Download 6. Heart failure

CHRONIC HEART FAILURE
Heart Failure
• What is Heart Failure?
Basic Definition
• Heart failure is a
medical term that
describes an
inability of the
heart to keep up
its work load of
pumping blood to
the lungs and to
the rest of the
body.
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Statistic
• It is estimated that as many as two
million Americans suffer from
congestive heart failure and that up to
29, 000 die annually from this chronic
disorder.
» Cannobio, Mary. Cardiovascular Disorders.
Missouri: C.V. Mosby Company, 1990.
Symptoms
(involving gravity/exhaustion of heart
• Swelling of the ankles, legs, and
hands
• Orthopnea, or the shortness of
breath when lying flat
• Shortness of breath during exertion
Symptoms
(involving circulation)
• Cyanosis, or a bluish color that is seen in the
lips and fingernails from a lack of oxygen
• Fatigue or weakness
• Rapid or irregular heart beat
• Changes of behavior such as restlessness,
confusion, and decreased attention span
Symptoms
(involving congestion)
•
•
•
•
•
Unexplained or unintentional weight gain
Chronic cough
Increased urination
Distended neck veins
Loss of appetite or indigestion
Congestive heart failure is a syndrome that can be caused by multiple
underlying diseases such as:
• Congenital heart disease
• Atherosclerosis
• Rheumatic fever
• Cardiomyopathy
• Valve disorders
• Ventricular failure
• Left or right-sided failure
• Hypertension
• Prolonged alcohol or drug addiction
• Previous heart attack
• Diabetes
• Chronic rapid heartbeats
Congenital Heart Disease
• CHD affects one out of
every one thousand
babies. In these babies
the marvelously intricate
combination of
chambers, valves, and
vessels making up the
heart and circulatory
systems fails to form
properly before birth.
Septal, atrial, and
ventricular defects are
the most common.
“Heart.” The World Book Encyclopedia. 1996 ed.
Rheumatic Fever
• Strep throat from the streptococcal
infection begins a disease process
where the heart valves are damaged.
This condition is called rheumatic fever
and it affects the connective tissues of
the body.
Cardiomyopathy
• Cardiomyopathy is the stretching and
enlarging of the heart cavity that
occurs making the heart weak so it
does not pump correctly
Ventricular Failure
• Ventricular failure occurs when there
are weak spots in the ventricular walls
causing a bulge, or an aneurysm.
Atherosclerosis
• Atherosclerosis is the gradual clogging
of the arteries by fatty, fibrous deposits.
A tiny lump of fibrous tissue grows as
the artery tries to repair the damage.
Cholesterol accumulates and more
tissue builds up. The arteries are
thickened and hardened making a loss
of elasticity causing congestion.
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KEY ISSUES IN CHRONIC HEART FAILURE
• Common
 1-3 % of the population, rising to 6-10 % of people
aged >65 years
 Incidence x2 in the last 10 years
 Dangerous – high mortality (>50% over 5 yrs,
50% of these deaths occur suddenly)
 Disabling – high morbidity (on average, 1 in 5
patients is readmitted within 12 months)
 Costly – 1.5-2.5% of health care budget
Contributors to Increased Incidence
- Improvements in:
- Survival post-MI
- Technologies (i.e.. Laser, stents etc.)
- Medical Treatments for ischemic heart
disease
- Overall survival
DEFINITION OF HEART FAILURE
Clinical syndrome that can result from any
structural or functional cardiac disorder
that impairs the ability of the ventricle to
fill with or eject blood
AHA / ACC HF guidelines 2001
Clinical symptoms / signs secondary to
abnormal ventricular function
ESC HF guidelines 2001
DEFINITION OF HEART FAILURE
I.
Symptoms of heart failure, typically
breathlessness or fatigue, either at rest or during
exercise, or ankle swelling
II.
Objective evidence (preferably by
echocardiography) of cardiac dysfunction (systolic
and/or diastolic) at rest
III.
Response to treatment directed towards heart
failure
Criteria I. and II. should be fulfilled in all cases
ESC HF guidelines 2005
Q’s to be answered while facing a patient
with suspected heart failure
1.
Are the patient’s symptoms cardiac in
origin?
2.
If so, what kind of cardiac disease is
producing these symptoms
HEART FAILURE should never
be the only diagnosis !
Etiology of Chronic Heart Failure
Coronary artery disease accounts for about
65%
Non-ischemic Cardiomyopathy:
Hypertension
Valvular Heart Disease
Idiopathic
Thyroid
Toxic or drug-induced
SYMPTOMS
I.
There is a poor relationship between symptoms
and the severity of cardiac dysfunction. Mild
symptoms should not be equated with minor
cardiac dysfunction
II.
Symptoms may be related to prognosis
particularly if persisting after therapy
III.
Once a diagnosis of heart failure has been
established, symptoms may be used to classify
the severity of heart failure and should be used to
monitor the effects of therapy
Electrocardiogram
•
A normal electrocardiogram (ECG) suggests
that the diagnosis of CHF should be carefully
reviewed
•
The presence of pathological Q-waves may
suggest myocardial infarction as the cause of
cardiac dysfunction.
•
A QRS width >120 ms suggests that cardiac
dyssynchrony may be present and a target for
treatment
Types of Rhythms Associated with CHF
– Left Ventricular Failure with Pulmonary
Edema
• Aka—systolic heart failure
– Right Ventricular Failure
• Aka—diastolic heart failure
The smooth, glistening pleural surface of a lung is shown here. This patient had
marked pulmonary edema, which increased the fluid in the lymphatics that run
between lung lobules. Thus, the lung lobules are outlined in white.
– Occurs when the left
ventricle fails as an
effective forward pump
– back pressure of blood
into the pulmonary
circulation
–  pulmonary edema
– Cannot eject all of the
blood delivered from the
right heart.
– Left atrial pressure rises
 increased pressure in
the pulmonary veins and
capillaries
– When pressure
becomes to high, the
fluid portion of the
blood is forced into
the alveoli.
– decreased
oxygenation capacity
of the lungs
– AMI common with
LVF, suspect
– Severe resp.
distress–
• Evidenced by
orthopnea, dyspnea
• Hx of paroxysmal
nocturnal dyspnea.
– Severe
apprehension,
agitation,
confusion—
• Resulting from
hypoxia
• Feels like he/she is
smothering
– Diaphoresis—
• Results from
sympathetic
stimulation
– Pulmonary
congestion
• Often present
• Rales—especially at
the bases.
• Rhonchi—associated
with fluid in the larger
airways indicative of
severe failure
• Wheezes—response
to airway spasm
– Jugular Venous
Distention—not directly
related to LVF.
• Comes from back
pressure building from
right heart into venous
circulation
– Vital Signs—
• Significant increase in
sympathetic discharge
to compensate.
• BP—elevated
• Pulse rate—elevated to
compensate for
decreased stroke
volume.
• Respirations—rapid and
labored
ECHOCARDIOGRAPHY
•
•
Assessment of LV systolic function (EF)
Assessment of LV diastolic function
Natriuretic peptides
•
Plasma concentrations of BNP and NT-proBNP
are helpful in the diagnosis in HF
•
A low-normal concentration in an untreated
patient makes HF unlikely as the cause of
symptoms
•
BNP and NT-proBNP have considerable
prognostic potential. Their role in treatment
monitoring remains to be determined
The value of BNP in HF diagnosis
A. Is well established in the general population
B. Is well established in persons at risk of heart
failure
C. Is well established in patients with suggestive
symptoms
D. Has an overall accuracy of 100%
E. Is based on a high negative predictive value
The value of BNP in HF diagnosis
A. Is well established in the general population
B. Is well established in persons at risk of heart
failure
C. Is well established in patients with suggestive
symptoms
D. Has an overall accuracy of 100%
E. Is based on a high negative predictive value
NYHA classification of HF
Class I No limitation: ordinary physical exercise does not
cause undue fatigue, dyspnea, or palpitations
Class II Slight limitation of physical activity: comfortable at rest
but ordinary activity results in fatigue, palpitations, or
dyspnea
Class III Marked limitation of physical activity: comfortable at
rest but less than ordinary activity results in symptoms
Class IV Unable to carry out any physical activity without
discomfort: symptoms of heart failure are present even
at rest with increased discomfort with any physical
activity
Hypertension
Diabetes, Hyperchol.
Family Hx
Cardiotoxins
A
Heart disease
(any)
B
Stages in the Evolution
of Heart Failure
Clinical Characteristics
Asymptomatic
LV dysfunction
Systolic / Diastolic
C
Dyspnea, Fatigue
Reduced exercise
tolerance
D
Marked symptoms
at rest despite
max. therapy
Treat risk factors
Avoid toxics
ACE-i in selected p.
A
ACE-i
 blockers
B
Stages in the Evolution
of Heart Failure
Treatment
In selected
patients
C
ACE-i
 blockers
Diuretics / Digitalis
D
Palliative therapy
Mech. Assist device
Heart Transplant
Goals of treatment in CHF
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
Prolong survival
•ACE inhibitors
•Beta blockers
•Spironolactone
•Angiotensin receptor blockers
•Implantable cardioverter-defibrillators
Symptom reduction and improved
activity tolerance
•Exercise training
•Diuretics
•ACE inhibitors
•Digoxin
•Beta blockers
Prevent progression (remodeling)
•ACE inhibitors
•Beta blockers
•Spironolactone
•Angiotensin receptor blockers
•Cardiac resynchronization (biventricular pacing)
Non-pharmacological management
•
Sodium and fluid restriction
•
Alcohol
•
Weight
•
Smoking
•
Rest and exercise
Dietary advice
•
2-2.5 g sodium restriction (about 5-6 g of salt)
•
Fluid restriction (in patients with refractory fluid
retention, significant hyponatremia or severely
impaired renal function
•
Low fat diet and caloric restriction when indicated
•
Abstention from alcohol or restriction to 1 drink per
day
Activity and exercise councelling
•
Encourage regular activity in all patients
•
Exercise training/cardiac rehabilitation in stable,
motivated patients
Activity and exercise councelling
Symptomatic and psychologic benefits:
•
Aerobic training results in increased exercise
capacity (peak oxygen consumption), improved
quality of life (questionnaires), reduced sympathetic
nervous system activity
•
Possible beneficial effect on prognosis
Treatment
Pharmacologic Therapy
• Diuretics
• ACE inhibitors
• Beta Blockers
• Digitalis
• Spironolactone
• Other
Approach to the patient with HF
Assess LV function
(EF < 40%)
Assess volume status
Fluid retention?
Yes
No
Diuretic
ACE inhibitor
Digoxin
Beta-blocker
Digitalis. Indications
• When no adequate response to
ACE-i + diuretics + beta-blockers
AHA / ACC Guidelines 2001
• AF, to slow AV conduction
Dose 0.125 to 0.250 mg / day
Spironolactone. Indications
• Recent or current symptoms despite
ACE-i, diuretics, dig. and -blockers
AHA / ACC HF guidelines 2001
• Recommended in advanced heart failure
(III-IV), in addition to ACE-i and diuretics
• Hypokalemia
ESC HF guidelines 2001
Angiotensin II Receptor Blockers (ARB)
• Candesartan, Eprosartan, Irbesartan
Losartan, Telmisartan, Valsartan
• Efficacy seems to be equal to ACE-I
• Indicated in patients intolerant to ACE-I
• Can be considered in combination with
ACE-I in patients who remain
symptomatic
Nitrates. Clinical Use
• CHF with myocardial ischemia
• Orthopnea and paroxysmal nocturnal dyspnea
• In acute CHF and pulmonary edema:NTG sl / iv
• Nitrates + Hydralazine in intolerance
to ACE-I (hypotension, renal insufficiency)
Positive Inotropic Therapy
•May increase mortality
Exception: Digoxin, Levosimendan
•Use only in refractory CHF
•NOT for use as chronic therapy
Drugs to Avoid (may increase symptoms, mortality)
• Inotropes, long term / intermittent
• Antiarrhythmics (except amiodarone)
• Calcium antagonists (except amlodipine)
• Non-steroidal antiinflammatory drugs (NSAIDS)
• Tricyclic antidepressants
• Corticosteroids
• Lithium
ESC HF guidelines 2001
New Drugs (ongoing research)
1. New neurohormonal modulators
• Beta-blockers
• Aldosterone receptor antagonists
• Angiotensin II receptor antagonists
• Endothelin inhibitors
• Vasopresin inhibitors
• Natriuretic Peptides
• Endopeptidase inhibitors
• Vasopeptidase inhibitors
Diastolic Heart Failure
• Treat as HF with low LVEF
• Control:
• Hypertension
• Tachycardia
• Fluid retention
• Myocardial ischemia
• Ongoing research
ICD
• Implantation of an ICD in combination with
biventricular pacing may be considered in patients
who remain symptomatic with severe heart failure
NYHA class III-IV with LVEF≤35% and QRS
duration ≥ 120 msec
• ICD therapy is recommended to improve survival
in patients after cardiac arrest or who have
sustained ventricular tachycardia
Heart Transplant. Indications
• Refractory cardiogenic shock
• Documented dependence on IV inotropic support
to maintain adequate organ perfusion
• Peak VO2 < 10 ml / kg / min
• Severe symptoms of ischemia not amenable to
revascularization
• Recurrent symptomatic ventricular arrhythmias
refractory to all therapeutic modalities
Contraindications: age, severe comorbidity
Thank you for attention!