Download Heart failure

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