Congestive heart failure

heart failure

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2. Congestive Heart Failure Presented to Dr. Smreen Hassan Presented by Group :03 2

3. Group Members: Muhammad Asif Sami. Sidra Akbar. Fatima Rahat Ali. Kanwal Mehboob . Soorath Bhatti . Maria Rehman . Zainab Hassan. Batch:04 (DPT) Institute: D.I.R.S( Dewan University) 3

4. Contents : Introdution to Heart Failure.. Epidemiology of Heart Failure Etiology of Heart Failure Pathophysiology of Heart Failure. Physiology of Hear Failure. Classification of Heart Failure. Sign & symptoms of Heart Failure. Physical Examination. Lab Analysis. Non Pharamacological therapy . Pharmacological Therapy. Goals of Management. General Life Style Advice. 4

5. In medical terms heart failure is defined as the condition when heart is unable to pump enough blood required for normal body functions. Human body needs sufficient amount of oxygen which is supplied by heart through blood. Heart failure is a serious condition and needs immediate medical care. What is Heart Failure? 5

6. Epidemiology The incidence: 1 in 1000 population per year; increasing by about 10% every year. In >85y incidence is 10 cases per 1000. The prevalence ranges from 3-20 cases per 1000 population, increasing to at least 80 cases per 1000 in people aged 75 years and over. The male to female ratio is about 2:1. The median age of presentation is 76 years. 6

7. Etiology INTRINSIC PUMP FAILURE : The important cause of heart failure is the weakening of ventricular muscle due to disease so that the heart fails to act as an efficient pump Ischaemic heart disease (35-40%) Cardiomyopathy (dilated) ( 30-34 %) INCREASED WORKLOAD ON THE HEART : It is due to either increased pressure load or volume load Increased pressure load Hypertension Chronic lung disease Increased volume load Severe anaemia Hypoxia due to lung disease IMPAIRED FILLING OF CARDIAC CHAMBERS: Cardiac failure may also result from defects in filling of heart 7

8. PATHOPHISIOLOGY Heart failure is associated with complex neurohormonal changes including activation of the renin angiotensin aldosterone system and the sympathetic nervous system 8

9. Physiology of Heart Failure Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood ( Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure ). 9

10. Classification of Heart Failure 10

11. Classification of Heart Failure (cont.) ACC/AHA Guidelines Stage A – High risk of HF, without structural heart disease or symptoms Stage B – Heart disease with asymptomatic left ventricular dysfunction Stage C – Prior or current symptoms of HF Stage D – Advanced heart disease and severely symptomatic or refractory HF 11

12. Types of Heart Failure Low-Output Heart Failure Systolic Heart Failure: decreased cardiac output Decreased Left ventricular ejection fraction Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic pressures May have normal LVEF 12

13. Types of Heart Failure 2.High-Output Heart Failure Seen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism , beri-beri , carcinoid , anemia Often have normal cardiac output 3.Right-Ventricular Failure Seen with pulmonary hypertension, large RV infarctions. 13

14. Causes of Low-Output Heart Failure Systolic Dysfunction: Coronary Artery Disease 50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) Ischemic heart disease, perpartum , hypertension, HIV, connective tissue disease, substance abuse, doxorubicin Hypertension Valvular Heart Disease 14

15. Causes of Low-Output Heart Failure Diastolic Dysfunction Hypertension Coronary artery disease Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy 15

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17. Difficulty in breathing particularly on exertion such as climbing stairs, walking and doing housework. Legs, ankles and abdomen get swollen due to the accumulation of water A lethargic and weak feeling Sign & Symptoms of Heart Failure 17

18. Difficulty in sleeping A feeling of breathlessness when lying down (lungs get congested on lying down because of the back damming effect). This condition is medically termed as pulmonary edema. This condition is inevitable since the patient can get collapsed anytime. 18

19. Physical Examination in Heart Failure: S3 gallop Low sensitivity, but highly specific Cool, pale, cyanotic extremities Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly . 19

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21. Lab Analysis 21

22. Lab Analysis in Heart Failure CBC Since anemia can exacerbate heart failure Serum electrolytes and creatinine before starting high dose diuretics Fasting Blood glucose To evaluate for possible diabetes mellitus Thyroid function tests Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF. Iron studies To screen for hereditary hemochromatosis as cause of 22

23. NON-PHARMACOLOGICAL TREATMENT: Revascularization Biventricular pacemaker Cardiac transplantation Nutritional therapy Diet/weight reduction recommendations-individualized and culturally sensitive  Dietary Approaches to Stop Hypertension (DASH) diet recommended Sodium- usually restricted to 2.5 g per day Potassium encouraged unless on K sparing diuretics (Aldactone) 23

24. PHARMACOLOGICAL TREATMENT Drugs used in CCF: Cardiotonic drugs: Cardiac glycosides (digitalis, digoxin,digitoxin. Vasodilators: ACE-I, ARBs, Na- nitroprusside, nitroglycerine, prazosine. Diuretics: Thiazides, loop diuretics, K + sparing diuretics. Miscellaneous : Aldosterone antagonist; spiranolactone. Β blockers: Carvedilol, metoprolol. 24

25. Order of Therapy Loop diuretics ACE inhibitor Beta blockers Digoxin Hydralazine , Nitrate. 25

26. Diuretics Loop diuretics Lasix ( furosemide ) Hydrochlorothiazide(HCTZ) Spironolactone These inhibit reabsorption of Na+ into the kidneys 26

27. Mechanism of Action Decrease the body’s retention of salt and water Reduces blood pressure Probably will be on potassium 27

28. ACE Inhibitor Improve survival in patients with all severities of heart failure. Begin therapy low and titrate up as possible: Enalapril – 2.5 mg Captopril – 6.25 mg Lisinopril – 5 mg 28

29. Mechanism of Action Prevent the production of the chemicals that causes blood vessels to narrow Resulting in blood pressure decreasing and the heart pumping easier 29

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31. Calcium Channel Blockers: Nifedipine Diltiazem Verapamil Amlodipine Felodipine 31

32. Mechanism of Action Used to dilate blood vessels Used mostly with CHF in the presence of ischemia 32

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34. Beta Blocker therapy Certain Beta blockers ( carvedilol , metoprolol , bisoprolol ) can improve overall and event free class II to III HF, probably in class IV. Contraindicated: Heart rate <60 bpm Symptomatic bradycardia COPD, asthma 34

35. Mechanism of Action: Useful by blocking the beta- adrengergic receptors of the sympathetic nervous system, the heart rate and force of contractility are decreased could actually worsen CHF 35

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37. Hydralazine plus Nitrates Dosing: Hydralazine Started at 25 mg , titrated up to 100 mg po TID Isosorbide dinitrate Started at 40 mg 37

38. Mechanism of Action: Widens the blood vessels, therefore allowing more blood flow Relaxation of smooth muscle Widens blood vessels Lowers systolic blood pressure 38

39. Digoxin Given to patients with HF to control symptoms such as fatigue, dyspnea , exercise intolerance . 39

40. Mechanism of Action: Digoxin Lanoxin Increases the contractility of the heart  increasing the cardiac output 40

41. AVOID in heart failure NSAIDS Can cause worsening of preexisting HF Thiazolidinediones Include rosiglitazone ( Avandia ), and pioglitazone ( Actos ) Cause fluid retention that can exacerbate HF Metformin People with HF who take it are at increased risk of potentially lethic lactic acidosis 41

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43. Newer drugs for heart failure Vasopeptidase inhibitors: Omapatrilat Nesiritide Omecamtiv mecarbil: selective cardiac myosin activator 43

44. Goals of Management Improve oxygenation, ventilation Decrease venous return to heart Decrease cardiac work, O 2 demand Improve cardiac output by Reducing afterload Increasing myocardial contractility 44

45. Role of in Physical Therapy 45

46. Measuring Jugular Venous Pressure 46

47. Exercises for CHF: Some examples of aerobic exercises are walking, jogging, running, aerobic dancing, cycling, stepping, cross country skiing, swimming, arm cycle ergometry , etc.  47

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49.   Resistance training:  can be done with use of dumbbells, cuff and hand weights, elastic bands, barbells, hand held blades, Pilates table, punching bags, inflated balls, stability balls, variable resistance exercise machines ( BTE, cybex ) etc.  49

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52. regular aerobic physical activity, preferably at. least 2 to 3 times per week for approximately 1 hour, while carefully keeping a regular heart rate of 70% to 85% of the theoretic age-related maximum rate. The American Heart Association recommends "Specifically, we recommend a total of 30 minutes of moderate-intensity activities on most days of the week and a minimum of 30 minutes of vigorous physical activity at least 3 to 4 days each week to achieve cardiovascular fitness ." 52

53. General lifestyle advice Education:Effective counselling of patients and family emphasizing weight monitoring and dose adjustment of diuretics may prevent hospitalization. Obesity control:Maintain desired weight and body mass index. Smoking: Smoking should be stopped, with help from anti-smoking clinics if necessary. Physical activity, exercise training and rehabilitation Dietary modification: Large meals should be avoided and if necessary weight reduction instituted. Salt restriction is necessary and foods rich in salt or added salt in cooking and at the table should be avoided . 53

54. y Reduce the number of sacks on the wagon Limit the speed, thus saving energy Like the carrot placed in front In o t r o p s Increase the efficiency Vasodilators  blockers Diuretics, ACE inhibitors 54

55. Summary : An imbalance in pump function in which the heart fails to maintain the circulation of blood adequately. Diagnosis : ETT, Echo- cardiogram, Cardiac-imaging, Angiography, Blood tests. Differential diagnosis. Treatment: Pharmacological (Nitrates, beta blockers, calcium channels blockers.), Combination therapy. Non pharmacological treatment : I mproving and managing risk factors , surgery . 55

56. Additional Resources and Information from the Web Heart Foundation of America ( www.heartfoundation.org ) Heart Foundation of Northeast Florida ( www.hffonf.org ) Online resource of Heart Failure Project ( www.heart failure.com ) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4865399/ by JMSC JAN’s webpage ( www.jan.wvu.edu/media/Heart Failure.htm ) 56

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