Coronary artery disease Hypertension Diabetes Obesity Heart valve disease Heart muscle disease • Alcohol • Viruses • Hypertrophic cardiomyopathy • Restrictive cardiomyopathy 4 9/22/2016 How does heart failure cause symptoms? • • • Decreased cardiac output • Less blood is pumped out of the heart with each contraction in heart failure. This leads to a drop in blood pressure and perfusion to the vital organs • Symptoms of decreased cardiac output include fatigue, end-organ dysfunction such as acute kidney injury Fluid retention • The decrease in blood pressure leads to compensatory mechanisms to increase blood pressure. These include retention of sodium and water • Retention of fluid is manifested symptomatically by peripheral edema, jugular venous distention, pulmonary edema Pulmonary edema • When the heart is not able to pump efficiently, blood can back up into the veins that enter the left atrium from the lungs. As the pressure in these vessels increases fluid is pushed into the lungs. • Symptoms of pulmonary edema include shortness of breath, orthopnea and paroxysmal nocturnal dyspnea Lund et al J of Heart and Lung Transplant 2016 How is heart failure diagnosed? History and physical exam findings consistent with heart failure: • Shortness of breath on exertion • Orthopnea • Paroxysmal nocturnal dyspnea • Fatigue • Jugular venous distension • Ascites • Peripheral edema • Rales • S3 Diagnostic testing includes: • Chest x-ray • BNP • Echocardiogram 5 9/22/2016 Classification of Heart Failure A B C ACCF/AHA Stages of HF At high risk for HF but without structural heart disease or symptoms of HF. Structural heart disease but without signs or symptoms of HF. Structural heart disease with prior or current symptoms of HF. NYHA Functional Classification None I I II III IV D Refractory HF requiring specialized interventions. No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. How does the body compensate for heart failure? 1) Enlarging 2) Increase in mass 3) Increase in heart rate 4) Narrowing blood vessels 6 9/22/2016 How is systolic heart failure treated? The body’s response to heart failure to maintain blood pressure acutely improves the situation but chronically are maladaptive. Medical treatment for heart failure involves blocking hormonal responses to prevent remodeling of the heart and diuretic medications to remove excess fluid. • ACEI • Beta blockers • Aldosterone antagonists • Loop diuretics Device therapy with ICD is indicated for the prevention of sudden cardiac death in patients on guideline directed medical therapy with LVEF <35%. Biventricular pacing is indicated select patients with LVEF <35% In patients whose symptoms progress despite these therapies or are unable to tolerate these therapies and have progressive symptoms, Advanced heart failure therapies should be considered 7