Download Diagnosis and Management of Heart failure in general practice

Heart Failure in Primary Care
Dr Selwyn Wong
Cardiologist
Ascot and Middlemore Hospitals
Heart Failure – Definition/Diagnosis
• HF is a clinical syndrome with symptoms/clinical signs/
some abnormality of cardiac structure and/or function
• Patients presenting with suspected HF should undergo a
full clinical assessment including history and examination.
• Investigations may aid the overall clinical assessment - no
single test
Heart Failure - Evaluation
• New-onset shortness of breath on exertion, orthopnoea or
paroxysmal nocturnal shortness
• Other symptoms lower extremity oedema, decreased
exercise tolerance, unexplained confusion or fatigue in
elderly, nausea or abdominal pain (ascites or hepatic
engorgement).
• The most specific signs of heart failure are elevated
jugular venous pressure, a third heart sound and a laterally
displaced apical impulse
Heart Failure - Evaluation
• Diagnosis difficult elderly, obese or have co-morbidities,
milder symptoms (community)
• History of causative factors (HTN, MI, valvular heart
disease, AF)
• SOBOE/ankle swelling common and non-specific
• Orthopnoea/PND more marked decompensation and more
specific.
• Greater than 1 physical sign increases the likelihood of HF
Heart Failure - Evaluation
• May be few abnormal physical findings.
• Elevated jugular venous pressure and a third heart sound
most specific clinical signs.
• Lower extremity oedema is a relatively non-specific
finding, common in older people, and usually due to chronic
venous insufficiency.
• Other findings (tachycardia, irregular pulse, laterally
displaced apical impulse; pulmonary rales)
Heart Failure – Diagnosis in Primary Care
• Symptoms and signs have limited sensitivity and
specificity
• Patients are often elderly with co-morbidity (esp.
respiratory disease)
• Investigations (CXR/echocardiography) may not be readily
available.
• Over-diagnosis of HF in the community is welldocumented. (Only one-quarter to one-third of patients
whose GP suspect HF have the diagnosis confirmed on
further cardiological assessment)
Heart Failure - Investigations
Electrocardiogram (ECG)
Left axis deviation, AF, bundle branch block, LV
hypertrophy and pathological Q-waves
Chest X-ray
Pulmonary vascular redistribution, cardiomegaly
(cardiothoracic ratio >0.5), pleural effusions and interstitial
oedema
Heart Failure - Investigations
• Full blood count: HF due to, or aggravated by, anaemia
•Serum creatinine: renal dysfunction, either primary or
secondary to cardio-renal syndrome
•Serum sodium and potassium: monitoring in context of HF
management
•Serum albumin: oedema secondary to low serum albumin
in nephrotic syndrome
• Thyroid function tests: HF due to or aggravated by hypo/
hyperthyroidism
B-type Natriuretic Peptide
• BNP assists in the diagnosis of patients presenting with
symptoms of suspected heart failure
• BNP - synthesised by and released from the heart
• Elevated plasma BNP/(NT-proBNP) associated with
reduced LVEF, LV hypertrophy, elevated LV filling
pressures, and acute MI and ischemia
• Can occur in other settings
• Sensitive to other biological factors, such as age, sex,
weight, and renal function
B-type Natriuretic Peptide
• A normal BNP level makes the diagnosis of HF unlikely
(rule out test)
• A high BNP level makes the diagnosis of HF very likely
(rule in or confirm test)
• Intermediate values of BNP require careful interpretation,
in light of patients age (consider age-adjusted cut-off
values) and co-existing conditions.
Echocardiography
• Imaging of the heart for a patient with HF is a crucial part
of the evaluation.
• While use of BNP can aid in the early assessment of
patients with suspected HF, this biomarker does not
replace the need for cardiac imaging in a patient with
confirmed HF.
• Sensible use of BNP can improve selection of patients in
whom HF appears likely and who will require further
investigation, including with echocardiography.
HF and Echocardiography
Single most useful diagnostic test
•  LVEF – preserved or reduced
•  LV structure – normal or abnormal
•  Other abnormalities contributing (valve,
pericardium, RV)
•  Regional wall motion abnormalities
Heart Failure - Aetiology
• Historically = impaired LV myocardial function
• HF with preserved LV systolic function common
• Coronary disease, hypertension and dilated
cardiomyopathy cause the substantial proportion
• Heart failure is the syndrome – underlying cause
needs diagnosis
Heart Failure - Aetiology
• Coronary artery disease
• Hypertension
• Endocrine disorders, e.g. diabetes, hypo/hyperthyroidism,
acromegaly, Cushing’s syndrome, aldosteronism, phaeochromocytoma
• Valvular heart disease
• Alcohol
• Cardiomyopathies
• Familial cardiomyopathy
• Infections, such as viral myocarditis
• Congenital heart disease
• Infiltrative conditions, such sarcoidosis, amyloidosis,
haemochromatosis
• Drugs, such as cytotoxic agents
• Nutritional, such as obesity, thiamine deficiency
• Chronic arrhythmias, e.g. uncontrolled AF, or bradycardia (complete
heart block)
Heart Failure – Precipitating Factors
• poor compliance with current management regime
• anaemia
• co-existing infections, such as pneumonia
• arrhythmias, especially AF
• concomitant drugs, such as nonsteroidal anti-inflammatory drugs,
calcium channel blockers, corticosteroids and liquorice
• alcohol excess
• renal dysfunction and/or renal artery stenosis
• unrecognised myocardial infarction
• excess salt intake.
Nomenclature – Ejection Fraction
LVEDV
105 ml
LVESV
78 ml
EF = 26%
LV Systolic Dysfunction
Quantifying LV dysfunction - ejection fraction
LV dysfunction
Ejection fraction
Nil (normal)
>55%
Mild
40-50%
Moderate
30-40%
Moderate-severe
20-30%
Severe
<20%
Nomenclature - Symptoms
NYHA classification of symptoms
• Rest (class IV)
• Less-than-ordinary exertion (class III)
• Ordinary exertion (class II)
• Levels of exertion that would limit normal individuals
(class I)
Neurohormonal activation
Angiotensin II
Noradrenaline
Hypertrophy, apoptosis, ischaemia,
arrhythmia, remodelling, fibrosis
Lifestyle Management in Heart Failure
• Dietary sodium should be restricted
• Excessive fluid intake avoided
• Alcohol intake limited
Medication in Heart Failure - Diuretics
• Symptomatic relief of fluid retention
• Loop diuretics +/- thiazide
• No randomised controlled clinical trials
Medication in Heart Failure – ACE I
• Multiple RCTs
• Overall mortality reduction 25% - all NYHA
classes and ACEs
• ARBs if ACE intolerant
Captopril
Enalapril
Quinapril
Cilazapril
Lisinopril
Range
6.25-150
2.5-20
5-20
0.5-5
2.5-40
Frequency
TDS
BD
BD
OD
OD
Target
50mg tds
10mg bd
10mg bd
5mg od
20mg od
β-Adrenergic Blocking Agents in HF
LVEF % Change
15
10
5
0
-5
-10
0
6
12
18
24
Time (weeks)
Initial hemodynamic deterioration followed by reverse remodeling (decrease in EDV
and ESV) with improved ventricular function over time (increased LVEF)
Effects of Different β Blocking Agents
Pharmacological differences
Sympathetic activation
β1
receptors
β2
receptors
Bisoprolol
Metoprolol
Carvedilol
Cardiotoxicity
α1
receptors
Medication in HF – Sprinolactone/ARBs
RALES (Spirinolactone v Placebo)
• NYHA 3-4, EF < 35%
• 30% mortality reduction ,35% reduction in
hospitalisation
CHARM - Alternative, Added, Preserved
Candesartan 4mg titrated up to 32mg
• Overall 9% mortality reduction
• CV death or CHF hospitalisation significantly
reduced in Alternative and Added
Medication in HF – Vasodilators/Digoxin
Hydralazine plus nitrate therapy
• HF and reduced LVEF unable to take both
ACE inhibitor/ARB
Digoxin
• Decreased hospitalisation without mortality
benefit
• Symptomatic HF on appropriate therapy
Heart failure - Management
Assessment of LV function
LVEF ≤ 40%
Assessment of volume status
Fluid retention
No fluid retention
Diuretic (to euvolaemia)
ACE inhibitor
B-blocker
Spirinolactone/ARB
Heart Failure With Preserved Ejection Fraction
• Clinical heart failure with normal EF and
evidence of diastolic dysfunction
• 40-60% of heart failure
• Evidence usually from echo
• Increased with age, HTN, DM, obesity, IHD
Diastolic Heart Failure – Difference
• Neurohormonal treatments not effective
• Prognosis less well defined
• Morbidity in symptomatic patients may be
equivalent
• Asymptomatic LV diastolic dysfunction is
prognostically important
Specialist Referral
• Younger patients
• History suggests severe myocardial ischaemia or
significant valvular disease
• Diagnosis is uncertain
• Aetiology is uncertain
• Arrhythmias
• Sudden onset of HF
• Inadequate response to treatment
Summary
• Presentation and symptoms are varied
• Syndrome diagnosis
• BNP and echo – important roles
• Medication to attain euvolaemia, then according
to clinical trials
• Specialist referal often appropriate