heart failure rev ukrida
TRANSCRIPT
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DR. Med. Dr. Tike Ha ri Prati kto, SpJP, FIHA,FICA
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The situation when the heart is incapable of maintaining a cardiac
output adequate to accommodate metabolic requirements and the
venous return. (E. Braunwald)
The inability of the heart to pump blood forward at a sufficient rate to
meet the metabolic demands of the body (forward failure), or the
ability to do so only if the cardiac filling pressure are abnormally high
(backward failure), or both. (Pathophysiology of Heart Disease 4 thed,
Liily, Leonard S)
DEFINITION
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Heart Failure is a clinical syndrome in which patients have the following
features :
DEFINITION
Symptoms typical of HF
(breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling
And
Signs typical of HF
(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raisedjugular venous pressure, peripheral oedema, hepatomegaly)
And
Objective evidence of a structural or functional abnormality of the heartat rest (cardiomegaly, third heart soud, cardiac murmurs, abnormality onthe echocardiogram, raised natriuretic peptide concentration)
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Symptoms
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ACC/AHA A New Approach To The
Classification of HF
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults
Stage AAt high risk of HF but
without structural heartdisease or symptoms of
HF
Stage Bstructural heart disease
but withoutsigns/symptoms of HF
Stage CStructural heart disease
with prior or currentsymptoms of HF
Stage DRefractory HF requiring
specializedinterventions
e.g. patient with-Hypertension-Atherosclerosisdisease-Diabetes
-Obesity-Metabolic syndr-Using cardiotoxin-with Familialhistory
e.g. patient with-Previous MI-LV remodeling:including LVH, lowEF-Asymptomaticvalvular disease
e.g. patient with-Known structuralheart disease-Shortness ofbreath and fatigue,reduced exercisetolerance
e.g. patient with-Who have markedsymptoms at restdespite maximalmedical therapy(recurrentlyhospitalized/cannot be safelydischarged fromhospital withoutspecializedinterventionStructural heart
diseaseDevelopment of HF
symptoms
Refractory symptomsof HF at rest
At Risk For Heart Failure Heart Failure
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Determinant of ventricular function
STROKEVOLUME
PRELOAD
CONTRACTILITY
CARDIAC OUTPUT
HEARTRATE
- Synergistic LV contraction- LV wall integrity- Valvular competence
AFTERLOAD
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The goal of treatment : relieve symptoms and signs
prevent hospital admission
improve survival
Treatment strategy for the use of drugs in patients with HR-REF
Three neurohumoral antagonist
ACE inhibitor (or Angiotensin Receptor Blocker (ARB))
Beta-blocker
MRA (Mineralocorticoid Receptor Blocker)
The aforementioned drugs commonly used in conjunction witha diuretic given to relieve the symptoms and signs ofcongestion
TREATMENT
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Evaluation of acutely decompensatedchronic HF
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THANK YOU
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Diagnosis of heart failure
The diagnosis of HF-REF requiresthree conditions to be satisfied :
Symptoms typical of HF
Signs typical of HF
Reduced LVEF
The diagnosis of HF-PEF requiresfor conditions to be satisfied :
Symptoms typical of HF
Signs typical of HF
Normal or only mildly reduced
LVEF and LV not dilated
Relevant structural heart disease(LV hypertrophy/LA
enlargement) and/or diastolicdysfunctions
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Patients who should get ACEI
LVEF 40%, irrespective of symptoms
Initiation of an ACEI :
Check renal function and serum electrolytes
Consider dose up-titration after 2-4 weeks
Do not increase dose if worsening renal function or hyperkalaemia
It is common to up-titrate slowly but more rapid titration is possiblein closely monitored patients
ACE inhibitors
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Starting dose (mg) Target dose (mg)
ACE Inhibitors
Captopril 6.25 mg t.i.d 50 t.i.d
Enalapril 2.5 b.i.d 10-20 b.i.d
Lisinopril 2.5- 5 o.d 20-35 o.d
Ramipril 2.5 o.d 5 o.d
Trandolapril 0.5 o.d 4 o.d
ACE Inhibitors (Dosage)
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Patients who should get an ARB
LVEF 40% and either
As an alternative in patients with mild to severe symptoms (NYHA fc II-IV) whoare intolerant of an ACEI
Or in patients with persistent symptoms (NYHA fc IV) despite treatment withan ACEI and beta blocker
Initiation of an ARB
Check renal function and serum electrolytes Consider dose up-titration after 2-4 weeks
Do not increase dose if worsening renal function or hyperkalaemia
It is common to up-titrate slowly but more rapid titration is possible in closelymonitored patients
ARBs
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ARBs (dosage)
Starting dose (mg) Target dose (mg)
ARB
Candesartan 4 or 8 mg o.d 32 o.d
Valsartan 40 b.i.d 160 b.i.d
Losartan 50 o.d 150 o.d
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Patients who should get a beta-blocker LVEF 40%
Mild to severe symptoms (NYHA fc II-IV)
Optimal dose level of an ACEI or/and ARB
Patients should be clinically stable(e.g. no recent change in dose of diuretic)
Initiation of a beta-blocker
Beta-blocker may be initiated prior to hospital discharge in recently
decompensated patients with caution
Visits every 2-4 weeks to up-titrate the dose of beta-blocker (slower dose up-titration may be needed in some patients). Do not increase dose if signs ofworsening HF, symptomatic hypotension (e.g. dizziness) or excessivebradycardia (pulse rate
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Beta-blockers (dosage)
Starting dose (mg) Target dose (mg)
Beta blockers
Bisoprolol 1.25 mg o.d 10 o.d
Carvedilol 3.125 b.i.d 25-50 b.i.d
Metoprolol (CR/XL) 12.5/25 o.d 200 o.d
Nebivolol 1.25 o.d 1o.d
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Patients who should get an MRA
LVEF 35%
Moderate to severe symptoms (NYHA fc II-IV)
Optimal dose of beta-blocker and an ACEI or an ARB (but not an ACEI and
an ARB)
Initiation of spironolactone (eplerenone)
Check renal function and serum electrolytes
Consider up-titration after 4-8 weeks. Do not increase dose if worseningrenal function or hyperkalaemia
Mineralocorticoid receptor antagonist(MRA)
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Diuretics and MRAs (dosage)
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Potential adverse effect Hyperkalemia
K > 5.5 halve dose
K > 6.0stop
Worsening renal function
Cr > 220 umol/L (~2.5 mg/dl) halve dose
Cr > 310 umol (~3.5 mg/dl)stop
Breast tenderness and/ enlargement
Switch from spironolactone to eplerenone
MRA (potential adverse effects)
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Ivabradine is a drug that inhibits the I fchannel in the sinusnode. Its only known pharmacological effect is to slowheart rate in patients in sinus rhythm (it does not slow theventricular rate in AF)
Patients who should get an Ivabradine
Mild to severe symptoms (NYHA fc II-IV)
Sinus rhythm with a rate 70 bpm
LVEF 35%
Ivabradine
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In patients in sinus rhythm with symptomatic HF andLVEF 40%, this treatment improve patient well-beingand reduce hospital admission for worsening HF
Patients in AF with ventricular rate at rest >80, and at
exercise >110-120 beat/minute should get digoxin
In patients with sinus rhythm and left ventricularsystolic dysfunction (LVEF 40%) receiving optimaldoses of diuretic, ACEI or/and ARB, beta-blocker and
aldosterone antagonist if indicated, who aresymptomatic, digoxin may be considered)
Digoxin
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Patients who should get H-ISDN
An alternative to an ACEI/ARB where both of the latter are not tolerated
As add-on, therapy to an ACEI if ARB or aldosterone antagonist is nottolerated or if significant symptoms persist despite therapy with an ACEI,ARB, beta-blocker, and aldosterone antagonist
Initiation of H-ISDN
Consider dose up-titration after 2-4 weeks. Do not increase dose withsymptomatic hypotension
Hydralazine and ISDN
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A h th i b d di d t i t i l
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Atrial Fibrillation
The most common arrhythmia in HF
increases the risk of thrombo-embolic complications (particularly stroke)and may lead to worsening of symptoms
The following issues need to be considered in patients with HF and AF,especially a first episode of AF or paroxysmal AF:
Identification of correctable causes (e.g. hyperthyroidism, electrolytedisorders, uncontrolled hypertension, mitral valve disease).
Identification of potential precipitating factors (e.g. recent surgery, chest
infection or exacerbation of chronic pulmonary disease/asthma, acutemyocardial ischaemia, alcohol binge) as this may determine whether arhythm-control strategy is preferred to a rate-control strategy.
Assessment for thromboembolism prophylaxis.
Arrhythmia, bradycardia, and atrioventricular
block in patients with heart failure with reduced EFand heart failure with preserved EF
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Atrial Fibrillation
Thrombo-embolism prophylaxis
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Ventricular arrhythmia in HF
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Chronic obstructive pulmonary disease and Asthma
may cause diagnostic difficulties, especially in HF-PEF
Beta-blockers are contraindicated in asthma but not in
COPDselective beta-1 adrenoceptor antagonist (i.e.bisoprolol, metoprolol succinate, or nebivolol) Preferred
Oral corticosteroids cause sodium and water retentionworsening of HF
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Diabetes Melitus
Associated with poorer functional status and worse prognosis
Prevented by treatment with ARBs and possibly ACE inhibitors.
Beta-blockers are NOTcontraindicated in diabetes and are aseffective in improving outcome in diabetic patients as in non-diabetic individuals
Thiazolidinediones (glitazones)sodium and water retention andincreased risk of worsening HF and hospitalization
Metformin is NOTrecommended in patients with severe RENAL
or HEPATIC IMPAIRMENT
HYPERTENSION
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HYPERTENSION
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Acute Heart Failure
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Defined as the rapid onset of, or change in,symptoms and signs of HF. It may occur withor without previous cardiac disease.
ESC guidelines for the Diagnosis & Treatment of Acute and Chronic Heart Failure 2012
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Precipitants and causes
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Clinical classification
Worsening or decompensated chronic HF There is usually a history of progressive worsening of known chronic HF
on treatment and evidence of systemic and pulmonary congestion
Pulmonary oedema
Present with severe respiratory distress, tachypnoea and orthopnoeawith rales over on lung fields. Artery O2 saturation is usually
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Oxygen
Given to treat hypoxemia (SpO2
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Vasodilators
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Positive Inotropes or vasopressors or both
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Goals of treatment in acute heart
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Immediate (ED/ICU/ICCU) Treat symptoms
Restore oxygenation
Improve haemodynamics and organ
perfusion Limit cardiac and renal damage
Prevent thrombo-embolism
Minimize ICU length of stay
Goals of treatment in acute heartfailure
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Most of the knowledge about the epidemiology, riskfactors,prognosis, treatment, and prevention of HF is based onNorth American and European studies
EPIDEMIOLOGY
(ESC Guidelines for the Diagnosis andTreatment of Acute and Chronic Heart
Failure ,2008)
ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart Failure
in the Adult 2001
Europe
The prevalence of symptomatic HFrange from 2-3%
Prevalence in 70- to 80-year-oldpeople is between 10 and 20%.
15 million HF pts in 900 million totalpopulation
Overall 50% of patients are dead at 4
years. Forty per cent of patientsadmitted to hospital with HF aredead or readmitted within 1 year
USA
Nearly 5 million HF pts. 500,000 pts are HF for the 1st time
each year.
Last 10 yearsnumber ofhospitalizations has increased.
Nearly 300,000 patients die of HFeach year.
Terminology related to the time-course
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A patient who/whose Never exhibited the typical signs or symptoms of HFasymptomatic LV
systolic dysfunction
Have had HFchronic HF
Chronic stable HF conditions deteriorates
decompensated Chronic stable HF resolves from acute conditioncompensated
HFs condition presents acutelyNew (de novo) HF
Terminology related to the time courseof heart failure
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Suspected Heart Failure
Acute onset
ECGChest x-ray
Echocardiography BNP/NT-pro BNP
ECG normaland
NT-proBNP
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Starting dose (mg) Target dose (mg)
MRA
Eplerenone 25 mg o.d 50 o.d
Spironolactone 25 o.d 25-50 o.d