Heart failure

Prepared by:Maha islami.

Supervised by :Majda Al-Attas.

outlineDefinition.Epidemiology.Etiology.Pathophysiology.Symptoms.Classification.Management.

Definition.Heart failure is defined as a syndrome in

which the heart fails to pump sufficient blood to meet the needs of the body.

Ejection fraction = % of the end-diastolic volume that is ejected during systole (normal > 50 % ).

Epidemiology• Heart failure is most commonly diagnosed at

ages > 65 yo , more frequent in men than women.

• Approximately 400,000 new cases each year.

Etiology Systolic Dysfunction :Ischemic disease myocardial ischemia,and MI.Non-Ischemic disease:I. 1ry myocardial muscle dysfunction (idiopathic ,

drug induced , familial).II.Valvular abnormalities.III.Structural damage +/- damage to myocardial

walls (e.g. ventricular septal defects).IV.Hypertension (pulmonary).

Etiology cont..…Diastolic Dysfunction:Hypertrophy cardiomyopathy.I. Hypertension.II.Myocardial Ischemia.Restrictive cardiomyopathy.I. Amyloidosis.II.Sarcoidosis.

Other precipitating causesInfection: fever, tachycardia, hypoxemia,and

increased metabolic demand place further strain on heart.

Anemia: lack of oxygenating RBC demands heart to increase output-failing heart unable to do so.

Pregnancy: for tissue to be adequately perfused, increased output is needed.

Arrythmias: erratic cardiac output.Dietary , and emotional excesses.

Drugs that may exacerbate HF.Negative inotropic effect:- anti-arrythmics, CCB (non-DHP).Cardiotoxic :- Doxorubicin, cyclophosphamide.Na+/H2O retention:- Glucocorticoids, androgens, estrogens,

NSAIDs.

pathophysiology

What Are The Symptoms of Heart Failure ?

Think FACES...• Fatigue.• Activities limited.• Chest congestion.• Edema or ankle swelling.• Shortness of breath.

Right-sided vs Left-sided HF.

Right-sidedAbd.pain, anorexia, nausea , constipation, peripheral edema, JVD, Hepatojugular reflex.

Left-sidedDyspnea on exertion, Prenight dyspnea, orthopnea, cough, pulmonary edema, pleural effusion, (+) S3 Gallop.

Non-specific symptoms

Fatigue, Weakness, Cardiomegaly, Pallor.

HF Classification systemNew York Heart Association Functional

classification:- Class I: NO Limitation of physical activity.- Class II: ordinary activity result in

symptoms of HF.- Class III: marked limitation of physical

activity.- Class IV: symptoms of HF at rest.

Stages of HF based on evolution and progression of clinical findings.

stagedescriptionexamples

APts at ↑risk of developing HF because of the presence of conditions that are strongly associated with the development of HF.such pts have no identified structural abnormalities and have never shown signs or symptoms of HF.

HTN,CAD,DM,Hx of cardiotoxic drug therapy,Hx of rheumatic fever, family Hx of cardiomyopathy.

BPts who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF.

Left ventricular hypertrophy or fibrosis, left ventricular dilation or hypocontractility, asymptomatic valvular heart disease, previous myocardial infarction.

Stages of HF based on evolution and progression of clinical findings cont…

stagedescriptionExamples

Cpts who have current symptoms of HF associated with underlying structural heart disease,

Dyspnea or fatigue duo to left ventricular systolic dysfunction.

DPts with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.

Pts who are frequently hospitalized for HF and cannot be safely discharged from the hospital receiving continuous IV support for symptom relief or being supported with a mechanical

circulatory assist device.

Evaluation of HF A. Assign stage of HF based on evaluation and

progression of clinical finding( Guidelines ).B. Obtain LVEF and dimensional echocardiogram.C. Ventricular hypertrophy and chest congestion can be

provided by chest X-ray(cardiomegaly, plural effusion).D. ECG.E. Liver enzyme elevation (hepatomegaly).F. Assess fluid status: -weight. -peripheral edema. -JVD.

-hepato/splenomegaly. - Rales.

Management of HFNon-pharmacologic /Adjunct therapy.1.Minimize sodium intake (< 3 gm daily).2.Weight loss.3.Smoking cessation.4.A form of exercise.5.Surgical : correction of valvular disease,

revascularization, heart transplant.6.Avoid NSAIDs.

Management of HF cont.…Pharmacological treatment:Most pts with symptomatic should be managed

with combination of 4 types of drugs:- ACEI +B-B(improve EF duo to effecting

remodling)+ Diuretics, +/- Digitals.(basic core ).Hydralazine and isosorbide for pt who can’t take

ACEI.Oxygination.Anticoagulation: is not recommended only in HF

pts at risk with :AF, DVT, PE,and EF≤25% may give Warfarin.

Management of HF cont.…Anti-arrhythmic: is the mode of death in

up to 50% of HF cases.class 1 anti-arrhythmic not recommended. (Amiodarone 1st line agent and Dofetilide appear to be safe ,does not appear to increase mortality.

HF Treatment optionsACEI:↓Preload and afterload,and ↑CO.1st line agents in the Tx. Showing a beneficial

effect on cardiac remodeling.Start at low dose and titrate , dose can be ↑q3-7

days.Elderly pts >75 YO should start ½ recommended

starting dose.

ACEI cont..…Dose:

SE:Dry cough, angioedema, neutropenia, skin rash,

proteinuria, hyperkalemia.

drugStarting dose Target dose Max dose

Captopril.enalapril.Cilazapril.

6.25-12.5 mg tid.2.5-5 mg qd.0.5 mg bid.

50 mg tid.10mg bid.1-2.5 mg bid.

100 mg tid.20 mg bid.5 mg bid.

HF Treatment options cont.…B-B:↓sympathetic stimulation by ↓plasma NE

peripheral vasoconstriction and cell death (apoptosis).

Dose:

drugInitial dose Target dose

Bisoprolol.1.25 mg once daily.10 mg once daily.

.Carvidolol3.125 mg twice daily.25 mg twice daily , 50 mg twice daily for pts >85 kg.

HF Treatment options cont.…SE: depression , nightmares , insomnia ,

bronchospasm , dizziness .Diuretics:↓edema and congestion (↓preload).IV for pulmonary edema.Oral doses are titrated according to symp and

body wt.Thiazid are weak diuretics and are used

infrequently in HF.

Diuretics cont.…Loop diuretics (furosemide)most widely used.Dose:

SE: ↓K , ↓Mg , DM , HA , jundice , arrythmia.

drugStarting doseMax dose

furosemide20-40 mg qd. 240 mg bid.

HCTZ25 mg qd. 50 mg qd.

Metalazone2.5 mg qd. 10 mg qd.

HF Treatment options cont.… digoxin:(+ ve )inotrope ,↑CO , May have beneficial effect

on vagal tone and ↓SNS.Used as second line therapy in pt not responding

to conventional therapy.Dose: initial dose 0.125-0.25 mg once daily.Target dose : 0.125-0.25 mg once daily.Digitalis Toxicity:Symptoms of toxicity: nausea , vomiting , headache , dizziness , chills , fever,

diarrhea , restlessness.

Digitalis Toxicity cont.… Treatment of the toxicity :1.Hold the medications.2.Observation.3.In case of A/V block or severe bradycardia →

atropine followed by temporary PM if needed.4.In life threatening arrhythmia → digoxin-

specific fab antibodies.5.Lidocaine and phenytoin could be used .

HF Treatment options cont.…CCB:Possible ↓in afterload.Amlodipine and Felodipine may have some

benefit in HF Pts with angina or HTN.Hydralazine and nitrates combination:Hydralazine :↓afterload.Nitrates:↓ preload.This combination the 1st to ↑survival in sever

HF.1st Tx in mild-moderate systolic HF.

Hydralazine and Nitrates combination cont ….

Not studied diastolic HF.Dose:

SE:Postural hypotension , sever HA , flushing , SLE .

drugStarting dose Target dose

Hydralazin and Isosorbide dinitrate

10 mg tid.10 mg tid.

75 mg tid-qid.40 mg tid-qid.

HF Treatment options cont.…Spironolactone:Block aldosterone chronically.Consider in pts with recent or current class IV

symptoms.Dose:

SE:Gynecomastia , agranulocytosis , N/V ,

Hyperkalemia.

Drug Starting dose Target dose Max dose

spironolactone25 mg qd.25-5o mg qd.100 mg.

Stage AStage BStage CStage DHigh risk of developing HF but no structural heart disease or symptoms of HF

Structural heart disease but without symptoms of HF.

Structural heart disease with prior or current symptoms of HF.

Refractory HF requiring specialized interventions.

Therapy

Treat HTN , encourage smoking cessation , treat lipid disorders , encourage regular exercise,ACEI in appropriate pts.

Therapy

All measures under stage A.ACEI in appropriate pts.B-adrenergic blockers in appropriate pts.

Therapy

All measures under stage A.Drugs for routine use:Diuretics.ACEI.B-B.+/-Digitalis.

Therapy

All measures under stages A, B,and C.Mechanical assist devices.Heart transplantation.Continuous IV inotropic infusions.

New Methods:Implantable ventricular assist devices.

New Methods cont…

• Biventricular pacing (only in patient with left bundle branch block).

References.• http://www.nlm.nih.gov/mdlineplus/

heartfailure.htm.

• http://www.emedicinehealth.com/congestive_heart_failure/article_em.htm.

Thank you