Download Heart Failure

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
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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