heart failure 2009

8/12/2019 Heart Failure 2009

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Heart FailureHeart Failure

Dr. Ira Andaningsih SpJPDr. Ira Andaningsih SpJP

20102010


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Definition:Definition:

A state in which the heart cannot provideA state in which the heart cannot providesufficient cardiac output to satisfy thesufficient cardiac output to satisfy themetabolic needs of the bodymetabolic needs of the body

Commonly termed Congestive Heart FailureCommonly termed Congestive Heart FailureCHF! sin"e symptoms o# in"rease venousCHF! sin"e symptoms o# in"rease venous

pressure are o#ten prominentpressure are o#ten prominent


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Definition of Heart Failure

HF is a complex clinical syndrome that can

result from any structural or functionalcardiac disorder that impairs the ability of

the ventricle to fill with or eject blood.


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Heart Failure vs. Congestive Heart Failure

ecause not all patients have volume overload at

the time of initial or subse!uent evaluation" theterm heart failure is preferred over the older

term congestive heart failure.


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EtiologyEtiology

End point for many diseases ofEnd point for many diseases of

cardiovascular systemcardiovascular system

Caused $y %Caused $y % &'olume and Pressure (ver&'olume and Pressure (verloadload

&)estri"ted #illing&)estri"ted #illing

&&*yo"yte loss*yo"yte loss


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Left ventricular failureLeft ventricular failure

Volume over loadVolume over load%% )egurgitate valve)egurgitate valve

High output statusHigh output status

Pressure overload:Pressure overload: Systemi" hypertensionSystemi" hypertension

(ut#lo+ o$stru"tion(ut#lo+ o$stru"tion

Loss of muscles:Loss of muscles: Post *I, Chroni" is"hemiaPost *I, Chroni" is"hemia Conne"tive tissue diseasesConne"tive tissue diseases

In#e"tion, PoisonsIn#e"tion, Poisonsal"ohol,"o$alt,Do-oru$i"in!al"ohol,"o$alt,Do-oru$i"in!

Restricted Filling:Restricted Filling: Peri"ardial diseases, )estri"tivePeri"ardial diseases, )estri"tive

"ardiomyopathy, ta"hyarrhythmia"ardiomyopathy, ta"hyarrhythmia


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EtiologyEtiology

VALVULAR HEART DISEASE :10%VALVULAR HEART DISEASE :10%

CADCAD

ARRHYTMIAARRHYTMIA

HYPERTENSIONHYPERTENSION

CARDIOMYOPATHYCARDIOMYOPATHY

DRUGS ( beta-blo!e"#$ al&' ata)o#t#$ at-a""*+t*'#$DRUGS ( beta-blo!e"#$ al&' ata)o#t#$ at-a""*+t*'#$+toto,#+toto,#

TO.INS (alo*ol$ oae$ 'e"&"+$ obalt$ a"#eTO.INS (alo*ol$ oae$ 'e"&"+$ obalt$ a"#e

ENDOCRINE (DM$ T*+"o/$ C*)# #+/"o'e$ a/"eal #&e+$ENDOCRINE (DM$ T*+"o/$ C*)# #+/"o'e$ a/"eal #&e+$e,e##2e )"o3t* *o"'oe$ 4*aeo*"o'o+to'ae,e##2e )"o3t* *o"'oe$ 4*aeo*"o'o+to'a

NUTRISIONAL (/eee# t*a'e$ #ele&'$ a"te$ obe#t+$NUTRISIONAL (/eee# t*a'e$ #ele&'$ a"te$ obe#t+$a*e,aa*e,a

CONNECTIVE TISSUE DISEASE ( #a"o/o##$ a'+lo/o##$CONNECTIVE TISSUE DISEASE ( #a"o/o##$ a'+lo/o##$*ae'o*"o'ato##$ L5le"# eo#o4*la*ae'o*"o'ato##$ L5le"# eo#o4*la

IN6ECTION (C*a)a#7/#ea#e$ HIVIN6ECTION (C*a)a#7/#ea#e$ HIV


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High-output failureHigh-output failure

Cardia" output is normal or in"reasedCardia" output is normal or in"reased

Can o""ur +ith a normal heart, $ut even earlier i# thereCan o""ur +ith a normal heart, $ut even earlier i# thereis heart diseaseis heart disease

Causes %Causes % AnemiaAnemia Pregnan"yPregnan"y HyperthyroidismHyperthyroidism

Pagets disease o# $onePagets disease o# $one A' mal#ormationsA' mal#ormations /eri $eri/eri $eri


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PathophysiologyPathophysiology

Hemodynami" "hangesHemodynami" "hanges

eurohormonal "hangeseurohormonal "hanges

Cellular "hangesCellular "hanges


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Hemodynamic changesHemodynamic changes

systolic dysfunction orsystolic dysfunction or diastolic dysfunctiondiastolic dysfunction


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Left-sided heart failureLeft-sided heart failure

Systoli" dys#un"tionSystoli" dys#un"tion& Impaired "ontra"tilityImpaired "ontra"tility

1. *yo"ardial in#ar"tion1. *yo"ardial in#ar"tion

2. ransient myo"ardial is"hemia2. ransient myo"ardial is"hemia

. Chroni" volume overload *),A) !. Chroni" volume overload *),A) !3. Dilated "ardiomyopathies3. Dilated "ardiomyopathies

& In"rease a#terload Pressure a#terload !In"rease a#terload Pressure a#terload !

1. Aorti" stenosis1. Aorti" stenosis2. 4n"ontrolled hypertension2. 4n"ontrolled hypertension


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Left-sided heart failureLeft-sided heart failure

Diastoli" dys#un"tionDiastoli" dys#un"tion& Impaired ventri"ular rela-ationImpaired ventri"ular rela-ation

1. 5e#t ventri"ular hyperthrophi1. 5e#t ventri"ular hyperthrophi

2. Hyperthrophi" "ardiomyopathy2. Hyperthrophi" "ardiomyopathy

. )estri"tive "ardiomyopathy. )estri"tive "ardiomyopathy3. ransient myo"ardial is"hemia3. ransient myo"ardial is"hemia

& ($stru"tion o# le#t ventri"ular #illing($stru"tion o# le#t ventri"ular #illing

1. *itral stenosis1. *itral stenosis2. Peri"ardial "onstri"tion or tamponade2. Peri"ardial "onstri"tion or tamponade


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Right-sided heart failureRight-sided heart failure&

Cardia" "ausesCardia" "auses1. 5e#t&side heart #ailure1. 5e#t&side heart #ailure

2. Pulmoni" valve stenosis2. Pulmoni" valve stenosis

. )ight ventri"ular in#ar"tion. )ight ventri"ular in#ar"tion

& Paren"hymal pulmonary diseaseParen"hymal pulmonary disease

1. Chroni" o$stru"tive pulmonary disease1. Chroni" o$stru"tive pulmonary disease

2. Interstitial lung disease2. Interstitial lung disease

. Chroni" lung in#e"tion or $ron"hie"tasis. Chroni" lung in#e"tion or $ron"hie"tasis

& Pulmonary vas"ular diseasePulmonary vas"ular disease

1. Pulmonary em$olism1. Pulmonary em$olism

2. Primary pulmonary hypertension2. Primary pulmonary hypertension


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Neurohormonal changesNeurohormonal changes

N/H changesN/H changes Favorable effectFavorable effect Unfavorable effectUnfavorable effect

Sympathetic activitySympathetic activity H) ,H) ,"ontra"tility,"ontra"tility,

vaso"onst.vaso"onst. ' return,' return,#illing#illing

Arteriolar "onstri"tionArteriolar "onstri"tion

A#ter loadA#ter load +or6load+or6load((22"onsumption"onsumption

Renin-ngiotensin !Renin-ngiotensin !

ldosteroneldosterone

Salt 7 +ater retentionSalt 7 +ater retention')') 'aso"onstri"tion'aso"onstri"tion

a#ter loada#ter load

"asopressin"asopressin Same e##e"tSame e##e"t Same e##e"tSame e##e"t

interleu#ins $%NFinterleu#ins $%NF *ay have roles in myo"yte*ay have roles in myo"ytehypertrophyhypertrophy

ApoptosisApoptosis

EndothelinEndothelin 'aso"onstri"tion'aso"onstri"tion ')') A#ter loadA#ter load


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Cellular changesCellular changes

Changes in CaChanges in Ca+2+2handling.handling.

Changes in adrenergic receptors:Changes in adrenergic receptors:

88SlightSlight inin 9911re"eptorsre"eptors 88 ::

11re"eptors desensiti;ationre"eptors desensiti;ation #ollo+ed $y do+n regulation#ollo+ed $y do+n regulation

Changes in contractile proteinsChanges in contractile proteins

Program cell death (Program cell death (poptosispoptosis&&

ncrease amount of fi!rous tissuencrease amount of fi!rous tissue


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SymptomsSymptoms

'' S()* (rthopnea* paro+ysmal nocturnal dyspneaS()* (rthopnea* paro+ysmal nocturnal dyspnea

'' Lo, cardiac output symptomsLo, cardiac output symptoms

'' bdominal symptomsbdominal symptomsAnorexianauseaAnorexianausea abdominal fullnessabdominal fullness

!t hypochondrial pain!t hypochondrial pain


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Physical SignsPhysical Signs

High diastoli" /P 7 o""asional de"rease in systoli"High diastoli" /P 7 o""asional de"rease in systoli"

/P de"apitated /P!/P de"apitated /P!

J'DJ'D

)ales)ales"#nspiratory$"#nspiratory$ Displa"ed and sustained api"al impulsesDispla"ed and sustained api"al impulses

hird heart sound


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Physical signs "cont%$Physical signs "cont%$

Fourth heart Sound .SFourth heart Sound .S//&&

&& 4sually at the end o# diastole4sually at the end o# diastole

& =-a"t me"hanism is not 6no+n& =-a"t me"hanism is not 6no+n

Could $e due to "ontra"tion o#Could $e due to "ontra"tion o#

atrium against sti## ventri"leatrium against sti## ventri"le

#ale" cold sweaty s$in


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Criteria #or Diastoli" Heart #ailureCriteria #or Diastoli" Heart #ailure

Symptoms and signs o# heart #ailure FraminghamSymptoms and signs o# heart #ailure Framingham

"riteria!"riteria!

0a1or criteria .2&0a1or criteria .2& 3aro+ysmal nocturnal3aro+ysmal nocturnal

dyspnea or orthopneadyspnea or orthopnea Nec#-vein distensionNec#-vein distension RalesRales 4ardiomegaly4ardiomegaly cute pulmonarycute pulmonary

oedemaoedema

S5 gallopS5 gallop 6ncreased 4"36ncreased 4"3 .789 cm H2(&.789 cm H2(& Hepato1ugular reflu+Hepato1ugular reflu+

0inor criteria .2 : 8 ma1or&0inor criteria .2 : 8 ma1or& n#le oedeman#le oedema Night coughNight cough ;yspnea on e+ertion;yspnea on e+ertion HepatomegalyHepatomegaly 3leural effusion3leural effusion "ital capacity < 8/5 from"ital capacity < 8/5 from

ma+imumma+imum

%achycardia .rate%achycardia .rate 82=/min&82=/min&

%ajor or minor criterion plus weight loss & '.( $g

in ( days in response to treatment


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N>H 4lasifficationN>H 4lasiffication

4lass 3atient Symptoms

Class I *ild! o limitation o# physi"al a"tivity. (rdinary physi"ala"tivity does not "ause undue #atigue, palpitation, ordyspnea shortness o# $reath!.

Class II *ild! Slight limitation o# physi"al a"tivity. Com#orta$le atrest, $ut ordinary physi"al a"tivity results in #atigue,

palpitation, or dyspnea.

Class III*oderate! *ar6ed limitation o# physi"al a"tivity. Com#orta$leat rest, $ut less than ordinary a"tivity "auses #atigue,palpitation, or dyspnea.

Class I'Severe!

4na$le to "arry out any physi"al a"tivity +ithoutdis"om#ort. Symptoms o# "ardia" insu##i"ien"y atrest. I# any physi"al a"tivity is underta6en,


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)tages of Heart Failure

At Risk for Heart Failure:

)*+,- + High ris$ for developing HF

)*+,- +symptomatic / dysfunction

Heart Failure:

)*+,- C #ast or current symptoms of HF

)*+,- D -nd0stage HF


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)tages of Heart Failure

8 Designed to emphasi1e preventability of HF

8 Designed to recogni1e the progressive

nature of / dysfunction


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&orms of 'eart &ailure&orms of 'eart &ailure

Systolic $ ;iastolic Heart FailureSystolic $ ;iastolic Heart Failure

High (utput FailureHigh (utput Failure Pregnan"y, anemia, thyroto-isis, A>' #istula, /eri$eri, Pagets diseasePregnan"y, anemia, thyroto-isis, A>' #istula, /eri$eri, Pagets disease

Lo, (utput FailureLo, (utput Failure cute Heart Failurecute Heart Failure

large *I, aorti" valve dys#un"tion&&&large *I, aorti" valve dys#un"tion&&&

4hronic Heart failure4hronic Heart failure Right vs Left sided heart failureRight vs Left sided heart failure


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Systoli" and Diastoli" HFSystoli" and Diastoli" HF

*any patients +ith heart #ailure have eviden"e*any patients +ith heart #ailure have eviden"eo# $oth.o# $oth.

S?S(5IC HF%S?S(5IC HF%

5' systoli" dys#un"tion 5'SD!%5' systoli" dys#un"tion 5'SD!% 5' e@e"tion #ra"tion 30B e"ho!5' e@e"tion #ra"tion 30B e"ho!

DIAS(5IC HFDIAS(5IC HF

Preserved systoli" 5' #un"tion HFPSF!Preserved systoli" 5' #un"tion HFPSF! normal e@e"tion #ra"tion HF=F!normal e@e"tion #ra"tion HF=F!


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)ight Heart Failure)ight Heart Failure

(ac)ward failure !*(ac)ward failure !* congestion of systemiccongestion of systemiccapillariescapillaries%% Causes%Causes%

Pulmonary em$olismsPulmonary em$olisms

Pulmonary hypertensionPulmonary hypertension)' in#ar"tion)' in#ar"tion

*itral Stenosis*itral Stenosis

4sually presents +ith%4sually presents +ith%an6le edema, as"ites, hepati" "ongesti, "ardia" "irrhosisan6le edema, as"ites, hepati" "ongesti, "ardia" "irrhosis

on the long run!on the long run!


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5e#t Heart Failure5e#t Heart Failure

&orward&orward#ailure 5'#ailure 5'"ongestion"ongestion

pulmonary vas"ulature symptomspulmonary vas"ulature symptomspredominantly respiratory !predominantly respiratory !

Su$divided % Failure o# the le#t atrium, the le#tSu$divided % Failure o# the le#t atrium, the le#t

ventri"le or $oth +ithin the le#t "ir"uit.ventri"le or $oth +ithin the le#t "ir"uit.


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Definition of +cute Heart Failure

+cute heart failure is characteri1ed by a rapid or

gradual onset of sign and symptoms of heart failure"

resulting in unplanned hospitali1ation or office or

emergency room visits.

ieminen *S, Har@ola '&P. Am J Cardiol 200Esuppl!%G&10G


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Clinical #resentation of +cute Heart Failure

+cute decompensated heart

failure 2de novo or acute

decompensation of CHF3

%ild symptoms" do not fulfil

criteria of pulmonary edema"cardiogenic shoc$" or

hypertensive crisis

Hypertensive acute heart failureHigh #" preserved / function"

pulmonary edema on chest x0 ray

#ulmonary edema4rthopnea" crac$les over the lung"

verified by chest x0ray

Cardiogenic shoc$

High output failure High C4" warm peripheries

5ight heart failureHypotension" elevated 6/#"

increased liver si1e

ieminen *S, Har@ola '&P. Am J Cardiol


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Differential diagnosisDifferential diagnosis

Peri"ardial diseasesPeri"ardial diseases

5iver diseases5iver diseasesephroti" syndromeephroti" syndrome

Protein losing enteropathyProtein losing enteropathy


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;iagnosis;iagnosis

Hystory a6ingHystory a6ing

Physi"al =-aminationPhysi"al =-amination

5a$oratory5a$oratory =CG=CG

Chest rayChest ray

="ho"ardiography="ho"ardiography


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Laboratory &indingsLaboratory &indings

/lood tests%/lood tests%

F/C, 4reum and "reatinine, 5Fs, glu"ose,F/C, 4reum and "reatinine, 5Fs, glu"ose,

#asting lipids,#asting lipids, thyroid #un"tion teststhyroid #un"tion tests, "ardia", "ardia"

en;ymes *I !, ele"trolytesen;ymes *I !, ele"trolytes

/P/P

&pro/P&pro/P
http://www.patient.co.uk/DisplayConcepts.asp?WordId=THYROID%20FUNCTION%20TESTS&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=THYROID%20FUNCTION%20TESTS&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=THYROID%20FUNCTION%20TESTS&MaxResults=50


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Laboratory &indingsLaboratory &indings

/&type atriureti" Peptide /P! and &erminal pro/&type atriureti" Peptide /P! and &erminal pro/P &pro/P!/P &pro/P!are released into the $lood +hen theare released into the $lood +hen themyo"ardium is stressedmyo"ardium is stressed

ormal "on"entrationormal "on"entration/P 100 pg>ml, &pro/P 300/P 100 pg>ml, &pro/P 300pg>ml! in an untreated patient ma6es heart #ailure an unli6ely "ause o#pg>ml! in an untreated patient ma6es heart #ailure an unli6ely "ause o#symptomssymptoms

High "on"entrationsHigh "on"entrations/P 300 pg>ml, &pro/P 2000/P 300 pg>ml, &pro/P 2000pg>ml! % "hroni" heart #ailurepg>ml! % "hroni" heart #ailure

(ne primary "are study % signi#i"ant per"entage o# asymptomati" or had(ne primary "are study % signi#i"ant per"entage o# asymptomati" or hadmild $reathlessness only #rom a high&ris6 group years +ith dia$etesmild $reathlessness only #rom a high&ris6 group years +ith dia$etes

or IHD!or IHD! =levated in other "onditions % "hroni" hypo-aemia, renal dys#un"tion,=levated in other "onditions % "hroni" hypo-aemia, renal dys#un"tion,advan"ed age, liver "irrhosis and sepsisadvan"ed age, liver "irrhosis and sepsis


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ElectrocardiogramElectrocardiogram

Sinus ta"hy"ardia or $rady"ardia, S'>AFSinus ta"hy"ardia or $rady"ardia, S'>AF

K +aves , Is"haemi" S "hangesK +aves , Is"haemi" S "hanges

/undle /ranh /lo"6/undle /ranh /lo"6

5'H5'H

L A$ =CG has little predi"tive value #or HFL A$ =CG has little predi"tive value #or HF

$ut ormal =CG ma6es 5'SD unli6ely$ut ormal =CG ma6es 5'SD unli6elynegative predi"tive value o# EMB!negative predi"tive value o# EMB!


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Chest +,rayChest +,ray

Ca"/o'e)al+Ca"/o'e)al+ (CTR 9 0%(CTR 9 0% Vet"&la" *+4e"t"o4*+Vet"&la" *+4e"t"o4*+ P&l'oa"+ 2eo o)e#to (P&l'oa"+ 2eo o)e#to (/late/ o" &44e" lobe/late/ o" &44e" lobe2e#2e#;;

4e"2a#&la" e/e'a4e"2a#&la" e/e'a

P"o'et &44e" lobe 2e# (P"o'et &44e" lobe 2e# (&44e" lobe /2e"#o&44e" lobe /2e"#o Pe"b"o*al &)Pe"b"o*al &) De te"#ttal o" al2eola" #*a/o3) - la##alDe te"#ttal o" al2eola" #*a/o3) - la##al

4e"*la" le#


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EchocardiogramEchocardiogram

The key testThe key testto assessment "ardia" #un"tionto assessment "ardia" #un"tion

Overall LV systolic functionOverall LV systolic function Diastolic function (necessary to diagnose HFPEF)Diastolic function (necessary to diagnose HFPEF) LV wall thicknessLV wall thickness Estiation of !ulonary artery systolic !ressureEstiation of !ulonary artery systolic !ressure Function of "oth ventriclesFunction of "oth ventricles #all otion a"norality that ay signify $%D#all otion a"norality that ay signify $%D Valvular a"norality and Pericardial a"noralityValvular a"norality and Pericardial a"norality &ntra'cardiac shunts&ntra'cardiac shunts


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EchocardiogramEchocardiogram

Determine%Determine%

Stro6e 'olumeStro6e 'olume

=nd Diastoli" 'olume =D'!=nd Diastoli" 'olume =D'! he S' in proportion to the =D'he S' in proportion to the =D'a valuea value

6no+n as the6no+n as the e-ection fractione-ection fraction=F!.=F!.

ormal =F 0B & N0Bormal =F 0B & N0B
http://en.wikipedia.org/wiki/Ejection_fractionhttp://en.wikipedia.org/wiki/Ejection_fractionhttp://en.wikipedia.org/wiki/Ejection_fraction


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dditional testsdditional tests

23&hr =CG H(5=)! to dete"t paro-ysmal arrhythmias23&hr =CG H(5=)! to dete"t paro-ysmal arrhythmias

CA)DIAC *)I & gold standard #or assessing ventri"ularCA)DIAC *)I & gold standard #or assessing ventri"ularvolumes, mass and +all motion in#lammation, in#iltrationvolumes, mass and +all motion in#lammation, in#iltration

and s"arring o# the myo"ardium!and s"arring o# the myo"ardium! ==)CIS= =S )=AD*I55!, C AGI(G)APH? or==)CIS= =S )=AD*I55!, C AGI(G)APH? or

C()(A)? AGI(G)APH? not routine diagnosis o# HFC()(A)? AGI(G)APH? not routine diagnosis o# HF$ut may $e "onsidered +here IHD is suspe"ted or i# heart$ut may $e "onsidered +here IHD is suspe"ted or i# hearttransplant is indi"atedtransplant is indi"ated

)ADI(4C5ID= imaging may $e help#ul to assess glo$al)ADI(4C5ID= imaging may $e help#ul to assess glo$alventri"ular #un"tion +hen e"ho"ardiography is not possi$leventri"ular #un"tion +hen e"ho"ardiography is not possi$le

=D(*?(CA)DIA5 /I(PS? rarely needed=D(*?(CA)DIA5 /I(PS? rarely needed


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Maa)e'et o H6

1? No P*a"'aolo)

Re#tL'tato o l&/ a/ #alt

ta!e

@? P*a"'aolo)

P"eloa/ "e/&to: D&"et#Ate"loa/ "e/&to

1? ACE-*bto"#

Va#o/lato"#

Iot"o4 /"&)#b-bl er


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.anagement '&.anagement '&

Corre"tion o# reversi$le "ausesCorre"tion o# reversi$le "auses Is"hemiaIs"hemia 'alvular heart disease'alvular heart disease hyroto-i"osis and other high output statushyroto-i"osis and other high output status

ShuntsShunts ArrhythmiaArrhythmia *edi"ations*edi"ations

Ca "hannel $lo"6ers, some antiarrhythmi"sCa "hannel $lo"6ers, some antiarrhythmi"s

Salt restri"tionSalt restri"tion

Fluid restri"tionFluid restri"tion Daily +eight tailor therapy!Daily +eight tailor therapy!

Gradual e-ertion programsGradual e-ertion programs


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P*a"'aolo) T"eat'et#

1? D&"et#

@? ACE-*bto"# a/

ot*e" 2a#o/lato"#

B? Iot"o4:

4. -blo!e"


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Diuretic /herapyDiuretic /herapy he most e##e"tive symptomati" relie#he most e##e"tive symptomati" relie# *ild symptoms*ild symptoms

HCO ine##e"tive +ith GF) 0 &&>minHCO ine##e"tive +ith GF) 0 &&>min ChlorthalidoneChlorthalidone *etola;one*etola;one

/lo"6 a rea$sor$tion in loop o# henle and distal "onvoluted tu$ules/lo"6 a rea$sor$tion in loop o# henle and distal "onvoluted tu$ules Side EffectsSide Effects

Pre&renal a;otemiaPre&renal a;otemia S6in rashesS6in rashes eutropeniaeutropenia hrom$o"ytopeniahrom$o"ytopenia

Hypergly"emiaHypergly"emia 4ri" A"id4ri" A"id Hepati" dys#un"tionHepati" dys#un"tion


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Diuretic /herapy "cont$Diuretic /herapy "cont$ 0ore severe heart failure0ore severe heart failure ? loop diuretics? loop diuretics

Lasi+Lasi+20 < 20 mg KD! Furosemide!20 < 20 mg KD! Furosemide! )ume+)ume+/umetanide 1&Mmg!/umetanide 1&Mmg! %orsemide%orsemide20&200mg!20&200mg!

0echanism of0echanism ofactionaction% Inhi$it "hloride rea$sortion in% Inhi$it "hloride rea$sortion inas"ending lim$ o# loop o# Henle results in natriuresis,as"ending lim$ o# loop o# Henle results in natriuresis,6aliuresis and meta$oli" al6alosis6aliuresis and meta$oli" al6alosis

dverse reactiondverse reaction

pre&renal a;otemiapre&renal a;otemiaHypo6alemiaHypo6alemia

S6in rashS6in rash

ototo-i"ityototo-i"ity


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0011Sparing AgentsSparing Agents

%riamterene $ amiloride%riamterene $ amiloride< a"ts on distal< a"ts on distal

tu$ules totu$ules to Q R se"retionQ R se"retion

SpironolactoneSpironolactoneAldosterone inhi$itor!Aldosterone inhi$itor!

recent evidence suggests that it mayrecent evidence suggests that it may

improve survival in C'& patients due toimprove survival in C'& patients due to

the effect on renin,angiotensin,the effect on renin,angiotensin,aldosterone system with subse2uent effectaldosterone system with subse2uent effect

on myocardial remodeling and fibrosison myocardial remodeling and fibrosis

#nhibitors of#nhibitors of


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#nhibitors of#nhibitors ofrenin,angiotensin, aldosteronerenin,angiotensin, aldosterone

systemsystemAngiotensin "onverting en;yme inhi$itorsAngiotensin "onverting en;yme inhi$itors

Angiotensin re"eptors $lo"6ersAngiotensin re"eptors $lo"6ers Spironola"toneSpironola"tone

A i i C i EA i i C i E


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Angiotensin Converting En3ymeAngiotensin Converting En3yme

#nhibitors#nhibitors bloc) the !,A,A system by inhibiting the conversion ofbloc) the !,A,A system by inhibiting the conversion of

angiotensin # to angiotensin ##angiotensin # to angiotensin ## 4 vasodilation and 5 6a4 vasodilation and 5 6aretentionretention

55(rady)inin degradation 4 7 P8 secretion and nitric oxide(rady)inin degradation 4 7 P8 secretion and nitric oxide

improve survival in CHF patientsimprove survival in CHF patients Delay onset 7 progression o# HF in pts +ith asymptomati"Delay onset 7 progression o# HF in pts +ith asymptomati"

5' dys#un"tion5' dys#un"tion QQ "ardia" remodeling"ardia" remodeling

Side =##e"tSide =##e"t AngioedemaAngioedema HypotensionHypotension )enal insu##ien"y)enal insu##ien"y )ash)ash

CoughCough


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Angiotensin ## receptor bloc)ersAngiotensin ## receptor bloc)ers

Has "ompara$le e##e"t to AC= IHas "ompara$le e##e"t to AC= I

Can $e used in "ertain "onditions +hen AC= I areCan $e used in "ertain "onditions +hen AC= I are

"ontraindi"ated angioneuroti" edema, "ough!"ontraindi"ated angioneuroti" edema, "ough!

Di i li 8l idDi it li 8l id


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Digitalis 8lycosidesDigitalis 8lycosides

"Digoxin Digitoxin$"Digoxin Digitoxin$ Sa#ety "on"ernSa#ety "on"ern )e"ent studies have sho+n that digitals does not)e"ent studies have sho+n that digitals does not

a##e"t mortality in CHF patients $ut "auses signi#i"anta##e"t mortality in CHF patients $ut "auses signi#i"ant

)edu"tion in hospitali;ation)edu"tion in hospitali;ation )edu"tion in symptoms o# HF)edu"tion in symptoms o# HF

Inotropi" e##e"t $yInotropi" e##e"t $y intra"ellular Ca 7 enhan"ing intra"ellular Ca 7 enhan"inga"tin&myosin "ross $ride #ormation $inds to the a&a"tin&myosin "ross $ride #ormation $inds to the a&

R APase inhi$its a pump intra"ellular aR APase inhi$its a pump intra"ellular a a&Ca e-"hange a&Ca e-"hange

'agotoni" e##e"t'agotoni" e##e"t Arrhythmogeni" e##e"tArrhythmogeni" e##e"t


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Digitalis /oxicityDigitalis /oxicity

arro+ therapeuti" to to-i" ratioarro+ therapeuti" to to-i" ratio

4ardiac manifestations Sinus $rady"ardia and arrest A>' $lo"6 usually 2nd degree!

Atrial ta"hy"ardia +ith A>' /lo"6 Development o# @un"tional rhythm in patients +ith a #i$ P'Cs, '> ' #i$ $i&dire"tional '!

on "ardia" mani#estationson "ardia" mani#estations

Anore-ia,Anore-ia,

ausea, vomiting,ausea, vomiting, Heada"he,Heada"he,

anthopsia sotoma,anthopsia sotoma,

DisorientationDisorientation


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9 (loc)ers9 (loc)ers

raditionally "ontraindi"atedraditionally "ontraindi"ated

o+ %o+ % t*e 'a t"eat'et o CH6t*e 'a t"eat'et o CH67 may $e7 may $e

the only medi"ation that sho+s su$stantialthe only medi"ation that sho+s su$stantial

improvement in 5' #un"tionimprovement in 5' #un"tion

he only "ontraindi"ation is severehe only "ontraindi"ation is severe

de"ompensated CHFde"ompensated CHF


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*asodilators*asodilators

Reduction of afterloadReduction of afterloadarteriolararteriolar

vasodilatation! hydrala;in!vasodilatation! hydrala;in! redu"eredu"e5'=DP, (5'=DP, (

22"onsumption, improve myo"ardial"onsumption, improve myo"ardial

per#usion,per#usion, stro6e volume and C(stro6e volume and C( Reduction of preload .Reduction of preload .venous dilation!venous dilation!

itrate! itrate! Q the venous returnQ the venous return Q the loadQ the loadon $oth ventri"les.on $oth ventri"les.

4sually the ma-imum $ene#it is a"hieved $y4sually the ma-imum $ene#it is a"hieved $y

using agents +ith $oth a"tion.using agents +ith $oth a"tion.


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Positive inotropic agentsPositive inotropic agents

yocardial contractilityyocardial contractility: adrenergi" agonists,: adrenergi" agonists,

dopaminergi" agents, phosphodiesterase inhi$itors!dopaminergi" agents, phosphodiesterase inhi$itors!

Dopamine, do$utamine, milrinone, amrinoneDopamine, do$utamine, milrinone, amrinone

Several studies sho+ed mortality +ith oralSeveral studies sho+ed mortality +ith oral

inotropi" agentsinotropi" agentsthe only use is in a"ute sittings asthe only use is in a"ute sittings as

"ardiogeni" sho"6"ardiogeni" sho"6


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Anticoagulation "coumadine$Anticoagulation "coumadine$

Atrial #i$rillationAtrial #i$rillation

=m$oli" episodes=m$oli" episodes

5e#t ventri"ular api"al throm$us5e#t ventri"ular api"al throm$us


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Anti ArrhythmicsAnti Arrhythmics

*ost "ommon "ause % Sudden death SCD! &*ost "ommon "ause % Sudden death SCD! &

ventri"ular ta"hyarrhythmiaventri"ular ta"hyarrhythmia

P- +ith sustained ' or SCDP- +ith sustained ' or SCD ICD implant ICD implant P- +ith non sustained 'P- +ith non sustained '

Corre"tion o# ele"trolytes and a"id $ase im$alan"eCorre"tion o# ele"trolytes and a"id $ase im$alan"e

P- +ith is"hemi" "ardiomyopathy ICD implant is theP- +ith is"hemi" "ardiomyopathy ICD implant is theoption a#ter t- a"ute is"hemiaoption a#ter t- a"ute is"hemia

P- +ith non is"hemi" "ardiomyopathyP- +ith non is"hemi" "ardiomyopathy ICD implantICD implant


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6ew .ethods6ew .ethods

6mplantable ventricular assist devices6mplantable ventricular assist devices

)iventricular pacing)iventricular pacingonly in patient +ithonly in patient +ith

5/// 7 CHF!5/// 7 CHF!

rtificial Heartrtificial Heart


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Cardiac /ransplantCardiac /ransplant

It has $e"ome more +idely used sin"e the advan"es inIt has $e"ome more +idely used sin"e the advan"es in

immunosuppressive treatmentimmunosuppressive treatment

Survival rateSurvival rate

1 year M0B & E0B1 year M0B & E0B

years N0B years N0B

,oals of the treatment of acute HF


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,oals of the treatment of acute HF

)H45*0*-5%

8 8mprovement of symptoms and signs

8 )tabili1ation of the hemodynamic condition

+voidance or limitation of myocardial damage

49,0*-5% favorable effects 2end0organ damage"

rehospitali1ation" mortality3

+nalgesia or

sedation?es


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#atient distressed or in painsedation

+rterial 4: saturation ;(= mm Hg

/asodilators"

consider diuresis if

volume overload

+de!uate preload

9o

9o

?es

9o

?es

?es

9o

9o

?es

Fluid challenge

+de!uate C4" metabolic acidosis"

)v4: @(< " inade!uate perfusion 9o

consider inotropes or

afterload manipulation


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PrognosisPrognosis

*ortality rate depends on patients symptoms and 5'*ortality rate depends on patients symptoms and 5'

#un"tion#un"tion

B in patients +ith mild symptoms and mildB in patients +ith mild symptoms and mild Q in 5'Q in 5'

#un"tion#un"tion 0B & 0B in patient +ith advan"es 5' dys#un"tion0B & 0B in patient +ith advan"es 5' dys#un"tion

and severe symptomsand severe symptoms

30B < 0B o# death is due to SCD30B < 0B o# death is due to SCD

PrognosisPrognosis


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PrognosisPrognosis

AC4= P45*(A)? =D=*AAC4= P45*(A)? =D=*A

prognosis is poorerprognosis is poorer

survival rates are predi"ted $y severity.survival rates are predi"ted $y severity.

CA)DI(G=IC SH(CR S/P E0 mmHg,CA)DI(G=IC SH(CR S/P E0 mmHg,

oliguria and lo+ "ardia" output!oliguria and lo+ "ardia" output! hospital mortality E0 Bhospital mortality E0 B

heart failure 2009

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