Heart FailureHeart Failure

By: Hala M. Al-Khalidi, Pharm.D.By: Hala M. Al-Khalidi, Pharm.D.

Faculty of Pharmacy Faculty of Pharmacy

Clinical Pharmacy Division Clinical Pharmacy Division

KAAU KAAU

EpidemiologyEpidemiology

HF is most commonly diagnosed at ages HF is most commonly diagnosed at ages > > 65 yo, more 65 yo, more frequent frequent in men then women.in men then women.Approximately 400,000 new cases each year.Approximately 400,000 new cases each year.A 4 fold increase in hospitalization over the past 20 A 4 fold increase in hospitalization over the past 20 years. years. The five-year survival rate is about 30-40% for HF The five-year survival rate is about 30-40% for HF patients.patients.Class IV heart failure patients, the 1 year survival rate is Class IV heart failure patients, the 1 year survival rate is only 50%.only 50%.

Definition Definition

Heart failure (HF)Heart failure (HF) is defined as a syndrome in which is defined as a syndrome in which the heart fails to pump sufficient blood to meet the needs of the heart fails to pump sufficient blood to meet the needs of the body the body Ejection fraction (EF)Ejection fraction (EF) = % of the end-diastolic volume that = % of the end-diastolic volume that is ejected during systole (normal > 50%)is ejected during systole (normal > 50%)Preload -Preload - is the volume of blood that fills the ventricle is the volume of blood that fills the ventricle during diastole during diastole (filling of blood)(filling of blood) creating tension or stretch creating tension or stretch on the ventricle on the ventricle Contractility -Contractility - isis the force with which left ventricular the force with which left ventricular ejection occurs, it's independent of preload & afterload ejection occurs, it's independent of preload & afterload effects effects AfterloadAfterload - is the ventricular tension that occurs during - is the ventricular tension that occurs during systole systole (contraction & ejection of blood)(contraction & ejection of blood)

EtiologyEtiologySystolic DysfunctionSystolic Dysfunction

↓↓EF + ↑LVEDVEF + ↑LVEDV - Ischemic diseaseIschemic disease Myocardial Ischemia, & MI. Myocardial Ischemia, & MI.- Non- Ischemic diseaseNon- Ischemic disease ◘◘11ry ry Myocardial muscle dysfunctionMyocardial muscle dysfunction(idiopathic(idiopathic, , alcalc.,.,drug-drug-

iduced, familial).iduced, familial). ◘ ◘ VValvular abnormalities. alvular abnormalities. ◘ ◘ SStructural damage +/- damage to myocardial walls (e.g. tructural damage +/- damage to myocardial walls (e.g.

ventricualr septal defects).ventricualr septal defects). ◘ ◘ Hypertension (plumonary, systemic).Hypertension (plumonary, systemic).

Dilated Cardiomyopathy

EtiologyEtiology

Diastolic DysfunctionDiastolic Dysfunction ↔↔↓↓EF + ↑LVEDVEF + ↑LVEDV

◘ ◘ Hypertension ◘Hypertension ◘ AmyloidosisAmyloidosis ◘ ◘ Myocardial Ischemia ◘Myocardial Ischemia ◘ SarcoidosisSarcoidosis

HypertrophyCardiomyopathy

RestrictiveRestrictiveCardiomyopathyCardiomyopathy

Pathophysiology Pathophysiology

Systolic DysfunctionSystolic Dysfunction IImpaired ventricular contractionmpaired ventricular contraction

Target therapy of systolic dysfunctionTarget therapy of systolic dysfunction

EF < 40%EF < 40%

Diastolic DysfunctionDiastolic Dysfunction IImpaired relaxation/filling of ventriclempaired relaxation/filling of ventricle

((often occurs along with systolic dysfunction)often occurs along with systolic dysfunction)

Target therapyTarget therapy EF EF ≥≥ 45% 45%

Right-sided vs Left-sided HFRight-sided vs Left-sided HF

Right-sidedAbd. pain, anorexia, nausea, constipation Abd. pain, anorexia, nausea, constipation

Peripheral Edema, JVD, hepatojugular Peripheral Edema, JVD, hepatojugular reflex. reflex.

Left-sided

Dyspnea on exertion, Dyspnea on exertion,

PND, orthopnea, CoughPND, orthopnea, Cough

Pulmonary edema, Bibasilar ralesPulmonary edema, Bibasilar rales

Pleural effusion, (+) S3 Gallop. Pleural effusion, (+) S3 Gallop.

Non-specific

Symptoms Fatigue, weaknessFatigue, weakness

Cardiomegaly, Pallor.Cardiomegaly, Pallor.

HF Classification SystemHF Classification System

New York Heart Association Functional New York Heart Association Functional Classification:Classification:

- - Class I No Limitation of physical activity. Class I No Limitation of physical activity.

- Class II ordinary activity results in symptoms - Class II ordinary activity results in symptoms

of HF.of HF.

- Class III Marked limitation of physical activity.- Class III Marked limitation of physical activity.

- Class IV Symptoms of HF at rest. - Class IV Symptoms of HF at rest.

Other Precipitating CausesOther Precipitating Causes

InfectionInfection:: Fever, tachycardia, hypoxemia, and Fever, tachycardia, hypoxemia, and increased metabolic demand place further strain on increased metabolic demand place further strain on heart.heart.Anemia:Anemia: lack of oxygenating RBC demands heart to lack of oxygenating RBC demands heart to increase output-failing heart unable to do so.increase output-failing heart unable to do so.Pregnancy:Pregnancy: For tissue to be adequately perfused, For tissue to be adequately perfused, increased output is needed.increased output is needed.Arrythmias:Arrythmias: Erratic cardiac output.Erratic cardiac output.Physical, dietary, fluid, environmental andPhysical, dietary, fluid, environmental and emotionalemotional excesses:excesses: Any may precipitate heart failure Any may precipitate heart failure that was previously compensated. that was previously compensated.

Drugs that may exacerbate Drugs that may exacerbate HF & Other precipitating causesHF & Other precipitating causes

Negative inotropic effectNegative inotropic effect

- Anti-arrythmics, CCB (non-DHP).- Anti-arrythmics, CCB (non-DHP).

CardiotoxicCardiotoxic

- Doxorubicin, daunomycin, cyclophosphamide.- Doxorubicin, daunomycin, cyclophosphamide.

NaNa++/H/H22O retention O retention

- Glucocorticoids, androgens, estrogens, NSAIDs, - Glucocorticoids, androgens, estrogens, NSAIDs, salicylates(high dose), Nasalicylates(high dose), Na+ + containing drugs. containing drugs.

Morbidity & MortalityMorbidity & Mortality

Number of death due to CHF (1Number of death due to CHF (1ryry & 2 & 2ryry) increased 6-) increased 6-fold during the past 40 yearsfold during the past 40 years

5 year survival is 30-40% once diagnosed5 year survival is 30-40% once diagnosed

1 year survival is 50% for patients in class IV1 year survival is 50% for patients in class IV

3.5 million hospitalization, a3.5 million hospitalization, a 4- 4-fold increase over last fold increase over last 2 decades2 decades

Twice the costs of all forms cancer, up to 50 billion Twice the costs of all forms cancer, up to 50 billion annually annually

Leading cause of hospitalization in pts. > 65 yoLeading cause of hospitalization in pts. > 65 yo

Evaluation of HFEvaluation of HF

A.A. Assign stage of HF based on evaluation & progression of Assign stage of HF based on evaluation & progression of clinical findings clinical findings (ACC/AHA Guidelines for the Evaluation & (ACC/AHA Guidelines for the Evaluation & Management of Chronic Heart Failure)Management of Chronic Heart Failure)

B.B. Obtain LVEF via 2-dimensional echocardiogram Obtain LVEF via 2-dimensional echocardiogram (EF%, systolic, diastolic, & valvular disease)(EF%, systolic, diastolic, & valvular disease)

C.C. Ventricular hypertrophy & chest congestion can be Ventricular hypertrophy & chest congestion can be provided by chest X-ray provided by chest X-ray (cardiomegaly, plural effusion)(cardiomegaly, plural effusion)

D.D. ECG ECG E. liver enzyme elevation (heptomegaly) F.F. Assess fluid status:Assess fluid status:

• • weightweight • Peripheral edema • Peripheral edema • • JVDJVD • Hepato/splenomegaly • Hepato/splenomegaly • • RalesRales

Management of HF Management of HF

Goals of treatment:Goals of treatment: - Improve symptoms, QOL, and prolong life.Improve symptoms, QOL, and prolong life.- Prevention and progression to sever HF & cardiogenic Prevention and progression to sever HF & cardiogenic

shock.shock.

Non-pharmacologic/ Adjunct therapyNon-pharmacologic/ Adjunct therapy 1. 1. Minimize sodium intake (<3gmdaily).Minimize sodium intake (<3gmdaily). 2. Weight loss.2. Weight loss. 3. Smoking cessation. 3. Smoking cessation. 4. EtOH limitation.4. EtOH limitation. 5. A form of exercise. 5. A form of exercise. 6. surgical; correction of valvular disease, revascularization, 6. surgical; correction of valvular disease, revascularization,

heart transplant.heart transplant. 7. Avoide NSAID’s. 8. Flu/Pneumococcoal vac. 7. Avoide NSAID’s. 8. Flu/Pneumococcoal vac.

Management of HFManagement of HF

Pharmacological treatmentPharmacological treatment Most patients with symptomatic LVD should be managed Most patients with symptomatic LVD should be managed

with combination of 4 types of drugs:with combination of 4 types of drugs:

- ACEI,& B-B - ACEI,& B-B (improve EF effecting remodling),(improve EF effecting remodling), Diuretics, +/- Digitals, form the basic core for tx. HF, Diuretics, +/- Digitals, form the basic core for tx. HF,

hydralazine, & isosorbide for pt. who can’t take ACEI. hydralazine, & isosorbide for pt. who can’t take ACEI.

- Oxygination, and hospitalization. - Oxygination, and hospitalization.

- These drugs were established in large-scale clinical - These drugs were established in large-scale clinical trials. trials.

{{Evaluation and management of chronic heart failure in the adult feb.2002.} Evaluation and management of chronic heart failure in the adult feb.2002.}

Dosing of treatment cont.Dosing of treatment cont.

vasodilatorsvasodilatorsHydralazineHydralazine

Isosorbide dinitrateIsosorbide dinitrate

10mg tid10mg tid

10mg tid10mg tid

75mg tid-qid75mg tid-qid

40mg tid40mg tid

100mg 120mg100mg 120mg

SpironolactoneSpironolactone25mg qd25mg qd 25-50mg qd25-50mg qd 100mg100mg

Management HF Management HF

AnticoagulationAnticoagulation is not recommended, only in is not recommended, only in HF patients at risk with; HF patients at risk with; - - AF, DVT, & PE AF, DVT, & PE - EF - EF ≤ 25% may give warfarin≤ 25% may give warfarin

AntiarrhythmicAntiarrhythmic therapy only AF, VT, is the therapy only AF, VT, is the mode of death in up to 50% of HF cases, class mode of death in up to 50% of HF cases, class I antiarrthymic not recommended, amiodarone I antiarrthymic not recommended, amiodarone 11stst line agent (NSR-AF) & dofetilide appear to line agent (NSR-AF) & dofetilide appear to be safe, does not appear to increase mortality.be safe, does not appear to increase mortality.

Clinical studie’s endpointsClinical studie’s endpoints

Significant reduction in HF ProgressionSignificant reduction in HF Progressionimprove (S&S).improve (S&S).Significant reduction in hospitalization.Significant reduction in hospitalization.Improve exercise capacity.Improve exercise capacity.Significant reduction in morbidity & mortality.Significant reduction in morbidity & mortality.

Important Thing To DoImportant Thing To Do

Take your scheduled medications, missing doses Take your scheduled medications, missing doses

may worsen condition.may worsen condition.

A system reminder pill box, calender.A system reminder pill box, calender.

Refill med’s before running out.Refill med’s before running out.

Discuss medications S.E. with your doctor.Discuss medications S.E. with your doctor.

Discuss if less expensive medications would work.oDiscuss if less expensive medications would work.o

Carry an updated list of medications, with each clinic visit, Carry an updated list of medications, with each clinic visit, & include OTC’s.& include OTC’s.

Weigh your self daily & record, if the weight cahnges by 3 Weigh your self daily & record, if the weight cahnges by 3 pounds in a day, or 5pounds in a week , call your doctor.. pounds in a day, or 5pounds in a week , call your doctor..