Heart failure , systolic and diastolic dysfunction, management of acute heart failure

heart failure is a chronic condition of the heart in which heart is unable to pump sufficient amount of blood to meet requirements of the metabolic tissues.

1. Heart failure Dr Erum Shaheen MBBS, FCPS Cardiologist Senior Registrar , FRPMC

2. Learning Objectives By the end of this lecture Cardiology final year MBBS students should be able to, 1. Define heart failure . 2. Classify systolic and diastolic heart failure . 3. Know clinical manifestations of heart failure. 4. Know etiology and diagnostic modalities to diagnose heart failure. 5. Explain the standard pharmacologic and non pharmacologic therapy of acute and chronic heart failure. 6. Identify current practice guidelines for treatment of acute and chronic heart failure.

3. Definition of Heart Failure Heart failure is a chronic, progressive condition which develops when the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressures.

4. There are two types of left-sided heart failure 1. Systolic heart failure 2. Diastolic heart failure

5. Systolic heart failure The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation. This is also known as heart failure with reduced ejection, or HFrEF . When this occurs, the heart is pumping less than or equal to 40% EF.

6. Diastolic heart failure The left ventricle loses its ability to relax normally because the muscle has become stiff. The heart can't properly fill with blood during the resting period between each beat. This is also known as heart failure with preserved ejection, or HFpEF . When this occurs, the heart is pumping greater than or equal to 50%. H eart failure with mid-range ejection fraction ( HFmrEF ) is a newer concept. In this type of heart failure, the left ventricle pumps between 41% and 49% EF . This places people with HFmrEF between the HFrEF and HFpEF groups.

7. Right-sided heart failure Right-sided or right ventricular heart failure usually occurs as a result of left-sided failure. When the left ventricle fails and can’t pump enough blood out, increased fluid pressure is transferred back through the lungs. This damages the heart’s right side. When the right side loses pumping power, blood backs up in the body’s veins.

8. Etiology The common causes of HF include ischemic heart disease and myocardial infarction (MI), hypertension, and valvular heart disease (VHD), Other non-ischemic causes include,

9. Risks of heart failure Type Diabetes 2. Metabolic syndrome. Hyperactive thyroid problems. Aging Smoking , Alcohol or drug abuse O besity

10. Clinical manifestations of heart failure Patient may present with; Exertional dyspnea and/or dyspnea at rest Orthopnea Acute pulmonary edema Chest pain/pressure and palpitations Tachycardia Fatigue and weakness

11. Cont. Nocturia and oliguria Anorexia, weight loss, nausea Distention of neck veins Weak, rapid, and thready pulse Rales, wheezing.

12. Cont. S  3  gallop and/or pulsus alternans Increased intensity of P  2  heart sound Hepatojugular reflux Ascites, hepatomegaly, and/or anasarca Central or peripheral cyanosis, pallor

13. Diagnosis Heart Failure Criteria The Framingham criteria for the diagnosis of heart failure consists of the concurrent presence of either two major criteria  or  one major and two minor criteria.

14. Major criteria Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S  3  gallop Central venous pressure greater than 16 cm water Circulation time of 25 seconds or longer Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy

15. Minor criteria Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion Tachycardia (rate of 120 bpm) Hepatomegaly Bilateral ankle edema

16. Classification The New York Heart Association (NYHA) classification system categorizes heart failure on a scale of I to IV,    as follows: Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Symptoms occur even at rest ; discomfort with any physical activity

17. Stages of Heart Failure

18. Stages of HF ( con’t .)

19. Stages of HF ( con’t .)

20. ACC/AHA Stages of HF

21. Classification and Trajectories of HF Based on LVEF

22. Testing Blood tests: Complete blood cell (CBC) count Urinalysis Electrolyte levels, Renal and liver function studies Fasting blood glucose levels Lipid profile TSH levels BNP/NT Pro BNP levels

23. Electrocardiography Chest radiography Two-dimensional (2-D) echocardiography Nuclear imaging CMR E xercise testing Pulse oximetry or arterial blood gas Noninvasive stress testing.

24. ABGs measurements Hypoxemia and hypocapnia occur in stages 1 and 2 of pulmonary edema H ypercapnia and respiratory acidosis In stage 3 of pulmonary edema. The decision regarding intubation and the use of mechanical ventilation is frequently based on many clinical parameters, including oxygenation, ventilation, and mental status.

25. Electrocardiographic Abnormalities In Patients With Preserved And Reduced Left Ventricular Ejection Fraction Sinus tachycardia RAD/LAD PVCS LVH LAE,RAE,BAE AF ST-T wave abnormality Minor IVCD Low voltage complexes

26. ECG

27. ECG

28. Chest Radiograph

29. Chest Radiograph

30. Two-dimensional (2-D) echocardiography

31. Stress Echocardiography Stress echocardiography with dobutamine or exercise, is used mainly to assess coronary artery disease. This imaging modality may be used to detect ventricular dysfunction caused by ischemia, evaluate myocardial viability in the presence of marked hypokinesis or akinesis, identify myocardial stunning and hibernation, and relate heart failure symptoms to valvular abnormalities

32. Cardiac MRI It is a noninvasive test useful in evaluating cardiac chamber size and ventricular mass, cardiac function, and wall motion; delineating congenital and valvular abnormalities; and demonstrating the presence of pericardial disease It can be used to assess ischemic versus nonischemic disease, infiltrative disease, and hypertrophic disease; and can be employed to determine viability. It is used principally for the delineation of congenital cardiac abnormalities and for the assessment of valvular heart disease, and it is the gold standard for evaluating right ventricular (RV) function

33. Nuclear Imaging Radionuclide multiple-gated acquisition scanning (MUGA scan) evaluates left ventricular (LV) function right ventricular (RV) function and wall motion abnormalities.

34. Electrocardiogram-gated myocardial perfusion imaging (MPI) ECG-gated single-photon emission computed tomography (SPECT) images allow for the assessment of the global LVEF, regional wall motion, and regional wall thickening at rest in patients with documented stress-induced wall motion and perfusion abnormalities

35. Radionuclide ventriculography O btains accurate measurements of LV function and RV ejection fraction (RVEF),    but it is unable to directly assess valvular abnormalities or cardiac hypertrophy and has limited value for assessing volumes or more subtle indices of systolic or diastolic function.

36. Catheterization and Angiography Coronary angiography can reliably demonstrate or exclude the presence of obstructed coronary vessels. The procedures are frequently indicated when systolic dysfunction of unexplained cause is present on noninvasive testing or when normal systolic function with episodic heart failure suggests ischemically mediated left ventricular (LV) dysfunction.

37. Right-sided heart catheterization useful in providing important hemodynamic information about filling pressures, vascular resistance, and cardiac output when there is doubt about the patient's fluid status; in heart failure refractory to initial therapy in the presence of significant hypotension (systolic BP typically < 90 mm Hg or symptomatic low systolic BP) and/or worsening renal function during initial treatment; and when heart transplantation or placement of a mechanical circulatory support device is being considered

38. Assessment of Functional Capacity Cardiopulmonary stress testing can help in the assessment of a patient’s chance of survival, as well as determine the need for referral for either cardiac transplantation or implantation of mechanical circulatory support.  A 6-minute walk test evaluates the distance walked, dyspnea index on a Borg scale from 0 to 10, oxygen saturation, and heart rate response to exercise. A normal value is walking > 1500 feet. Patients who walk < 600 feet have severe cardiac dysfunction and a worse short- and long-term prognosis

39. PRECIPITATING FACTORS IN HEART FAILURE Diet (excessive sodium or fluid intake, alcohol) Noncompliance with medication or inadequate dosing Sodium-retaining medications (NSAIDs) Infection (bacterial or viral) Myocardial ischemia or infarction Arrhythmia (atrial fibrillation, bradycardia) Breathing disorders of sleep Worsening renal function Anemia Metabolic (hyperthyroidism, hypothyroidism) Pulmonary embolus

40. Management of Acute and Chronic Heart failure: Pharmacologic Non-pharmacologic Invasive strategies

41. Pharmacologic therapies Diuretics (loop/thiazide) Angiotensin-converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) Angiotensin receptor-neprilysin inhibitors (ARNIs) ( saccubitral /valsartan) Hydralazine and nitrates

42. Cont. Beta-adrenergic blockers Aldosterone receptor antagonists (MRA) Digoxin Anticoagulants Inotropic agents Soluble guanylate cyclase ( sGC ) stimulators (vericiguat) Selective sodium-glucose cotransporter-2 (SGLT2) or dual SGLT1/SGLT2 inhibitors, ( dapagliflozin, empagliflozin) .

43. Management of Stage A and B Heart Failure

44. Management of Stage C and D Heart Failure

45. Device Recommendations ICDs and CRTs are recommended in special circumstances in patients with non-ischemic DCM, or with ischemic heart disease with >40 days Post MI with EF <35% and NYHA II/III symptoms on chronic GDMT with expected survival> 1 year

46. N onpharmacologic therapies dietary sodium and fluid restriction; physical activity as appropriate; and attention to weight gain

47. Ionotropic support In hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly low cardiac index, short-term, continuous intravenous inotropic support may be reasonable to maintain systemic perfusion and preserve end-organ performance. More prolonged use of inotropes as “bridge” therapy for those awaiting either heart transplantation or MCS may have benefit in reducing pulmonary hypertension and maintaining end-organ perfusion beyond initial stabilization of patients

48. Cardiac Transplantation Cardiac transplantation provides a mortality and morbidity benefit to selected patients with stage D HF (refractory, advanced)

49. Question no 1 A 76-year-old man with a history of heart failure visits your clinic for a routine scheduled examination. He has underlying coronary heart disease, and his last echocardiogram 12 months ago revealed a left ventricular regional wall motion abnormality in the anterior wall. His ejection fraction at that time was 40%. He takes lisinopril 20 mg/d, carvedilol 6.25 mg bid, atorvastatin 40 mg/d, and aspirin 81 mg/d, all of which he is tolerating well. His physical examination reveals a blood pressure of 132/82 mm Hg, a heart rate of 83 bpm and regular, a respiratory rate of 18 breaths/min, and a room air oxygen saturation of 96%. He has no jugular venous distension (JVD). His lungs are clear in all fields, and his heart examination reveals an S3 at the cardiac apex, which has been noted on previous examinations. He has no edema in his extremities. The next step in this patient’s management is to: A: Document his current level of activity B: Start furosemide 20 mg/day C: Start valsartan 50 mg/day D: Stop his aspirin

50. Question no 2 A 52-year-old woman who has type 2 diabetes mellitus (T2DM), heart failure from coronary artery disease, and an ejection fraction of 40% comes to your office for a routine follow-up visit. She has mild dyspnea while climbing stairs but reports no other limitations in her usual activities. Her hemoglobin A1C 3 weeks ago was 7.2%. She is maintained on extended-release metformin 2000 mg/d, atorvastatin 40 mg/d, lisinopril 40 mg/d, carvedilol 25 mg bid, and aspirin 81 mg/d. Her vital signs reveal stable body weight at 185 lb , a blood pressure of 126/78 mm Hg, a heart rate of 68 bpm and regular, and a respiratory rate of 18 breaths/min. Her examination is otherwise normal The next most appropriate step in this patient’s management would be to? A: Increase carvedilol to 50 mg bid B: Add basal insulin to her regimen C: Add sitagliptin to her regimen D: Add Dapagliflozin to her regimen

51. Advise your patients to: Weigh yourself every day Take your medications Eat a heart healthy low-salt (sodium) diet Exercise on most days Check for Symptoms See your doctor for regular follow up visits 58 Take Home Message