Heart failure

Basic understanding of heart failure at undergraduate level
pathophysiology , etiology , clinical features, diagnosis and treatment

1. HEART FAILURE ASWIN RM 20.08.2021

2. DEFINITION Clinical syndrome that develops when the heart cannot maintain adequate cardiac output, or can do so only at the expense of elevated ventricular filling pressures AHA Complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal clinical symptoms of dyspnea and fatigue and signs of HF, namely edema and rales .

3. EPIDEMIOLOGY 64.34 Mn Current world wide prevalence 2% Age > 65 6-10% Developed countries No 1 1in 5 Every Individual Life time risk of developing Heart Failure Cause of Hospitalization 25% Rehospitalisation rate within 1 months of discharge

4. CLASSIFICATION

5. ETIOLOGY

6. RIGHT SIDED HEART FAILURE Most common cause left heart Failure Predominant right heart failure occur in some conditions

7. PATHOPHYSIOLOGY Cardiac Output determined by 3 factors Depressed contractility is the primary factor mostly in heart failure with reduced EF

8. PATHOPHYSIOLOGY Compensatory Mechanism includes Activation of 3 systems

9. PATHOPHYSIOLOGY Tachycardia Increased Contractility Adverse LV remodeling Arrythmias Vasoconstriction Decreased peripheral circulation Incresed SVR Endothelial dysfunction Sodium & Water Retention

10. PROGRESSIVE HEART FAILURE – A VICIOUS CIRCLE

11. CLINICAL FEATURES Chronic Heart Failure – A relapsing remitting course With intermittent worsening episodes of systemic & pulmonary congestion Acute Heart Failure can be de novo or decompensation of chronic heart failure

12. STAGES OF HEART FAILURE

13. SYMPtOMS

14. NYHA FUNCTIONAL CLASSIFICATION

15. CHRONIC HEART FAILURE- other systems

16. ACUTE HEART FAILURE Patients presents with Acute pulmonary edema or cardiogenic shock Sudden Onset sever dyspnea associated with orthopnea Coughing with pink frothy sputum Autonomic symptoms like diaphoresis Altered sensorium due to hypoxia, Cyanosis Cheyne stokes breathing Cold clammy peripheries

17. CLINICAL FEATURES Not able to lie supine Tachypnea , accessory muscles for respiration Pallor – due to low cardiac output Peripheral pitting edema Cold extremeties - hypoperfusion Tachycardia , Low volume pulse , Pulsus alternans Systemic BP – Normal , Low or high Accelerated hypertension – causes acute pulmonary edema

18. CLINICAL FEATURES JVP elevated Cardiomegaly may be present LV 3 rd heart sound HFpEF – LV 4 th heart sound MR / TR murmurs Basal Crepitations – severe cases can extent upto higher lung fields Features of pleural effusion Tender hepatomegaly & ascites

19. INVESTIGATIONS

20. ECG

21. CXR REDISTRIBUTION PHASE PCWP 12-18 mm Hg INTERSTITIAL EDEMA PCWP 18-25 mm Hg ALVEOLAR EDEMA (A/C PULM EDEMA) PCWP >25 mm Hg

22. ECHOCARDIOGRAM

23. BIO markers BNP & NT pro BNP – markers of myocardial stretch Useful in Diagnosis & Prognosis Differentiate from Non cardiac causes of breathlessness & edema

24. DIFFERENTIAL DIAGNOSIS

25. COMPLICATIONS

26. MANAGEMENT-ACUTE PULMONARY EDEMA Admission to ICU Propped up position O2 inhalation if hypoxia If oxygenation not improving or patient in severe distress – Non invasive ventilation Intravenous Loop Diuretics as bolus / infusion – Frusemide (40-240 maintenance mg/day), torsemide 10-100 mg/day maintenance Frusemide – pulmonary venodilator also- sudden improvement before diuresis Nitroglycerin infusion (20-200 mcg/kg/min) – with BP monitoring Dobutamine , milrinone – increases contractility & dilates systemic vessels – increase cardiac output

27. MANAGEMENT-ACUTE PULMONARY EDEMA Patient in shock – vasoconstrictors – Nor adrenaline , dopamine , adrenaline Persistent hypoxemia – mechanical ventilation Refractory shock – Circulatory assist devices Treatment of etiology

28. LONG TERM MANAGEMENT

29. DRUGS FOR HEART FAILURE Drugs that decrease mortality ACE Inhibitors Angiotensin receptor blockers ARNI Beta Blockers Mineralocorticoid receptor antagonists Isosorbide and hydralazine Ivabradine SGLT2 inhibitors Drugs that may improve symptoms without improving outcome Cardiac glycosides (digoxin) Loop diuretics Inotropes

30. MAJOR DRUG GROUPS FOR HEART FAILURE

31. MAJOR DRUG GROUPS FOR HEART FAILURE

32. DRUGS FOR HEART FAILURE Metoprolol Carvedilol Bisoprolol Spiranolactone elplerenone Enalapril Lisinopril Ramipril Perindopril Etc.. Candesartan Losartan Valsartan Telmisartan Olmesartan Etc..

33. NON PHARMACOLOGICAL TREATMENT DEVICE THERAPY Cardiac Resynchronization therapy Implantable cardioverter defibrillator Ventricular Assist devices – short term & Long term INTERVENTION & SURGERY PCI CABG Valve surgeries LV reconstruction surgeries Cardiac transplantation

34. CRT Cardiac Resynchronisation theapy for HFrEF LBBB with wide QRS > 120, Non LBBB > 150 Ensures simultaneous contraction of different segments of heart ICD Implantable cardioverter defibrillator- to prevent death from lethal arrythmias HFrEF , HCM

35. VENO ARTERIAL ECMO (EXTRA-CORPOREAL MEMBRANE OXYGENATION LV ASSIST DEVICE

36. PCI or CABG Post MI Heart Failure Ischemic Cardiomyopathy heart failure CARDIAC TRANSPLNTATION Only definitive treatment in Advanced heart Failure

37. THANK YOU