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CHRONIC CONGESTIVE HEART FAILURE American Heart Association in collaboration with Sociedad Española de Cardiologia June, 1999 Chronic Congestive Heart Failure Committee on Post Graduate Education, Council on Clinical Cardiology, American Heart Association Developed in collaboration with the Sociedad Española de Cardiologia Prepared by: Ann F. Bolger, MD José Lopez Sendón, MD The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org). Chronic Congestive Heart Failure DEFINITION “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return." E. Braunwald Chronic Congestive Heart Failure EVOLUTION OF CLINICAL STAGES NORMAL Asymptomatic LV Dysfunction No symptoms Compensated Normal exercise CHF Abnormal LV fxn No symptoms Decompensated Exercise CHF Abnormal LV fxn Symptoms Refractory Exercise CHF Abnormal LV fxn No symptoms Normal exercise Normal LV fxn Symptoms not controlled with treatment Chronic Congestive Heart Failure DETERMINANTS OF VENTRICULAR FUNCTION CONTRACTILITY PRELOAD AFTERLOAD STROKE VOLUME - Synergistic LV contraction - LV wall integrity - Valvular competence CARDIAC OUTPUT HEART RATE Chronic Congestive Heart Failure TREATMENT OBJECTIVES Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms Chronic Congestive Heart Failure TREATMENT PHARMACOLOGIC THERAPY DIURETICS INOTROPES VASODILATORS NEUROHORMONAL ANTAGONISTS OTHERS (Anticoagulants, antiarrhythmics, etc) Chronic Congestive Heart Failure DIURETICS Thiazides Inhibit active exchange of Cl-Na in the cortical diluting segment of the ascending loop of Henle Cortex K-sparing Inhibit reabsorption of Na in the distal convoluted and collecting tubule Medulla Loop of Henle Loop diuretics Inhibit exchange of Cl-Na-K in the thick segment of the ascending loop of Henle Collecting tubule Chronic Congestive Heart Failure DIURETIC EFFECTS Volume and preload Improve symptoms of congestion No direct effect on CO, but excessive preload reduction may Neurohormonal activation Levels of NA, Ang II and PRA Exception: with spironolactone Chronic Congestive Heart Failure THIAZIDES MECHANISM OF ACTION Excrete 5 - 10% of filtered Na+ Elimination of K Inhibit carbonic anhydrase: increase elimination of HCO3 Excretion of uric acid, Ca and Mg No dose - effect relationship Chronic Congestive Heart Failure LOOP DIURETICS MECHANISM OF ACTION Excrete 15 - 20% of filtered Na+ Elimination of K+, Ca+ and Mg++ Resistance of afferent arterioles - Cortical flow and GFR - Release renal PGs - NSAIDs may antagonize diuresis Chronic Congestive Heart Failure K-SPARING DIURETICS MECHANISM OF ACTION Eliminate < 5% of filtered Na+ Inhibit exchange of Na+ for K+ or H+ Spironolactone = competitive antagonist for the aldosterone receptor Amiloride and triamterene block Na+ channels controlled by aldosterone Chronic Congestive Heart Failure DIURETICS ADVERSE REACTIONS Thiazide and Loop Diuretics Changes in electrolytes: Volume Na+, K+, Ca++, Mg++ metabolic alkalosis Metabolic changes: glycemia, uremia, gout LDL-C and TG Cutaneous allergic reactions Chronic Congestive Heart Failure DIURETICS ADVERSE REACTIONS Thiazide and Loop Diuretics Idiosyncratic effects: Blood dyscrasia, cholestatic jaundice and acute pancreatitis Gastrointestinal effects Genitourinary effects: Impotence and menstrual cramps Deafness, nephrotoxicity (Loop diuretics) Chronic Congestive Heart Failure DIURETICS ADVERSE REACTIONS K-SPARING DIURETICS Changes in electrolytes: Na+, K+, acidosis Musculoskeletal: Cramps, weakness Cutaneous allergic reactions : Rash, pruritis Chronic Congestive Heart Failure American Heart Association in collaboration with Sociedad Española de Cardiologia CHRONIC CONGESTIVE HEART FAILURE The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org) Chronic Congestive Heart Failure Medical Nutrition Therapy •Energy: Moderate 1.3-1.5 x BEE Severe 1.6-1.8 x BEE •Protein (variable) 1.0-1.5 •Na+ Restriction •Fluid Restriction (inpatient) •Small Frequent Meals •Nutrient dense foods/bevs •Easy to chew foods
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