Download - Heart Failure Update
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Heart Failure
Common
Costly
Disabling
Deadly
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Heart Failure (HF)
Definition
Pathophysiology
Types of HF
When do we suspect HF ?
Investigations ?
Management of HF
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Definition of HF
A clinical syndrome following the inability of the heart to maintain
adequate Cardiac output due to a structural (or functional) defect othe heart.
Structural defect - commonlyVentricular dysfunction
Valvular malfunction
- rarelyAbnormal shunts
or pericardial disease
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Framingham -Survival after HF onset was overall poor and didn't differ signific
between patients with systolic or diastolic heart failure, 5 year mortality
reached 74% and didn't vary significantly by sex.
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Types of Heart failure
Left heart failure
Right heart failure
Congestive heart failure
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Causes of Left Heart Failure
Coronary artery disease
Hypertension
Cardiomyopathy
Valvular disease ( congenital or acquired)
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Adapted with permission from: Vasan RS, Levy D.Arch Intern Med.1996;156:1790.
Hypertension to HF
HTN
SmokingLipids
Diabetes
Obesity
DiabetesIGT
MI
LVH
Normal LVStructure
and Function
LVRemodeling
Subclinical LVDysfunction
Overt HF
Diastolic
Dysfunction
SystolicDysfunction
CHFCAD
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Causes of Right Heart Failure (RHF)
No 1 cause of RHF is Left Heart Failure
Chronic Lung diseaseCor Pulmonale
Recurrent Pulmonary embolism
Congenital Heart Disease- ASD,VSD,PDA
Primary Pulmonary H/T
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Neurohormonal activation in HF(1)
1.Sympathetic activation
Vasoconstriction (Afterload)
Sinus tachycardia (Preload)
2.Renin angiotensin system
Vasoconstriction (Afterload)
salt & water retention (Preload)
Preload - volume of blood in the LV immediately before systole
After load - resistance to blood flow in arter ies
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Neurohormonal activation in HF (2)
3. Natriuretic peptides
Atrial natriuretic peptides ( ANP)
Secreted from atria
Brain natriuretic peptides ( BNP)
Secreted from ventricles (cardiac)
diuresis, vasodilatation (by reducing angiotensin,
aldosterone, & endothelin)
Reduction of preload and afterload
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Final Common Pathway in Heart Failure
Cardiac dysfunction leads to elevated filling pressures
Right atrial pressure increases from 2-5 to > 7-20 mmHg
leads to ascites, liver congestion and peripheral oedema
Left atrial pressure increases from 5-12 to >18-40 mmHg
results in dyspnoea, pulmonary edema and pleural effusions
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Symptoms of Left heart failure
1. Shortness of breath on exertion
2. Impaired exercise tolerance
3. Paroxysmal nocturnal dyspnoea
4. Orthopnoea ( indicative of fluid overload)
5. Fatigue
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Increased respiratory rate
Cyanosis
central or peripheral
Increased heart rate regular/irregular
CardiomegalyDisplaced apex
Third heart sound, Murmur
Lung crepitations
Signs of Left heart failure
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Symptoms of Right heart failure
1. Dyspnoea
2. Peripheral oedema
3. Abdominal distension
4. GI symptoms- Nausea, vomiting, loss of appetite
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Signs of Right heart failure
1. Raised JVP
2. Parasternal heave RV enlargement
3. Murmur, third heart sound
4. Hepatomegaly with signs of liver dysfunction
5. Leg or sacral oedema
6. Ascites
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ECG
CXR
Echocardiography
BNP / NT-pro BNP
Blood tests -FBC, U &E , LFT, TFT , Glucose
Investigations of Heart Failure
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Role of Echocardiography in HF
Gold standard investigation
Confirms HF
Differentiates Systolic and diastolic function
LVEF quantifies Systolic function (N> 55 %)
Identify the cause of heart failure
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ESC Guidelines for Heart Failure
Diagnosis
Suspected Heart Failure
because of symptoms & signs
Assess presence of cardiac disease by ECG, X-ray or
BNP(where available)
Imaging by echocardiography
Test abnormal
Assess aetiology, degree, precipitating
factors & type of cardiac dysfunction
Choose therapy
Normal
Heart Failure
unlikely
Normal
Heart Failure
unlikely
Additional diagnostic tests
Where appropriate
(e.g. coronary angiography)
Test abnormal
Eur Heart Journal (2001)22, 1527-1560
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G l f H t F il Th
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Goals of Heart Failure Therapy
Relieve HF symptoms
Make patients feel better
Stabilize acute episodes of
decompensation
Decrease morbidity and mortality
Slow and/or reverse disease progression
Identify and treat reversible causes of
LV dysfunction
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Treatment of Heart failure
Non pharmacological
Pharmacological
Surgical
Device therapy
Transplant
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Non pharmacological
Avoid alcohol,smoking
Bed rest
Counseling
Diet low in salt
Exercise
Fluid restriction
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How Do We Make Heart Failure
Patients Feel Better?
Diuretics
Vasodilators Nitrates, ACEI
Positive inotropic agents
Mechanical interventions that improve hemodynamics (e.g.,CRT, LVADs)
Oxygen
How Do We Make Heart Failure Patients
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Angiotensin II(Renin-Angiotensin System [RAS])
Norepinephrine(Sympathetic Nervous System [SNS])
RAS Inhibition -Blockade
Disease Progression
How Do We Make Heart Failure Patients
Live Longer?
Triple therapy
+
Device therapy
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Improve survival & symptoms
First line therapy
Titrate to effective dosage
ARBs for patients who dont tolerate ACEIs
ACE Inhibitors in HF
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Drug Treatment of Heart Failure
Diuretic - Frusemide, metolazone, Spironolactone
Vasodilator - ACEI , AT2 blockers
Beta blocker - Carvedilol, metoprolol, bisoprolol
Anti arrythmic - Digoxin , Amiodarone
Anti coagulant - Warfarin ? aspirin
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DEVICE THERAPY
ICDLVAD Biventricular pacing
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