HEART FAILURE

Prevalence increasing in our ageing population

Incidence doubles with each decade between 40 and 80

At any age more common in men than women

One of the commonest causes of hospital admission

Heart Failure

1. A cardiac disorder that prohibits delivery of sufficient output to meet the perfusion requirements of metabolizing tissues

2. A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic and hormonal responses

Causes of heart failure

• Coronary artery disease

• Hypertension

• Cardiomyopathy

• Valvular heart disease

• Other causes

Heart failure: aggravating factors

• Cardiac arrhythmias (esp AF)

• Hypertension

• Anaemia

• Chest infection

Sympatho-adrenalactivation

Renin-angiotensinactivation

Redistribution ofvenous flow

Salt and waterretention

Ventricular dilatation

Inotropic state

Myocardial mass

Contractile Function

Compensatory Physiology in Heart failure

Heart failure: symptoms and signs

Symptoms Signscardiac output fatigue cool skin

(peripheral hypoperfusion) peripheral cyanosis

Fluid retention dyspnoea basal crackles

(congestion) oedema JVP ankle swelling, ascites

sympathetic activity - tachycardiasweating

Other findings - S3, alternating pulse

S3

Heart failure: S3, alternating pulse

Heart failure: ECG (never normal)

Inferior Q waves

Anterior T wave + ectopics

Left bundle branch block

Heart failure: CXR

Pulmonary congestion Pulmonary oedema

Heart failure: m-mode echo

Cardiomyopathy:global LV dysfunction

Coronary heart disease:regional LV dysfunction

S3

Heart failure: 2D echo

LV

LV

LA

LARA

RVRV

4 chamber view

Long axis view

Heart failure: brain natriuretic peptide (BNP)

Secreted by myocardial cells in response to raised left atrial pressure

• Promote natriuresis, vasodilatation

• Inhibit ADH and aldosterone release

• Levels >50pg/ml indicate heart disease as cause of dyspnoea and fluid retention

Heart failure: Complications

• Intravascular thrombosis

– pulmonary embolism– systemic embolism

• Infection– chest infection– ulcerated cellulitic legs

• Functional valvular dysfunction– MR, TR

• Multi-organ failure– renal failure– liver failure

• Cardiac Arrhythmias– AF– VT VF

• Sudden death

Heart failure: non-drug treatment

• Severely oedematous patient– bed rest– nurse in head up position– oxygen therapy– aspiration of large pleural effusions– salt restriction

• Ambulant patient– no added salt– regular walking exercise

Heart failure: treat aggravating factors

• Atrial fibrillation

– rate control + warfarin

– DC cardioversion

• Hypertension

– ACE-Is + beta blockers + diuretics

• Anaemia

– haematinics

– erythropoetin (?)

– blood transfusion (?)

• Chest infection

– physiotherapy

– antibiotics

Sympatho-adrenalactivation

Renin-angiotensinactivation

Redistribution ofvenous flow

Salt and waterretention

Ventricular dilatation

Inotropic state

Myocardial mass

Contractile Function

Treatment of Heart failure

Beta-blockers ACE-Is, ARBsSpironolactone

Beta-blockers

Carvedilol in theCOPERNICUS trial

Circulation 2002

ACE-Inhibitors

Meta-analysis of allrandomized trials

Lancet 2000

Spironolactone

RALES trialNEJM 1999

ARBs Losartan in ELITE II

Lancet 2000

Treatment of Heart failure: Evidence base

ACE-I

Placebo

Losartan

Captopril

Heart failure: treatment

• Fluid retention– diuretics

• Symptoms and prognosis in systolic heart failure•Drugs– ACE-Is (all grades of heart failure)– ARBs (if ACE-Is cannot be tolerated)– beta-blockers (all grades of heart failure)– spironolactone (NYHA grade III and IV only)

•Devices– Cardiac resynchronization therapy (CRT)

Heart failure: treatment ofcomplications

•Atrial fibrillation– cardioversion (often not possible) – rate control (beta-blockers ± digoxin)– warfarin

•Ventricular arrhythmias– implantable defibrillator

Canadian Implantable Defibrillator Study

Circulation 2004

Heart Transplantation

• Indications: resistant ccf without:

– major organ failure– major co-morbidity– psychological disability– severe pulmonary hypertension

• Procedure– orthotopic transplant

• Prognosis– 80% 1 year survival

Prognosis of Heart Failure

The End