An approach to diagnosis and management of Heart failure

PowerPoint presentation on Heart failure

1. Heart failure and its management Presented by :- Dr. Aniruddh sharma

2. Definition :- It is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to maintain sufficient cardiac output (impaired filling or ejection) to maintain the demand of the body.

3. HEART FAILURE Aetiology of HF VALVULAR HEART DISEASE Mitral Aortic Tricuspid Pulmonary MYOCARDIAL DISEASE Coronary artery disease Hypertension Cardiomyopathy PERICARDIAL DISEASE Constrictive pericarditis Pericardial effusion HIGH OUTPUT STATES Anaemia Sepsis Thyrotoxicosis Paget‘s disease Arteriovenous fistula ARRHYTHMIA Tachyarrhythmia Atrial Ventricular Bradyarrhythmia Sinus node dysfunction CONDUCTION DISORDERS Atrioventricular block VOLUME OVERLOAD Renal failure Iatrogenic (e.g. post-operative fluid infusion CONGENITAL HEART DISEASE

4. Pathophysiology : In patients without valvular disease the primary abnormality is impairment of ventricular myocardial function, leading to a fall in cardiac output. This can occur because of impaired systolic contraction, impaired diastolic relaxation, or both. ● Reduce in CO→ will cause Neurohormonal activation → to increase blood pressure and cardiac work. ● Neurohormonal activates the following systems, 1-Sympathetic nervous system 2- Renin-angiotensin system 3- vasopressin system 4- Endothelin . ● Causing either vasoconstriction → increasing the afterload or/and sodium and water retention → increasing intravascular volume. These hemodynamic changes will trigger a compensatory mechanism,but with time these mechanisms will be overwhelmed and become pathophysiological affecting both preload and afterload.

5. Biventricular heart failure Example: dilated cardiomyopathy or ischaemic heart disease, affects both ventricles or because disease of the left heart leads → chronic elevation of the left atrial pressure→ pulmonary hypertension → right heart failure . Left sided heart failure Reduction in left ventricular output. Increase in left atrial and pulmonary venous pressure. Causes :- MI Hypertension Aortic and Mitral valve disease Coarctation of aorta Arrhythmias Right sided heart failure Reduction in right ventricular output. Increase in right atrial and systemic venous pressure. Causes :- Chronic lung disease ( cor pulmonale ) Pulmonary embolism Pulmonary valvular stenosis .

6. Diastolic dysfunction – Poor ventricular filling and high filling pressures(either impaired relaxation or increase stiffness of ventricle or both). -Preserved ejection fraction. -No S4 gallop,No apex beat displacement Systolic dysfunction Impaired myocardial contraction. -Impaired Ejection Fraction → Low. -S4 gallop - apex beat displacement

7. Acute Heart Failure Sudden onset of dyspnea→ acute respiratory distress. Inappropriate brady or tachycardia Causes :- MI Hypertensive crisis Valvular heart disease Arrhythmias Infection Volume overload Pulmomary embolism ARDS Metabolic disturbances Chronic heart failure Patient follow relapsing & remitting course with periods of stability in between. Causes :- CAD Hypertension Cardiomyopathy Congenital heart disease Chronic lung disease Toxins and medications

8. Heart Failure : Initial assessment 1. Does the patient have Heart Failure or is there an alternative cause for symptoms and signs (COPD, anemia, Acute Renal Failure, Pulmonary Embolism)? 2. If the patient does have Heart Failure, is there a precipitant and does it require immediate treatment or correction (arrhythmia or ACS)? 3. Is the patient’s condition immediately life-threatening because of hypoxemia or hypotension leading to underperfusion of the vital organs?

9. Volume overload Symptoms Dyspnea ( exertional , paroxysmal nocturnal dyspnea , orthopnea , or at rest) Cough Wheezing Abdominal discomfort/bloating Early satiety or anorexia right upper quadrant pain or discomfort; Signs Rales , pleural effusion Ascites /increased abdominal girth; hepatomegaly/splenomegaly Increased weight Elevated jugular venous pressure, abdominojugular reflux S3, accentuated P2

10. Hypoperfusion Symptoms Fatigue Altered mental status, daytime drowsiness, confusion or difficulty concentrating Dizziness, presyncope , or syncope Other symptoms Depression, sleep deprivation, palpitation Signs Cool extremities Pallor, dusky skin discoloration, hypotension Pulse pressure (narrow ) Extreme Decompensation :- Cardiogenic shock Cardiorenal syndrome( Decreased urine ) Shock liver ( Elevated liver enzymes )

11. Investigations A   CBC :- A naemia , leukocytosis.   R enal profile   :- Renal injury and for guiding medication. Liver profile   :- E levated gamma-glutamyl transferase levels, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). ECG :- Ischaemia , Hypertrophy , infiltration , Previous MI , conduction block , arrhythmias. Chest X ray :- P ulmonary edema , cardiomeghaly , respiratory infections . Echo :- Right ventricular and left ventricular systolic and diastolic function, valvular structure and function , chamber size and to exclude cardiac tamponade. Coronary angiogram . Cardiac MRI . Thyroid function test. Lipid profile Urine analysis.

12. Natriuretic peptides Counterregulatory hormones— vasodilatory effects released from cardiomyocytes in response to stretch Uses – HF diagnosis Estimation of HF severity Prognosis Exclusion Diagnosis BNP <30-50 pg/ mL ≥400 pg/mL NT proBNP <300 pg/ mL ≥900 pg/ mL

13. ACC/ AHA classification Stage A AT RISK OF HEART FAILURE NO STRUCTURAL HEART DISEASE Stage B STRUCTURAL HEART DISEASE NO SYMPTOMS/SIGNS OF HEART FAILURE Stage C STRUCTURAL HEART DISEASE WITH SYMPTOMS & SIGNS OF HEART FAILURE Stage D REFRACTORY HEART FAILURE

14. NYHA class Class Patients symptoms I No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in symptoms of heart failure III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes symptoms of heart failure IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest.

15. Acute Heart Failure classification Acute Heart Failure presents as :- preserved (90–140 mmHg) or elevated (>140 mmHg--hypertensive AHF) systolic blood pressure (SBP) low SBP (<90 mmHg; hypotensive AHF)

16. Classification based on Ejection Fraction Type of HF HFrEF HFmrEF HFpEF Criteria 1.Symptoms ± signs 1.Symptoms ± signs 1.Symptoms ± signs 2. LVEF<40% 2.LVEF 40-49% 2.LVEF ≥50% 3. Elevated levels of natriuretic peptides and At least one additional criteria Relevant structural heart disease Diastolic dysfunction 3. Elevated levels of natriuretic peptides and At least one additional criteria Relevant structural heart disease Diastolic dysfunction

17. Clinical classification

18. Management of Heart Failure

19. Oxygen therapy and Ventilatory support Monitoring of SpO2 is recommended Measurement of blood pH and carbon dioxide (possibly including lactate) -- acute pulmonary oedema or previous history of COPD NIV Patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) Mechanical ventilation Intubation is recommended Respiratory failure, leading to hypoxaemia (PaO2 <60 mmHg) or hypercapnea ( PaCO2 > 50 mmHg (6.65 kPa)) and acidosis (pH <7.35) cannot be managed conservatively

20. Management :- Non Pharmacological :- Reduce cardiac work Weight loss Low sodium diet Acute heart failure Diuretics Vasodilators Ionotropic therapy Chronic heart failure ACE inhibitors Beta-blockers ATII antagonists Aldosterone antagonists Digoxin Diuretics

21. Therapy for Chronic Heart Failure 1. General measures a. Restrict salt intake b. Avoid NSAIDs c. Immunize against influenza and pneumococcal pneumonia 2. Diuretics a. Use in volume-overloaded pts b. Weight daily to adjust dose c. For diuretic resistance, administer IV or use two diuretics in combination (e.g., furosemide plus metolazone ) 3. ACE inhibitor or angiotensin receptor blocker a. For all pts with LV systolic heart failure or asymptomatic LV dysfunction b. Contraindications: Serum K+ >5.5, advanced renal disease (e.g., creatinine >3 mg/ dL ), bilateral renal artery stenosis, pregnancy

22. 4 . Beta blocker a. For pts with symptomatic or asymptomatic heart failure and LVEF <40%, combined with ACE inhibitor and diuretics b. Contraindications: Bronchospasm, symptomatic bradycardia or advanced heart block, unstable heart failure 5 . Aldosterone antagonist a. Consider for class II–IV heart failure and LVEF <35% b. Avoid if K+ >5.0 or creatinine >2.5 mg/ dL 6 . Digoxin a. For persistently symptomatic pts with systolic heart failure (especially if atrial fibrillation present) added to ACE inhibitor, diuretics, beta blocker

23. 7. Other measures a. Hydralazine and oral nitrate if not tolerant of ACE inhibitor/ARB, and as additive therapy. b. Ivabradine for LVEF ≤35%, if in sinus rhythm, rate >70, already on maximum tolerated beta blocker, or if contraindication to beta blocker c. Ventricular resynchronization (biventricular pacemaker) for pts with class III–IV heart failure, LVEF <35%, and prolonged QRS (especially LBBB with QRS ≥150 msec ) d. Consider implantable cardioverter -defibrillator in pts with class II–III heart failure and ejection fraction <35% e. Assess and treat sleep apnea Abbreviation: LBBB, left bundle branch block. d. Sacubitril/ valsartan for patients with NYHA class II– IV patients with HFrEF . e. SGLT 2 inhibitors – Empagliflozin – 10 mg QID Dapagliflozin – 10 mg QID

24. Take Home message Heart failure is a common medical condition that is often misdiagnosed. Multidimensional approach is needed for management of Heart failure. Stabilise the patient , simultaneously look for the cause . Selection of drugs as per profile is very important in treatment . Drugs shown to decrease Mortality :- ACEi / ARBs ARNI Beta Blocker Aldosterone receptor antagonist Hydralazine or nitrate

25. Drugs with no mortality benefit :- Loop Diuretic Digoxin Ivabradine

26. Thank you