Congestive Heart Failure.pptx

Heart Failure

1. Congestive Heart Failu r e

2. Results from any structural or functional abnormality that impairs the ability of the heart to eject blood ( Systolic Heart Failure ) or to fill with blood ( Diastolic Heart Failure ) . Heart's pumping power is weaker than normal. With heart failure , blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. Congestive Heart Failure (CHF) Congestive Cardiac Failure(CCF) Heart Failure (HF)

3. Epidemiology and Demographics Prevalence About 5.7 million adults in the united states have heart failure Prevalence of HF will increase 46% from 2012 to 2030 Incidence Approximately 915000 new HF cases annually Data from NHLBI’s Framingham Heart Study indicate that HF incidence approaches 10 per 1,000 population after age 65 75% of heart failure cases have antecedent hypertension An increase of 26% in the number of hospitalizations due to heart failure in 2017 Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB, Murabito JM, Vasan RS, Benjamin EJ, Levy D; Lifetime Risk for Developing Congestive Heart Failure. Framingham Heart Study. Circulation. 2002; 106: 3068–72 PMID 12473553

4. Congestive Heart Failure Heart Failure can be divided: Right Sided Heart Failure Left Sided Heart Failure Can be Either From, Diastolic Dysfunction( Inability to relax ) Systolic Dysfunction ( Inability to Contract )

5. Congestive Heart Failure Etiology - Increase in Pulmonary pressure results fluid in alveoli (PULMONARY EDEMA) Increase in Systemic pressure results in fluid in tissues (PERIPHERAL EDEMA) Health conditions that either damage the heart or make it work too hard - Coronary Artery Diseases (CAD) -Myocardial Infarction. -Heart muscle diseases (cardiomyopathy) -Heart inflammation (myocarditis)

6. Congestive Heart Failure Risk Factors Coronary artery Diseases Myocardial Infarction Hypertension Diabetes Heart Valve Disease( e.g.Aortic Stenosis) Smoking Obesity Cardiomyopathy (Heart Muscle Diseases) 1)Dialated Cardiomyopathy ( e. g . Alco h ol, V i r al I n fect i on s ) Hypertrophic Cardiomyopathy ( Thickening of Heart Muscle ,septum between Rt and Lt Ventricle ) Restrictive Cardiomyopathy ( Heart Muscles are rigid and unable to expand e.g Fibrosis)

7. Congestive Heart Failure Decreased Blood Pressure and Decreased Renal perfusion Stimulates the Release of renin, Which allows conversion of Angiotensin to Angiotensin II . Angiotensin II stimulates Aldosterone secretion which causes retention of Na+ and Water, increasing filling pressure LV Dysfunction causes Decreased cardiac output

8. Symptoms of Congestive Heart Failure

9. Classes of Heart Failure

10. Congestive Heart Failure Pathophysiology In order to maintain normal cardiac output, several compensatory mechanisms play a role as under: Compensatory enlargement in the form of cardiac hypertrophy, cardiac dilatation, or both. Tachycardia due to activation of neurohumoral system. e.g. release of norepinephrine and atrial natrouretic peptide, activation of renin-angiotensin aldosterone mechanism.

11. Congestive Heart Failure STARLING’S LAW Within limits, the force of ventricular contraction is a function of the end-diastolic length of the cardiac muscle, which in turn is closely related to the ventricular end-diastolic volume. This is achieved by increasing the length of sarcomeres in dilated heart Increases the myocardial contractility and thereby attempts to maintain stroke volume .

12. Congestive Heart Failure Heart failure results in DEPRESSION of the ventricular function curve. COMPENSATION in the form of stretching of myocardial fibers results. Stretching leads to cardiac dilatation which occurs when the left ventricle fails to eject its normal end diastolic volume

13. Congestive Heart Failure Compensatory Mechanisms Sympathetic nervous system stimulation Renin-angiotensin system activation Myocardial hypertrophy Altered cardiac Rhythm

14. Congestive Heart Failure

15. Congestive Heart Failure

16. Congestive Heart Failure V entri c ular r emodel i ng Altered cardiac rhythm

17. Congestive Heart Failure 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 High-Output Heart Failure Seen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism, beri-beri, carcinoid, anemia Often have normal cardiac output Right-Ventricular Failure Seen with pul m onary h y pert e nsion, l a r ge R V inf a rc t ions.

18. Congestive Heart Failure Clinical Features Left Sided Heart Failure: Pulmonary Edema Dyspnea (SOB) b)Orthopnea c)Paroxysmal Nocturnal Dyspnea 2)Decreased forward Perfusion Activated Renin Angiotensin Aldosterone System, which cause fluid retention and worsenen CHF.

19. Congestive Heart Failure Clinical Features Right Sided Heart Failure: Most common cause of cause of Right Heart Failure is Left side Heart Failure. Dyspnea(SOB) Jugular Venous Distention Pitting Edema d)Ascitis e)Nutmeg Liver “Hepatomegaly”

20. Congestive Heart Failure Physical Examination S3 gallop Low sensitivity, but highly specific Cool, pale, cyanotic extremities Have sinus tachycardia, diaphoresis and peripheral vasoconstriction Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>

21. Congestive Heart Failure Diagnosis Echocardiogram -Distinguish systolic from Diastolic dysfunction by measuring Ejection Fraction -Determining Myocardial Ischemia is the precipitating cause. -Identify Valve Diseases. B Type Natriuretic Peptide (BNP) -Secreted by the Ventricles -Differentiate between causes of dyspnea due to heart Failure from the other cause of dyspnea. Chest Xrays -Determine any Cardiomegaly. Cephalization of the pulmonary vessels Kerley B-lines Pleural effusions 4)EKG -To Identify arrhythmias,Ischemic Heart Diseases,Right and Left ventricular Hypertrophy, and presence of conduction delays or abnormalities.

22. Congestive Heart Failure

23. Congestive Heart Failure Lab Investigations 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 heart failure. ANA To evaluate for possible lupus Viral studies If viral mycocarditis suspected

24. Congestive Heart Failure BNP With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures Usually is > 400 pg/mL in patients with dyspnea due to heart failure.

25. Congestive Heart Failure Cardiac Testing Exercise Testing Should be part of initial evaluation of all patients with CHF. Coronary arteriography Should be performed in patients presenting with heart failure who have angina or significant ischemia Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina. Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure. Endomyocardial biopsy Not frequently used Really only useful in cases such as viral-induced cardiomyopathy

26. Congestive Heart Failure Chronic Treatment of Systolic Heart Failure Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension Lifestyle modification Lower salt intake Alcohol cessation Medication compliance Maximize medications Discontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers)

27. In-Hospital Management of CHF Criteria for Inpatient Heart Failure Therapy

28. Common Precipitating Factors for Heart Failure Hospital Admission Non adherence to guideline directed medical therapy, diet, and fluid and/or sodium retention Accelerated or uncontrolled hypertension Arrythmia Acute myocardial infarction Concurrent infections Medications- addition of negative inotropes (calcium channel and beta blockers) Medications that increase sodium retention (steroids, NSAID’s) Pulmonary Embolism Excessive alcohol or illicit drug use Endocrinologic comorbidities Acute CVD

29. Congestive Heart Failure Pharmacological Therapy Loop diuretics. ACE i n h ibitor ( or Angiotensin Receptor2 Blocke r s if not tolerated ). Beta blockers. Digoxin. Hydralazine, Nitrate. Potassium sparing diuretcs.

30. Congestive Heart Failure Loop diuretics Furosemide, buteminide For Fluid control, and to help relieve symptoms Potassium-sparing diuretics Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF

31. Congestive Heart Failure ACE Inhibitors Improve survival in patients with all severities of heart failure. Begin therapy low and titrate up as possible: Enalapril – Captopril Lisinopril If cannot tolerate, may try ARB(Angiotensin II receptor blockers)

32. Congestive Heart Failure Beta Blockers Certain Beta blockers ( carvedilol , metoprolol , bisoprolol ) can improve overall and event free survival in NYHA class II to III HF, probably in class IV. Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma PR interval > 0.24 sec, 2 nd or 3 rd degree block

33. Congestive Heart Failure Hydralazine plus Nitrates Dosing: Hydralazine Started at 25 mg po TID, titrated up to 100 mg po TID Isosorbide dinitrate Started at 40 mg po TID/QID Decreased mortality, lower rates of hospitalization, and improvement in quality of life.

34. Congestive Heart Failure Digoxin Given to patients with HF to control symptoms such as fatigue, dyspnea, exercise intolerance Shown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality.

35. Congestive Heart Failure Statin Therapy Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease. Some studies have shown a possible benefit specifically in HF with statin therapy Improved LVEF Reversal of ventricular remodeling Reduction in inflammatory markers (CRP, IL-6, TNF- alphaII)

36. Congestive Heart Failure Treating Congestive Heart failure U pright position N itrates L asix O xygen A CE inhibitors D igoxin F luids(decrease) A fter load (decrease) S odium retention T est (Dig level, ABG’s, Potassium level)

37. Congestive Heart Failure Medications to avoid In HF 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 lactic acidosis

38. Congestive Heart Failure Implantable Cardioverter-Defibrillators for HF Sustained ventricular tachycardia is associated with sudden cardiac death in HF. About one-third of mortality in HF is due to sudden cardiac death. Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.

39. Congestive Heart Failure Management of Refractory Heart Failure Inotropic drugs: Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin Mechanical circulatory support: Intraaortic balloon pump Left ventricular assist device (LVAD) Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication

40. GAPS in Heart Failure Care

41. Strategies to prevent HF Rehospitalization

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