HEART FAILURE Study day November 2017

Sarah Briggs and Janet Laing

Overview and Introduction

• This course is an introduction and overview of heart

failure. Normal heart function and basic pathophysiology

of heart failure is explained. This will be then related to

the diagnosis of heart failure and to the overall

management of patients with heart failure. Device therapy

will be explained, and also finally we will have discussion

session about palliative care and heart failure.

Demographics of heart failure

• Heart failure is serious

• Heart failure is terminal

• Heart failure is unpredictable

• Heart failure causes severe symptoms

• Heart failure outcomes are directly linked to good

management and self monitoring.

You can make a profound difference to a patient’s life

Plan of the Day

• The normal heart

• Pathophysiology of heart failure

• Clinical presentation: History, assessment and clinical

examination

• Differential diagnosis, Investigations and Diagnosis

• Pharmacological Management

• Non medical Management

• Palliative care

• Device therapy

1. The Normal Heart

1. Normal Heart Function

• The Cardiac Circulation

• The Cardiac Valves

• The Coronary Circulation

• The Cardiac Electrical System

The Heart = A house!

Coronary circulation

Coronary circulation

2. Pathophysiology of Heart

Failure

2. Pathophysiology of heart failure

The two types of heart failure affecting the left ventricle.

• HFrEF – can’t pump

• HFPEF – can’t relax

2. Pathophysiology of heart failure

Causes: Myocardial Infarction

Ischaemia

2. Pathophysiology of heart failure

Causes: Hypertension

and aortic stenosis

Hypertension

Hypertension

Aortic Stenosis

Left Ventricular Hypertrophy

Other causes include:

• Mitral regurgitation

• Atrial fibrillation

• Cardiomyopathies

• Chemotherapy …….

Neurohormonal Activation

• Increased Sympathetic activation

• Reduction in renal perfusion results in activation of the

RAAs

• Brain natriuretic peptide release

Neurohormonal Activation

The Natriuretic Peptide System

Heart failure is unpredictable!

3. History, Assessment and

Clinical Examination

History

• Presenting Complaint:

• History of Presenting Complaint:

• Past Medical History:

Its Systemic

• Fatigue

• Cool extremities

• Pallor

• Heavy leaden legs

• Renal dysfunction

• Anaemia

• Acute/increasing breathlessness

• Presents/punctuated with unpredictable episodes of fluid

retention…..

3. Clinical Presentation

Signs of Heart Failure

- General Appearance – distress, gait, mobility, colour, pallor,

tachypnoea, breathlessness, audible breath sounds,habitus,

• Tachycardia/irregular

• Hypertension/hypotension

• Pallor/mallor flush

• Elevated JVP (>5cm)

• Heart Sounds – third heart sound

• Added Breath Sounds – Crepitations/wheeze

• Abdominal distension

• Oedema – legs/sacral

Elevated JVP

Crepitations

• https://youtu.be/9C5RFb1qWT8

Pulmonary Oedema

Ascites

Pitting Oedema

The Burden of Heart Failure

Warning Signs

Weight Gain!!

Lets Talk about it!!.......

5. Differential Diagnoses

???

Is it ?

• Chest

infection/pneumonia?

• Pulmonary Embolism?

• COPD?

• N/AFLD?

• Obesity?

• Reduced Venous Return?

• Lymphoedema?

Or is it?

• Heart Failure?

6. Investigation

Investigations

• BNP

• ECHO

• ECG

• CXR

• Holter monitor

• 24hour BP

• Also Cardiac MR, MPS, Angiography

7. Diagnosis

Heart Failure??

Lets review the ECHO………

8. Pharmacological Management

Neurohormonal deactivation

1. Adrenaline

• Beta Blockers

Dose

Side Effects

Monitoring

Neurohormonal Deactivation

2. Angiotensin II

• ACE Inhibition

Dose

Side Effects

Monitoring

ARNI – Angiotensin receptor/Neprilysn

Inhibition

ARNI

Neurohormonal Deactivation

3. Aldosterone

• MRA

Dose

Side Effects

Monitoring

Symptomatic management

•Diuretics Loop/thiazide

Dose

Side Effects

Monitoring

Other Pharmacological agents and

contraindications • Digoxin

• Oral Anticoagulations – NOACS

• Ivabradine

• Antianginals

• Antihypertensives

• Palliative Medications

• Contraindications

9. Non Pharmacological

Management

Non Pharmacological Management

• Anxiety/stress management

• Depression/low mood

• Support Groups

• Telehealth

• Salt intake

• Fluid intake

• Dry mouth

Non Pharmacological Management

• Exercise

• General weight management

• Smoking, alcohol

• Fatigue management – goal setting

• Sleep

• Caffeine intake

• Vaccinations

• Holidays

11. Palliative Care

10. Device Therapy

CRT and ICD

NYHA class

QRS interval I II III IV

<120 milliseconds ICD if there is a high risk of sudden

cardiac death

ICD and CRT not

clinically indicated

120–149 milliseconds

without LBBB

ICD ICD ICD CRT-P

120–149 milliseconds

with LBBB

ICD CRT-D CRT-P or

CRT-D

CRT-P

≥150 milliseconds with

or without LBBB

CRT-D CRT-D CRT-P or

CRT-D

CRT-P

LBBB, left bundle branch block; NYHA, New York Heart Association

• https://www.youtube.com/watch?v=7hEw4o06Fwc

CRT