2. Heart Failure.pptx cggggfgggdshjfddht

Congestive heart failure

1. CARDIOLOGY Cardiology l ecture 2 :- Heart Failure Date:- 15/09/2020 Prepared by Dr Guled Mohamud Nur (GMN@N ) MBBS

2. OVERVIEW Heart failure is inability of the heart to maintain adequate cardiac output to meet the demands of the body is known as cardiac failure. It can result from any structural or functional cardiac disorder.

3. Epidemiology The prevalence of heart failure is 1–2% of the adult population in developed countries and rises to ≥ 10% in persons of 70 years or older. The lifetime risk of developing heart failure is estimated to be 20% for all persons older than 40 years. In the USA , approximately 5.1 million have heart failure that leads to 27100 deaths per year.

4. Clinical features Typical symptoms breathlessness at rest or on exercise, fatigue , tiredness, ankle oedema Typical signs tachycardia , tachypnoea , pulmonary rales , pleural effusion, raised jugular venous pressure, peripheral oedema , hepatomegaly .

5. Clinical features Objective evidence of a structural or functional abnormality of the heart at rest cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, such as reduced LVEF or valve disease or other structural disorder, raised natriuretic peptide concentration.

6. Classification of the heart failure

7. Classification The heart failure may be classified in several ways Acute versus chronic heart failure Left versus right and biventricular failure Systolic versus diastolic failure Low output versus high output failure

8. Acute versus chronic heart failure Acute heart failure Heart failure developing suddenly in hours or days in a previously asymptomatic patient is called acute heart failure. Chronic heart failure Heart failure developing gradually is chronic heart failure.

9. Systolic versus diastolic failure In majority of patients heart failure is due to combined systolic and diastolic dysfunction . Heart failure with reduced ejection fraction (<40%) ( HFrEF ), Also referred to as systolic HF . Heart failure may develop as a result of impaired myocardium contraction ( systolic dysfunction ). Heart failure with preserved ejection fraction (>40 %) ( HFpEF ), Also referred to as diastolic HF . Heart failure may develop due to poor ventricular filling caused by impaired ventricular relaxation.

10. Left versus right and biventricular failure Left heart failure refers to predominant congestion of the pulmonary veins with fluid retention and pulmonary oedema . Right heart failure refers to congestion of the systemic veins with fluid retention and peripheral oedema . These conditions may coexist, and the most common cause of right ventricular failure is raised pulmonary artery pressure due to left ventricular failure .

11. Low output versus high output failure High-output heart failure refers to the syndrome caused by circulatory high-output conditions, such as anaemia , thyrotoxicosis, septicaemia , arteriovenous shunts, liver failure, Paget’s disease, and beriberi. Low output failure Low cardiac output at rest or during exertion characterizes heart failure caused by common conditions such as congenital, valvular , rheumatic, hypertensive, coronary and cardiomyopathic .

12. Etiology Hypertension and coronary artery disease are the commonest causes of heart failure in industrialized countries whereas , in underdeveloped countries, other causes, such as infectious diseases , are more important . Valvular heart disease , cardiomyopathies ,and congenital heart disease are also important causes.

13. Etiology Patients with diabetes mellitus have a four times higher risk for heart failure and higher mortality compared to non–diabetics. Alcohol is a direct myocardial toxin and a reversible cause of heart failure . Tobacco and cocaine increase the risk for CAD, which can lead to heart failure . Both hyperthyroidism and hypothyroidism can be reversible causes of heart failure .

14. etiology Pulmonary arterial hypertension may lead to RV failure. Male sex , less education , physical inactivity , and overweight have also been identified as independent risk factors for CHF . Obstructive sleep apnoea is associated with hypertension and a higher incidence of heart failure . Patients with metabolic syndrome , hypertriglyceridaemia , low HDL, hypertension, and fasting hyperglycaemia ) are at higher risk of cardiovascular disease and heart failure. HIV infection is also an important cause of left or biventricular dysfunction.

15. Presentation Presenting symptoms of heart failure, such as dyspnoea , exercise intolerance , and fatigue , are non-specific and mimicked by many other conditions, especially in the elderly . Several classification schemes (the most popular being by the New York Heart Association ( NYHA ), Canadian Cardiovascular Society ( CCS ), have been presented for a semi-quantitative assessment of symptom severity.

16. Presentation Orthopnoea , dyspnoea that occurs in the recumbent position , is a later manifestation. It may also be seen in patients with COPD and abdominal obesity or ascites. Paroxysmal nocturnal dyspnoea refers to acute episodes of dyspnoea and coughing that occur at night and awaken the patient. It is relatively specific for heart failure.

17. Presentation Pulmonary oedema may develop in acute exacerbations of heart failure. Minor episodes of haemoptysis may represent transient, exercise-induced pulmonary oedema . Cardiac asthma refers to wheezing due to bronchospasm or increased pressure in the bronchial arteries.

18. Presentation Altered mental status may reflect hypoperfusion . Anorexia or nausea and right upper quadrant pain and ascites reflect bowel and liver congestion. Ankle oedema may be caused by heart or renal failure and pericardial constriction, particularly with elevated JVP, chronic venous insufficiency, calcium channel blockers, IVC obstruction, prolonged air travel, idiopathic, liver congestion and hypoalbuminaemia , secondary hyperaldosteronism.

19. Presentation Unilateral ankle oedema may be due to venous thrombosis, lymphatic obstruction, and saphenous vein harvesting for CABG. Young patients may be not edematous despite intravascular volume overload. In obese patients and elderly patients, edema may reflect peripheral rather than cardiac causes.

20. Physical examination Physical signs are also non-specific: Sinus tachycardia or AF in 30% of patients with advanced disease Tachypnea Raised jugular venous pulse Third heart sound (S 3 ) Basal pulmonary rales Peripheral oedema with ankle swelling and hepatomegaly . Systolic murmurs may be present

21. NYHA functional classification NYHA (New york heart association)

22. NYHA functional classification Class I Patients with cardiac disease but no resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation , dyspnoea , or anginal pain . Class II Patients with cardiac disease resulting in slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue , palpitation, dyspnoea , or anginal pain. By limiting activity, patients still able to lead a normal social life.

23. NYHA functional classification Class III Patients with cardiac disease resulting in marked limitation of physical activity. Comfortable at rest, but less-than-ordinary physical activity results in fatigue, palpitation, dyspnoea , or anginal pain. Patients unable to do any housework .

24. NYHA functional classification Class IV Patients with cardiac disease resulting in inability to carry out any physical activity without symptoms. Dyspnoea or angina may be present, even at rest. Comfortable at rest, but less-than-ordinary physical activity results in fatigue, palpitation, dyspnoea , or anginal pain. Patients incapacitated and virtually confined to bed or a chair.

25. ACC/AHA stages of heart failure ACC ( American college of cardiology ) AHA (American heart association)

26. ACC/AHA stages of heart failure Stage A At high risk for developing heart failure. No identifi ed structural or functional abnormality; no signs or symptoms. Stage B Developed structural heart disease that is strongly associated with the development of heart failure but without signs or symptoms .

27. ACC/AHA stages of heart failure Stage C Symptomatic heart failure associated with underlying structural heart disease. Stage D Advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy.

28. Investigations Complete blood count (CBC) , blood urea nitrogen and creatinine , glucose and HbA1c , serum electrolytes, liver function tests, lipid profile, and thyroid function tests are taken routinely. Natriuretic peptide ( BNP ) and its precursor N terminal pro-BNP are sensitive and specific This peptide is raised with advanced age, female sex, and renal insufficiency and lowered with obesity.

29. Investigations Other biomarkers In ambulatory chronic heart failure patients, such as high-sensitivity C-reactive protein , B-type natriuretic peptide . Screening for haemochromatosis , sleep-disturbed breathing, HIV, rheumatological diseases , amyloidosis, or phaeochromocytoma is also undertaken when there is a clinical suspicion of these diseases.

30. Investigations ECG Left ventricular hypertrophy, atrial enlargement, previous myocardial infarction, active ischaemia , conduction abnormalities , and arrhythmias may be present. An entirely normal ECG makes the diagnosis of systolic dysfunction unlikely (<10%). Chest radiography may reveal cardiomegaly and/or pulmonary congestion ( Kerley B lines and interstitial oedema with upper lobe blood diversion). Pleural effusions may be present , with biventricular failure .

31. Investigations Echocardiography ( key investigation ) echo, may provide important information about ventricular dimensions , extent of systolic dysfunction, whether dysfunction is global or segmental, the status of valves, and estimates of pulmonary artery pressure. MRI provides the most accurate estimate of ventricular structure and function .

32. Investigations Holter monitoring may be considered in patients who are being investigated for ventricular arrhythmias . Coronary angiography is indicated when the patient has angina or coronary artery disease is suspected. Cardiac catheterization may also be needed when echocardiography is insufficient to define the severity of valve disease and/or pulmonary pressures.

33. Prognosis Conditions associated with a poor prognosis in heart failure are as age, aetiology , NYHA class, LVEF, key co-morbidities (renal dysfunction, diabetes, anaemia , hyperuricaemia ), and plasma natriuretic peptide concentration .

34. Therapy General measures Patients with heart failure should be enrolled in a multidisciplinary care management programme to reduce the risk of heart failure hospitalization. Regular aerobic exercise is beneficial for patients with stable, non-decompensated heart failure REST : bed rest reduces the demands of the heart, therefore beneficial. Head of the patient should be proposed up to reduce lung congestion. Sexual activity is not advised for patients with decompensated or advanced ( NYHA class III or IV ) heart failure.

35. Therapy General measures Salt restriction is usually advisable, especially in patients with stages C and D. Fluid restriction to 1.5–2 L/day may be considered only in patients with severe symptoms and hyponatraemia . Weight loss is initially advisable in patients with coronary artery disease.

36. Therapy General measures Alcohol, Smoking cessation, avoidance of high altitude (> 1500 m), and vaccination against influenza and pneumococcus are recommended. Contraception with combined hormonal contraceptives is contraindicated due to fluid retention and increased thrombotic risk.

37. Therapy General measures Non-steroidal antiinflammatory drugs (including COX-2 inhibitors) as well as corticosteroids and herbal preparations (licorice, ginseng, ma huang ) cause salt and water retention and should be used with much caution . Tricyclic antidepressants are contraindicated due to pro-arrhythmic potential .

38. Stages in the development of HF and recommended therapy by stage.

39. STAGE A At high risk for HF but without structural heart disease of symptoms of HF. e.g., Patients with: HTN, Atherosclerotic disease, DM, Obesity, Metabolic syndrome, or Patients using cardiotoxins , With family history of cardiomyopathy. Therapy Goals:- Heart healthy lifestyle, Prevent vascular, coronary disease Prevent LV structural abnormalities Drugs ACEI or ARB in appropriate patients for vascular disease or DM, Statins as appropriate

40. STAGE B Structural heart disease but without signs or symptoms of HF. e.g., Patients with: Previous MI, LV remodeling including, LVH and low EF, and Asymptomatic valvular disease. Therapy Goals:- Prevent HF symptoms, Prevent further cardiac, remodeling. Drugs ACEI or ARB is appropriate Beta blockers as appropriate In selected patients ICD, Revascularization or valvular surgery as appropriate.

41. STAGE C Structural heart disease with prior or current symptoms of HF. e.g ., Patients with: Known structural heart disease and HF signs and symptoms. HF p EF : Therapy Goals :- Control symptoms, Improve HRQOL (health related quality of life), Prevent hospitalization, and Prevent mortality Strategies:- Identification of comorbidities

42. STAGE C Treatment Diuresis to relieve symptoms of congestion Follow guideline driven indications for comorbidities e.g., HTN, AF, CAD, DM Revascularization or valvular surgery as appropriate.

43. STAGE C HF r EF : Therapy Goals:- Control symptoms, Patient education, Prevent hospitalization, and Prevent mortality Drugs for routine use Diuretics for fluid retention ACEI or ARB Beta blockers Aldosterone antagonists

44. STAGE C Drugs for use in selected patients Hydralazine/ isosorbide dinitrate ACEI and ARB Digoxin selected patients CRT (cardiac resynchronization therapy) ICD (implantable cardioverter -defibrillator) Revascularization or valvular surgery as appropriate.

45. STAGE D Refractory HF e.g ., Patients with : Marked HF symptoms at rest, Recurrent hospitalizations, and Patients despite GDMT ( guideline-directed medical therapy) THERAPY Goals:- Control symptoms, Improve HRQOL, Reduce hospital readmissions, Establish patient’s end of life goals.

46. STAGE D Refractory HF Options Advanced care measures Heart transplant Chronic inotropes Temporary or permanent MCS (mechanical circulatory support) Experimental surgery or drugs Palliative care and hospice ICD deactivation

47. Control of congestive heart failure Reduction of cardiac workload Physical and emotianal rest, 1-2 weeks in symptomatic cardiac failure. Small but frequent meals Weight loss by reducing calories intake Use vasodilators Control of excessive retention of salt and water Decreased intake, low salt diet Increased excretion, diuretics

48. Control of congestive heart failure Enhancement of myocardium contractility Use digitalis Use dopamine and dobutamine

49. Drug management of the heart failure

50. Diuretics Loop diuretics, e.g. frusemide ( lasix ) Potassium sparing diuretics e.g. spirolactone ( aldactone ) Thiazide diuretics e.g. hydrochlorothiazide Diuretics are the most effective means of providing symptomatic relief to patient with moderate to severe congestive heart failure. Loop diuretics is most effective in severe heart failure.

51. Diuretics In acute conditions , diuretics should be given iv because they may not be absorbed adequately due to congestion in the gut. Frusemide is given in the dosage of 20-320 mg daily preferably in two or more divided doses. In severe renal insufficiency , larger doses of frusemide such as 500 mg may be required. Patient with refrectory edema may respond to combination of frusemide and thiazide such as metolazone .

52. Angiotensin converting enzyme (ACE) inhibitors ACE inhibitors should be considered as a part of the initial therapy of the cardiac failure. All patient of cardiac failure should be on ACE inhibitors if there is no contraindication. Prognosis is markedly improved and development of heart failure is slowed with the use of ACE inhibitors. e.g. captopril, enalapril , ramipril , and lisinopril .

53. Spirolactone Spirolactone ( aldactone ) is a specific competitive antagonist to aldosterone . Along with its effect of potassium sparing diuretics, it inhibits myocardium remodeling and fibrosis and should be given in severe heart failure.

54. Angiotensin receptors blockers These agents as effective as ACE inhibitors in the management of cardiac failure. The advantage is that they do not cause cough and skin rash. E.g. Losartan , valsartan

55. Vasodilators Nitrates Are not used routinely in heart failure Long acting nitrates such as isosorbide nitrate may be given if paroxysmal noctural dyspnea in uncontrolled. Nitrates are mainly used in acute heart failure, in acute cardiogenic pulmonary edema, acute decompensated of chronic heart failure.

56. Vasodilators Hydralazine Combination of oral hydralazine and oral nitrates is an alternative to ACE inhibitors for the treatment of cardiac failure in patients who do not tolerate ACE inhibitors. Nesiritide This new agent is a recombinant form of human brain natriuretic peptide and is a potent vasodilator that reduces ventricular filling pressure and improve cardiac output .

57. Digitals Digoxin is a positive inotropic agent and is the first line therapy in patients with hear failure associated with atrial fibrallation . Dosage : Initial dose ( digitalization ) rapid digitalization (duration 24 hours) single dose of 0.5 mg IV over 10-20 minutes followed by additional 0.25 mg IV every 6 hours to maximum of 1mg in 24 hours .

58. Digitals Dosage : Slow digitalization (duration 1 week) Single oral dose of 0.5 mg for 3 days followed by maintenance dose (0.15-0.5 mg daily ). Antacids and broad spectrum oral antibiotics decrease the absorption of digoxin.

59. Role of the beta-blockers Although beta-blockers have traditionally been considered contraindicated in cardiac failure, however, there is now strong evidence that these agents have important beneficial effect. First trial was done non cardioselective beta-blocker ( carvedilol ) but later trial with metaprolol and bisoprolol , also proved 30-35% reduction in mortality as well as reduced hospitalizations .

60. Non pharmacological treatment of heart failure

61. Coronary revascularization Since underlying coronary artery disease is the cause of heart failure in the majority of patients, coronary revascularization may improve symptoms and prevent progression if there is evidence of ischemia.

62. Biventricular pacing In patients with heart failure and bundle branch block and functional class III heart failure, cardiac conduction abnormalities can trigger mechanical dys -synchrony of ventricular contraction impairing cardiac performance. In these patients biventricular pacing in both right and left ventricle produce improvement in symptoms and exercise tolerance.

63. Implantable cardio- verter defibrillator (ICD) Patients with sustained episodes of ventricular tachycardia should be receive implantable cardioverter defibrillator (ICD).

64. Left ventricular assist devices (LVAD) There is pump like devices that receive blood and pump with pressure working like ventricles. They are required in severe heart failure when the pumpimg function of ventricles is severely impaired. These devices are very expensive

65. Surgical treatment cardiac transplantation Patient with severe heart failure and limited life expectancy are considered candidates for heart transplantation. One year survival rate after transplantation exceeds 80-90% and five year survival rates above 70%

66. Reference By Clinical Cardiology Current Practice Guidelines