HEART FAILURE Jamil Mayet Consultant Cardiologist.

35
HEART FAILURE Jamil Mayet Consultant Cardiologist

Transcript of HEART FAILURE Jamil Mayet Consultant Cardiologist.

Page 1: HEART FAILURE Jamil Mayet Consultant Cardiologist.

HEART FAILURE

Jamil MayetConsultant Cardiologist

Page 2: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure

• Cardiac output that is insufficient to meet the needs of the body

– Myocardial dysfunction eg IHD, CM– Volume overload eg AR, MR– Obstruction eg AS, HCM– Diastolic dysfunction eg Constriction– Mechanical problems eg LV aneurysm– Rhythm disturbance eg A fib– High output eg anaemia, shunts, thyrotox

Page 3: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 4: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 5: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 6: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure - diagnosis

Page 7: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure symptoms• SOBE

• Orthopnoea, PND

• Ankle swelling

• Anorexia, weight loss

• Cold peripheries

• Tiredness

Heart failure signs• Tachycardia, hypotension

• Raised JVP, S3

• May be PSM of MR (or TR)

• Basal crepitations

• Ankle oedema

Not useful to divide into right and left heart failure

Page 8: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure - diagnosis

Page 9: HEART FAILURE Jamil Mayet Consultant Cardiologist.

ECG - normal

If ECG normal very unlikely to be systolic dysfunction

Page 10: HEART FAILURE Jamil Mayet Consultant Cardiologist.

ECG - abnormal

Previous MI, LBBB, Non-specific ST/T abnormalities

Page 11: HEART FAILURE Jamil Mayet Consultant Cardiologist.

CXR – pulmonary oedema

Page 12: HEART FAILURE Jamil Mayet Consultant Cardiologist.

CXR – septal lines

Page 13: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Echocardiography

• Confirms / refutes diagnosis of systolic dysfunction

• Can exclude significant valvular disease• Can suggest ischaemic aetiology if regional

wall motion abnormality• Can assess diastolic dysfunction

Page 14: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment – Acute heart failure• Sit up

• High dose oxygen

• Intravenous loop diuretic

• Venodilation eg intravenous GTN

• Possibly intravenous diamorphine

• (Venesection, dialysis)

• Intubation and ventilation

Cardiogenic shock•Severe hypotension

•Poor tissue perfusion - Oliguria, Confusion

•Mortality 80%+

•Inotropes eg Dopamine, Dobutamine

•IABP +/- angioplasty if cardiac ischaemia

Page 15: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Chronic heart failure - Mortality

Page 16: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure - treatment

• Salt restriction

• Fluid restriction

• Diuretics– Usually loop diuretics– Occasionally add thiazides

• May lead to excessive diuresis, electrolyte imbalance

• Amiloride, triamtarene may prevent low K

Page 17: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment – vasodilators

• Reduce preload / afterload– ACEI

• Reduce morbidity and mortality• Interact with RAAS• Prevent adverse remodelling post MI• May precipitate renal failure• Cough in 10-15% (consider AII blockers)

– Nitrates and hydralazine• Reduce morbidity / mortality but less than ACEI

Page 18: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 19: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 20: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 21: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment - inotropes

• Digoxin – Reduces hospital admissions– No reduction in mortality– Stopping may precipitate deterioration

• All other oral positive inotropes to date have caused an increased mortality

Page 22: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 23: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment – beta blockers

Page 24: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment – beta blockers

• Similar degree to ACEI and additive

• Possibly via reduction in sympathetic activation

• May precipitate pulmonary oedema– Start low doses and slowly titrate up

Page 25: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment – spironolactone

Page 26: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Treatment - spironolactone

• Probably via blockage of aldosterone

• May precipitate hyperkalaemia and renal failure

Page 27: HEART FAILURE Jamil Mayet Consultant Cardiologist.
Page 28: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Diagnosing ischaemic heart Diagnosing ischaemic heart diseasedisease

• 75% of white males in SOLVD were related 75% of white males in SOLVD were related to ischaemic heart diseaseto ischaemic heart disease

• 50% of patients in Framingham had an 50% of patients in Framingham had an ischaemic aetiology to their heart failureischaemic aetiology to their heart failure

• Identification of patients who will benefit Identification of patients who will benefit from revascularisationfrom revascularisation

Page 29: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Hibernating myocardiumHibernating myocardium

• Chronic LV dysfunction does not Chronic LV dysfunction does not necessarily imply dead myocardiumnecessarily imply dead myocardium

• ““Hibernating myocardium” termed by Hibernating myocardium” termed by Rahimtoola in 1989Rahimtoola in 1989

• LV systolic function improved following LV systolic function improved following coronary revascularisationcoronary revascularisation

Rahimtoola. Am Heart J 1989;117:211-Rahimtoola. Am Heart J 1989;117:211-2121

Page 30: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Hibernating myocardiumHibernating myocardium

Page 31: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Pacing for heart failurePacing for heart failure

Page 32: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Defibrillators for heart failureDefibrillators for heart failure

Page 33: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Diastolic heart failure

• Up to a third of patients have clinical heart failure with normal LV systolic function

• Underlying pathophysiology relates to diastolic dysfunction

• Commonest underlying pathologies – Normal ageing– Hypertension– Myocardial ischaemia

Page 34: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Mechanisms of diastolic dysfunction

• Impaired ventricular relaxation– Energy dependent process– Susceptible to myocardial ischaemia

• Decreased myocardial compliance– Altered compliance mediated by collagen– Fibrosis related to activation of RAAS

Page 35: HEART FAILURE Jamil Mayet Consultant Cardiologist.

Heart failure therapy - rule of halves

Treatment - no CCF

CCF - inadequatetherapy

CCF -appropriatetherapy