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Transcript
HEART FAILURE František Bednář III. Interní-kardiologická klinika FNKV Heart Failure (HF) definition An abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues, despite normal filling pressures. CHRONIC HEART FAILURE diagnostic criteria 1. Symptoms of HF (dyspnoe rest/excersise, fatigue, tiredness) 2. Signs of HF (tachycardia, tachypnoe,gallop rhytm, pulmonary crepitations, perif.oedema, pleural effusion,..) 3. Failure of heart function (systolic / diastolic dysfunction) 4. Response to treatment (in the case of controversial diagnosis) HEART FAILURE epidemiology • Prevalence 1-2% • Incidence 1-3 new cases annually per 1000 inhabitants • Causes – ischemic heart disease 70% – Other myocardial diseases incl. cardiomyopathy 10-15% – Valvular heart disease 10% – Hypertension 6-10% Cardiac Output • Cardiac output is the amount of blood that the ventricle ejects per minute Cardiac Output = HR x SV Determinants of Ventricular Function Contractility Afterload Preload Stroke Volume • Synergistic LV Contraction • Wall Integrity • Valvular Competence Heart Rate Cardiac Output Left Ventricular Dysfunction Volume Overload Pressure Overload Loss of Myocardium Impaired Contractility LV Dysfunction EF < 40% ↑ End Systolic Volume ↓ Cardiac Output Hypoperfusion ↑ End Diastolic Volume Pulmonary Congestion Hemodynamic Basis for Heart Failure Symptoms LVEDP ↑ Left Atrial Pressure ↑ Pulmonary Capillary Pressure ↑ Pulmonary Congestion Chronic heart failure Compensatory Mechanisms • Frank-Starling Mechanism • Neurohormonal Activation • Ventricular Remodeling Compensatory Mechanisms I. Frank-Starling Mechanism a. At rest, no HF b. HF due to LV systolic dysfunction c. Advanced HF Compensatory Mechanisms II. Neurohormonal Activation • Sympathetic nervous system (SNS) • Renin-angiotensin-aldosterone system (RAAS) • Vasopressin ( ADH) Compensatory mechanism III. Concentric remodelation Excentric remodelation CHRONIC HEART FAILURE initial investigations • • • • • • • Patient history Physical examination Laboratory tests ECG Chest X-ray Echocardiography Coronary angiography CHRONIC HEART FAILURE clinical signs and symptoms symptoms pulmonary dyspnoe ortopnoe caugh astma cardiale cardiac systemic Chest pain palpitation weakness fatigue nykturia insomnia nausea.. CHRONIC HEART FAILURE clinical signs and symptoms Dyspnoe (breathlessness) - result of pulmonary congestion - sign of LVHF - on effort / at rest - astma cardiale: paroxysmal nocturnal dyspnoe - pulmonary oedema New York Heart Association Functional Classification Class I: No symptoms with ordinary activity Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnoe, or angina Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Class IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest CHRONIC HEART FAILURE clinical signs and symptoms signs pulmonary Pulmonary crepitations pleural effusion tachypnoe cardiac systemic Tachycardia Third heart sound (gallop rhytm) Pulsus alternans Cardiomegalia LV hypertrophy Elevated jugular venous pressure Hepatomegaly Wheight gain Periferal oedema Cyanosis Ascites CHRONIC HEART FAILURE laboratory tests • Hematological tests (Hb, HTc, leuko, platelets) • Biochemical tests (Na, K, creatinine, liver enzymes, urine analysis,..) • Thyroid test, D-dimers, Astrup… • Natriuretic peptides CHRONIC HEART FAILURE ECG • SVT, VT, LV or RV hypertrophy, ischemic changes, AV blocks,… CHRONIC HEART FAILURE chest X-ray CHRONIC HEART FAILURE echocardiography CHRONIC HEART FAILURE coronary angiography CHRONIC HEART FAILURE TREATMENT • Lifestyle modifications • Pharmacological treatment • Non-surgical device treatment • Surgical treatment CHRONIC HEART FAILURE General Treatment Measures Lifestyle modifications: • Weight reduction • Discontinue smoking • Avoid alcohol and other cardiotoxic substances • Exercise (improve physical condition) CHRONIC HEART FAILURE Pharmacologic Management Diuretics • Used to relieve fluid retention (decrease symptoms –pulmonary congestion and peripheral edema) • Improve exercise tolerance • Electrolyte depletion a frequent complication • Hydrochlorthiazid, indapamid, furosemid CHRONIC HEART FAILURE Pharmacological treatment ACE Inhibitors • Blocks the conversion of angiotensin I to angiotensin II; prevents functional deterioration • Recommended for all heart failure patients, whether they are symptomatic or not • Relieves symptoms and improves exercise tolerance • Reduces risk of death and decreases disease progression • Captopril (Capoten), enalapril (Enap), perindopril (Prestarium), ramipril (Tritace), trandolapril (Gopten)… CHRONIC HEART FAILURE Pharmacologic Management Angiotensin Receptor Blockers (ARBs) • Block AT1 receptors, which bind circulating angiotensin II • In clinical practice, ARBs should be used to treat patients who are ACE intolerant due to intractable cough or who develop angioedema • valsartan, telmisartan, candesartan, losartan CHRONIC HEART FAILURE Pharmacologic Management Beta-Blockers • Cardioprotective effects due to blockade of excessive sympathetic stimulation • In the short-term, beta blocker decreases myocardial contractility; increase in EF after 1-3 months of use • Reduce the combined risk of morbidity and mortality, or disease progression • Metoprolol SR (Betaloc ZOK), bisoprolol (Concor COR), carvedilol (Dilatrend) , nebivolol CHRONIC HEART FAILURE Pharmacologic Management Aldosterone Antagonists • Shown to reduce heart failure-related morbidity and mortality • Generally reserved for patients with NYHA Class III-IV HF • Side effects include hyperkalemia and gynecomastia. Potassium and creatinine levels should be closely monitored • spironolacton (Verospiron), eplerenon CHRONIC HEART FAILURE Pharmacologic Management Digoxin • Slightly enhances inotropy of cardiac muscle • Reduces activation of SNS and RAAS • Reduces symptoms, Increases exercise tolerance • Reduces hospitalization rates for decompensated HF • DIG Trial demonstrated that digoxin had no effect on mortality; however, digoxin did reduce the hospitalization rate for decompensated heart failure • digoxin + diuretics + ACE inhibitor + beta-blocker in patients with LV systolic dysfunction who remain symptomatic and heart failure is accompanied by rapid atrial fibrilation CHRONIC HEART FAILURE Pharmacologic Management Farmakoterapie CHSS podle stadia NYHA digoxin Při FiS je Digoxin indikován i u NYHA I-II spironolacton/eplerenon diuretika betablokátory ACE-inhibitory/AT1 blokátory NYHA I NYHA II NYHA III NYHA IV SF (tepů/min) 90 80 0 léčeno 7 pacientů z 1 ně 7,5 mg 2xden 80 75 75 70 67 64 60 Procoralan placebo 50 0 2 týdny 1 4 8 12 16 20 24 28 32 Doba (měsíce) Swedberg K, et al. Lancet 2010; 376:875-885. Results: Primary combined end-point ( mortality/hospitalization for HF) Procoralan n = 793 (14,5 % za rok) placebo n = 937 (17,7 % za rok) HR = 0,82 Kumulativní frekvence (%) 40 p<0,0001 - 18% e in s a e r Dec ality mort after dy alrea nth 3 mo 30 20 Procoralan placebo 10 0 0 6 12 18 24 30 Doba (měsíce) Swedberg K, et al. Lancet 2010; 376:875-885. Ivabradin Indication: Compensated heart failure with sinus rhythm when heart rate remaining > 70/min after maximum tolerated dose of betablockers. Dose: LD MD 2 x 2.5 mg 2 x 7.5 mg CHRONIC HEART FAILURE Non-pharmacological device treatment Cardiac resynchronization therapy – Standard pacing lead in RA and RV – Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right Atrial Lead Right Ventricular Lead Left Ventricular Lead CHRONIC HEART FAILURE Non-pharmacologic management • Left-ventricle assisst devices (LVAD) • Implantable cardioverter-defibrilator (ICD) • Surgery – coronary revascularization - aneurysmectomy • Heart transplantation