heart failure 2013 therapy
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TRANSCRIPT
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Congestive Heart Failure
3. Treatment
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Medical Science Tanzania Cardiology Lectures
Prof. Hennersdorf SES
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General signs and symptoms
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Definition of Heart Failure CHF
• New York Heart Association (NYHA)– I no visible signs and symptoms– II signs and symptoms at high level exercise– III signs and symptoms at low level exercise– IV no physical exercise possible, bed rest
necessary
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Worldwide used as functional definition of CHF!
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Treatment Goals
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IV
III
II
I
??
??
??
HTX option
Main treatment goalfor chronic disease
Main treatment goalfor acute disease
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Therapeutic objectives
• Acute CHF– Treatment of life threat– Improvement of life quality
• Chronic CHF– Improvement of life quality– Reduction of Disability– Increase of longevity
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Adding life to years rather than years to life
Main approachVasodilation
Organ protectionVolume control
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Therapeutic options
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Acute Heart Failure
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Therapeutic options (ER, ICU)• Physical approach in cardiogenic pulmonary edema
– Oxygen delivery– Bed rest / upright position– Secure (central) venous line– Urinary catheter– Blood letting
• Drugs (iv administration)– Diuretics (short term, furosemide)– Digitalis (?; fast AF ?)– Thrombembolic prophylaxis (heparin; PTT necessary)
• Drugs orally (cave hypotension)– Nitroglycerine sublingually– Consider ACEI sublingually
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Therapeutic options (cardiogenic shock)
• Volume expansion under hemodynamic control– Pulmonary artery cath– Arterial pressure line
• Mechanical assistance: IABP• Cathlab: PCI• Surgery: revascularization• Drugs
– Catecholamines: Dopamin, Dobutamin– Phosphodiesterase (PDE)-Inhibitors: Amrinone, Milrinone (not
evidence based)– Thrombembolic prophylaxis: heparine (PTT)– Fast acting diuretics
• Acid base control• Electrolyte contol (potassium)
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Therapeutic options
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Chronic Heart Failure
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Evidence
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Therapeutic challenge
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Systolic heart failure: mostly common in CHD and RHDDrugs and recommendations according to guidelines
Diastolic heart failure: mostly common in hypertensionLong term follow up dependent on treatment of underlying diseaseDrugs recommendations not yet established
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Therapeutic options
• First line recommendation: Prevention– Prevention of CHD, Hypertension, valvular
disease, infections– Information, home care, transmission of simple
behavior rules:• Hygiene and clean water supply• Motion: physical activity, limited sport action• Nutrition: salt restriction• Refrain smoking
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Therapeutic options• Conservative
– RAS modification• ACE-I• AT1-receptor antagonists• Aldosterone antagonists (Eplerenone ®)
– beta-AR competition• Betablockers
– classical 3D options• Diuretics (fast acting, medium acting; cave potassium)• Diet• Digitalis (?) not first choice!
– Others: (Pulmonary artery Hypertension)• Bosentan • Sildenafil
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Avoid use of NSAIDs like COXIBs
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ß-Blockade in CHF
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ß-Blockade in CHF
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ß-Blockade in CHF
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Muscle cell; contractilityNENEE
Muscle cell; contractility
NENENENEEEE
Muscle cell; contractility
NENENENEEEE
Betablockade: receptor recovery,function improves
AR Reduction
AR Recovery
Reduction of adrenergic receptors AR
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ß-Blockade in CHF
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Recommended: ß1-selective drugs like metoprolol, bisoprolol+ vasodilatation: carvedilol, nevibolol
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Therapeutic options. ACE-I
• Trials– CONSENSUS 1987 Captopril– SOLVD 1999 Enalapril– SAVE 1992 Captopril– VHEFT 1991 Enalapril/Hydralazin– CIBIS III 2005 Enalapril/Bisoprolol
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Demonstrate highly significant improvement of survival in different stages of heart failure (II –IV): Evidence Class A - IA
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Dosage recommendations
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Dosage recommendations
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Improvement of HF in cardiac CXR
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before treatment after treatment
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Therapeutic options
• Surgical– Heart transplantation, bridging– Cardiomyoplasty
• Resynchronizing pacemaker therapy (CRT)• Stem cell replacement
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Therapeutic options
• HTX– Surgically solved– Concomitant therapy problems (rejection) solved– Donor problems unsolved and will persist
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But: therapeutic choice for subsets of younger patients with severe symptoms mostly on
iv therapy and/or ICU care without chance to recover appropriately.
Bridging procedure desirable
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Heart transplantation HTX
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Heart transplantation
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Heart transplantation
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3rd september 1967
original OR theatreGroote Schuur HospitalCape Town SAR
Christian Neethling Barnard
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Artificial heart
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Heartmate® for bridging procedures
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Survival after HTX
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Therapeutic options: cardiac resynchronization therapy CRT
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Therapeutic options
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Therapeutic options: resynchronization therapy
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Therapeutic options: stem cells
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Therapeutic challenge: home care
• Medication starts in the hospital• Medication continues in household enviroment, rural areas • Doctor‘s contacts rare• Patient‘s survey difficult.• Therefore: narrow control schedules concerning
– Nurse directed home care– Continuous medical education of both patient and personal
(nurses/doctors)– Outpatient visits– Establishing telemedical processes
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Therapeutic home care options• Home care (nurse driven)
– Scheduled visits on regular basis (nurse, AMO)– Visits following questionnaire– Data acquisition and transmission
(telemedicine?)• Severity of symptoms• Daily activities ability• Controls
– Medication– Weight (listing by patient)– Blood pressure– other
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CHF Questionnaire; example
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How do you feel since last visit? Scale of 10 ptsIn your opinion, are there main changes:
breathingweight gainUrinary outputpalpitation?
How do you think developed your personal daily activities (DAs)?
worsesamebetter
which kind of DAs is mostly impaired?homeleisureemployment
What about your medication:intake OK?complaints?self made changes?incompatibilty?wishes?
Suggestions?
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Heart Network
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Patient
Hospital
Home Care
OPD
District Hospital
Dispensary
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Heart Network: nurse
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+
Hospital
Nurse
home care
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Heart Network: Internet
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Patient data file, database: EPF*Access by authorized personal throughout the country
*electronic patient file
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Heart Network
• Telecardiology (telemedicine)– Electronic provision of data transmission– Generation of medical data in remote areas (rural)– Overcoming of doctors shortages – Secure transmission line– Targets:
• Hospital Centers• Home care physician• Home care nurse• Specialized medical call centers
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Heart Network
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• Telemedical patient kit – Smartphone with Apps (Skype)– Balance– ECG device– Blood pressure device– Glukose test kit– Finger tip pulse oxymeter– Questionnaire
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The End
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