heart failure update

5/28/2018 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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heart failure update

Documents

types of heart failure

diastolic heart failure

functional defect othe

hf onset

neurohormonal activation

atrial pressure

pulmonary edema

gi symptoms