Heart Failure etiology investigations and

Hshs

1. HEART FAILURE Moderator : Dr. Ganga Prasad Garu , M.D [ General Medicine ] Professor , Dept. of General Medicine. Presenter : Dr.SasikanthKumar Perala , Junior Resident

2. Definition: Complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood leading to cardinal manifestations of dyspnoea , fatigue and fluid retension. Chronic HF : Longstainding ( Months to years ) symptoms and signs of HF typically titrated with drugs and device therapy Acute HF : Rapid onset or Worsening of symptoms of HF [ 20% New onset , 80% worsenig of Chronic HF ] Acute Pulmonary Edema : Rapidly worsening signs and symptoms of pilmonary congetion, due to severe elevation of left heart filling pressure.

3. Epidemiology : Prevalce of HF increase with age 1-2 % in 40-59 yrs and 12% in > 80yrs Life time risk at 55 yrs age is 33% in Men and 28% in women Incidence : May decrease due to Improves recognition and management Risk factors : Obesity , HTN , DM Socioeconomic status Access to Health 5 yr survival : 50% [Most common : SCD ] Progonosis : Tratment of Risk Factors , Guide line directed Therapies

4. Phenotypes & Causes : Based on EF : Due to Difference in Demographics, comorbities , and respose to Therapy HFrEF : EF < 40% HFpEF : EF > 50% HFrecEF : HFrEF treated with Guideline directed therapy , have rapid or gradual improvement in EF to normal range. Younger age Shorter duration of HF Non-ischemic etiology Smaller Ventricular Volumes Abscence of myocardial fibrosis

5. Phenotypes & Causes : HFrecEF has Better prognosis than either HFrEF or HFpEF HFmrEF : EF : 40-50% , Treated for Risk factors , comorbities and are in line treated with that of HFrEF Acquired vs Familial , Congenital and other Disorders : Children and young adults Late presentation due to missed diagnosis Non intervention or lack of access Repaired or palliative defects Inherted Cardiomyopathies : Heart Muscle Disease , Muscular Dystrophies , Mitochondrial disease Autosomal Dominant

6. Phenotypes & Causes : Systemic Diseases : Amyloidosis , Sarcoidosis Auto-Immune : SLE , RA Infectious Diseases : Chagas , HIV Drug Toxity : Chemotherapy High Cardiac Output State : Anemia , Thyrotoxicosis

7. Pathophysiology : Primary event may be Acute MI Asymptomatic or mildly symptomatic due to compensatory mechanisms Ventricular Remodelling : In response to Excessive cardiac work load Concentric - Increased mass [ Pressure Overload ] Eccentric - Increased Volume [Volume Overload ]

8. Pathophysiology : Neurohormonal Activation : Symapathetic Nervous System and RAAS ↑HR , ↑BP, ↑Cardiac Contractability , retention of Sodium and water

9. Pathophysiology : Vasodialatory harmones : Counter Regulatory Hormones : ANP, B-type Natriuretic Peptide [BNP] , PGE1, Prostacyclin [PGI2], Bradykinin, adrenomedulin and NO. Stimulation of Guanylate cyclase : systemic and pulmonary vasodilatation, ↑ Increased sodium and water excretion , inhibition of renin , aldosteron and barorecptor modulation. Endothelin , Inflammatory Cytokines and Oxidative Stress : Endothelin - Potent Vasocostrictor peptide - Myocyte hypertrophy and interstitial Fibrosis Alfa-TNF , IL 1Beta , superoxide - sources GIT and Liver Novel Biologic Targets : SGLT-2 : Protien loacated on PT of kidney Sodium and water rentention , endothelial dysfuntion , abnormal myocardial metabolism and impaired calcium handling.

10. Pathophysiology : Dyssynchrony and Electrical Instability : Prologation of QRS interval and LBBB Secondary Mitral Regurgitation: ↓Contractile Force →↓ Coaptation of leaflets Cardiorenal and Abdominal Interactions : Impairment of forwardflow systemic venous congetion with increased backward presuure ↑ Intra abdominal pressure in Right HF correlate with renal imapirment Gut congetion, the Microbiome, and Inflammation : Proinflammatory cytokines Altaration and loss of diversity in microbial environment LPS [ Gram negative Bacterial cell wall ]

11. Evalution: History : Symptoms of congetion Symptoms of reduced perfusion Pricipitating Factors Physical Examination : General Appearence Vital signs JVP Lung Examination Cardiac Examination Abdomen and Extremities

12. Diagnosis : Routine Laborateries Cheast X-Ray ECG Non-Invasive Imaging : 2D-ECHO , Doppler ,TE-ECHO , CMR , CT ,PET Cardiopulmonary Exercise Testing Biomarkers - BNP, N-terminal Pro-BNP [ New : Galectin-3 and Soluble ST-2] Invasive studies : Pulmonary artery catheter , CAG , Left ventriculography , Right ventricular endomyocardial Biopsy

13. Comorbidities: Diabetes sleep Apnea Obesity Depression

14. Management: Based on phenotype at presentation Measure of LVEF Focus is on Heamodynamic stabilisation, Decongetion, Appropriate disease modifyng therapy Advanced or Refractory HF phenotypes - Consider for Cardiac transplant or mechanical circulatory support Last is Palliative measures

15. Management: Exercise - Change in 6 minute walk distance Selected comorbidity : Sleep-disorderd breathing Anemia Depression Atrial Arrhythmias DM Neuromodulation Using Device Therapy : Vagal stimulation, Baroreflex activation , Renal sympathetic Denervation , Spinal cord stimulation

16. Management : Cardiac Contractability Modulation : Device therapy Non-excitatory electrical stimualtion to Right ventrical septal wall during during absolute myocardial refractory period to improve myocardial contraction Predominantly in HFrEF and narrow QRS duration Cardiac Resynchronisation Therapy : Mechanical dyschrony - Widened QRS and LBBB Placing lead via coronary sinus to lateral wall of ventricle Improved exercise capacity, Reduction in symptoms and reverse remodelling

17. Management : Surgical Therapy : CABG : Considered in Ischemic cardiomyopathy with Multivessel coronary artery disease Hibernating myocardium : Abnormal function with normal cellular function Surgical Ventricular Restoration : Left ventricular aneurysmal surgery Funtctional MR : Percutaneous approach to edge-to-edge MVR Cellular and Gene-based Therapy : BM derived precursor cells Cardiac-derived stem cells