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HEART FAILURE “pump failure” DEFINITION Heart failure is the inability of the heart to supply adequate blood flow and therefore oxygen delivery to the peripheral tissues and organs Cardiac output is about 5 l /min at rest Increases to upto 25 l/ min Heart failure occurs when the heart is unable to meet the demand EPIDEMIOLOGY Only cardiovascular disease with increasing incidence and prevalance due to Aging population Increased survival after MI--thrombolysis Improvement of medical and surgical treatment Important cause of morbidity and mortality 1 yr mortality –10 – 20 % NYHA class 1V -- > 50 % 4 yr mortality –50 % Debilitating disease Significant decrease in quality of life • Due to symptoms • Decrease functional capabilities • Frequent hospitalizations CLASSIFICATION OF HEART FAILURE This is based on: How rapid symptoms develop---acute HF ---chronic HF Which ventricle is involved---right side HF ---left side HF Over all cardiac output---systolic HF ---diastolic HF CLASSIFICATION ACCORDING TO ONSET OF SYMPTOMS: Acute heart failure --characterized by a rapid onset of heart failure that may occur following 1- MI 2-myocarditis 3-arrythmias 4- infection 5- PE If it is not fatal may progress to chronic heart failure Chronic heart failure This results from the heart undergoing adaptive responses to precipitating cause and this cardiac response leads to impaired function. 1- anemia 2-thyrotoxicosis 3-non compliance to medications 4- diet—high salt ETIOLOGY Myocardial infarction Coronary artery disease Valvular heart disease Idiopathic cardiomyopathy Viral or bacterial cardiomyopathy myocarditis ETIOLOGY cont. Pericarditis Arryhthmias Hypertension Thyroid disease Pregnancy Septic shock ETIOLOGY cont. Toxins—anthracyclines amphetamine cocaine Metabolic---haemachromatosis wilson,s disease pheochromocytoma SYMPTOMS cont.{ FACES} Fatigue Activity decrease Cough { specially supine,frothy red sputum Edema Shortness of breath { NYHA } SYMPTOMS NYHA classification of dyspnoe Class 1—no shortness of breath {SOB} Class 11—SOB on severe exertion Class 111—SOB on mild exertion Class 1v---SOB at rest Heart failure management issues High mortality High readmission rates Poor Rx adherance On going symptoms Reduced quality of life Dose adjustment in the elderly Heart failure therapeutic goals 1ry goal = reduce symptoms Improve quality of life Reduce hospitalization Prevent sudden death DIET approach to the pt. with heart failure D—diagnose---eteiology ---severity of LV dysfunction I –initiate---diuretics { thiazide , frusemide } ---beta blockers ---ACEI ---digoxin ---spironolactone E—educate----diet ---exercise ---life style T---titrate---optimize ACEI ---optimize beta blockers General measures Correct precipitating causes Treat ischemia Control hypertension D/C smoking Treat lipid abnormality Treat and control hypertension Low salt diet Fluid restriction Regular exercise Upright position to reduce pulmonary congestion Prophylactic anticoaggulation Avoid –ve inatropic drugs Identify triggers Acute sudden onset Chronic gradual onset ischemia anemia arrythmia thyrotoxicosis infection Non compliance P.E diet Acute valvular pathology Drugs like NSAID INVESTIGATION CBC U+E LFT Cardiac enzymes CXR ECG Echocardiogram TREATMENT Diuretics Digoxin ACE inhibitors Vasodilators Beta blockers DRUGS Diuretics ---thiazide diuretic ---frusemide {loop diuretic} ----spironolactone { K sparing} Titrate to euvolumic state Maintain ideal body wt ={ dry wt= normal JVP / trace or no pedal edema} ACEI Cornerstone in the Rx of heart failure Continue indefinitely if EF < 40 % Rx for all asymptomatic pts with EF < 35% Rx for all symptomatic pts with EF =35% Use max. tolerated dose ACEI cont.. Captopril---capoten Enalapril----renetic Lisinopril----zestril Fosinopril---staril Angiotensin receptor blockers Same action and benefits as ACEI Used in pts who cannot tolerate ACEI due to side effects Candesartan Irbesartan Losartan Valsartan Telemisartan Beta blockers Titrate to max. tolerated dose Continue indefinitely Bisoprolol Carvidelol metaprolol patient selection for successful beta blocker initiation Stable symptoms Stable background heart failure medication No hypotension No bradycardia Euvolumic status Start low and titrate slowly Patients with heart failure who should NOT be started on beta blockers Bronchospastic pulmonary disease Severe bradycardia High degree A / V block Sick sinus syndrome NYHA class 1V Pts. Who require IV therapy for HF Hospitalized pts specially for worsening HF Unstable symptoms Digoxin For persisting symptoms in systolic dysfunction For symptomatic and rate control of AF To decrease the dose in elderly and pts with renal failure Aldosterone antagonist Spironolactone Add to ACEI , diuretics , beta blockers ,+/digoxin Used in NYHA class 111 and 1V CHF EF < 35% It leads to 30 % ↓ in death from progressive HF Cardiac resynchronization therapy {CRT} ACC / AHA guidline summary– management of pts with current or prior symptoms of heart failure and a reduced left ventricular EF Diuretics and salt restrictions for fluid retention ACE I in all pts unless CI Beta blockers in all stable pts , unless CI Three beta blockers proven to reduce mortality should be used… Metaprolol Bisoprolol Carvidelol Drugs that adversely affect the pts should be avoided or withdrawn if possible… • NSAID • Most antiarrythmic drugs • Most calcium channel blockers Angiotensin 11 receptor blockers are used in pts who cannot tolerate ACEI. Two drugs which are approved are • Candesartan • larsartan An implantable cardioverter-defibrillator ICD for 2ry prevention to prolong survival in pts with h/o cardiac arrest , vent. Fib. Drugs that should be avoided or used with caution NSAID Thiozolidindione group PDE-5 inhibitors—sildenafil Antiarryhtmics