Ravi Kanth Heart Failure

8/4/2019 Ravi Kanth Heart Failure

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DR.RAVIKANTHDR.RAVIKANTH

PG[GEN. MED]PG[GEN. MED]



DEFINITIONDEFINITION

EPIDEMIOLOGYEPIDEMIOLOGY

CLASSIFICATIONCLASSIFICATION ETIOLOGYETIOLOGY

PATHOGENESISPATHOGENESIS

MANAGEMENTMANAGEMENT



DEFINITIONDEFINITION

Heart failure (HF) is a clinical syndromeHeart failure (HF) is a clinical syndrome

that occurs in pt¶s who because of that occurs in pt¶s who because of

inherited or acquired abnormality of inherited or acquired abnormality of cardiac structure or function, develop acardiac structure or function, develop a

constellation of clinical features that leadconstellation of clinical features that lead

to frequent hospitalizations, a poor qualityto frequent hospitalizations, a poor quality

of life, and a shortened life expectancyof life, and a shortened life expectancy



EPIDEMIOLOGYEPIDEMIOLOGY

HF prevalence rises with age.HF prevalence rises with age.

affects 6affects 6± ±10% of people over the age of 10% of people over the age of

65.65. relative incidence of HF is lower in womenrelative incidence of HF is lower in women

overall prevalence of HF is increasing, inoverall prevalence of HF is increasing, in

part because of advances in managementpart because of advances in managementof cardiac disorders, such as MI, valvular of cardiac disorders, such as MI, valvular

heart disease, and arrhythmias,heart disease, and arrhythmias,



Prevalence of CHF by Year 2030Prevalence of CHF by Year 2030Prevalence of CHF by Year 2030Prevalence of CHF by Year 2030

5.7

4.2

3

0

1

2

3

4

5

6

1990 Estimate 2010 Projection 2030 Projection

Cardiology Roundtable. 1998. Estimate based on expert interviews. Aging America: Trends and

Projections. 1991 ed. US Dept. of Health and Human Services, Washington, DC, 1991.



1

11

% OF

POPULATION

45 - 54 55 -64 65 - 74 75+

AGE [YRS]

PREVALENCE OF HF

MALES

FEMALES

Braunwald 8th edn



classificationclassification

HF patients categorized into two groups:HF patients categorized into two groups:

Because these two conditions haveBecause these two conditions have

distinct pathophysiology & prognosis.distinct pathophysiology & prognosis.



CLASSIFICATION

OF

HEART FAILURE

HF with Depressed

EF[Systolic failure]

HF with Preserved

EF[Diastolic failure]



ETIOLOGYETIOLOGY

DEPRESSED EF

CAD

CHRONIC PRESSURE OVERLOAD

CHRONIC VOLUME OVERLOAD

NON ISCHAEMIC DILATED CARDIOMYOPATHY

DISORDERS OF RATE & RHYTHM



PRESERVED EF

PATHOLOGICAL HYPERTROPHY

AGING

RESTRICTIVE CARDIOMYOPATHY

FIBROSIS

ENDOMYOCARDIAL DISORDERS



ETOLOGIES OF HF

CAD

OTHERS

CAD -HTN

CAD

CAD -HTN

OTHERS



Pulmonary Heart DiseasePulmonary Heart Disease

Cor pulmonaleCor pulmonale

Pulmonary vascular disordersPulmonary vascular disorders

HighHigh--Output StatesOutput States

Metabolic disorders ;Thyrotoxicosis,Metabolic disorders ;Thyrotoxicosis,Nutritional disorders (beriberi)Nutritional disorders (beriberi)

Excessive bloodExcessive blood--flow requirements;flow requirements;--Systemic arteriovenous shuntingSystemic arteriovenous shunting

--Chronic anemiaChronic anemia



Pathogenesis of HFPathogenesis of HF

with depressed EFwith depressed EF

Progressive disorder Progressive disorder

initiated by index eventinitiated by index event

Initially asymptomatic due to activatinInitially asymptomatic due to activatinof compensatory mechanismsof compensatory mechanisms

Transition from asymptomatic toTransition from asymptomatic to

symptomatic HF occurs due tosymptomatic HF occurs due to

ventricular remodellingventricular remodelling..



Compensatory mechanisms areCompensatory mechanisms are--

Activation of RAA & adrenergic nervous Activation of RAA & adrenergic nervous

system.system. Inc. myocardial contractility.Inc. myocardial contractility.

Activation of vasodilatory agents like Activation of vasodilatory agents like

ANP/BNP/PGE2/PGI2/NO ANP/BNP/PGE2/PGI2/NO



NEURO HORMONAL ACTIVATION NEURO HORMONAL ACTIVATION ± ±

Facilitate perfusion of vital organs initially.Facilitate perfusion of vital organs initially.

But finally contribute to end organ changes inBut finally contribute to end organ changes inheart & excess salt & water retention inheart & excess salt & water retention in

advanced HFadvanced HF



Compensatory mechanisms of HF



SHORT & LONGTERM RESPONSES TOSHORT & LONGTERM RESPONSES TO

IMPAIRED CARDIACIMPAIRED CARDIAC

PERFORMANCESPERFORMANCESRESPONSERESPONSE SHORT TERM EFFECSSHORT TERM EFFECS

± ± ACUTE HEART ACUTE HEART

FAILUREFAILURE

LONG TERM EFFECTSLONG TERM EFFECTS--

CHRONIC HEARTCHRONIC HEART

FAILUREFAILURE

Salt & water Salt & water

retention,retention,

vasoconstrictionvasoconstriction

SympatheticSympathetic

stimulationstimulation

Cytokine activationCytokine activation

HypertrophyHypertrophy

Inc. collagenInc. collagen

Inc.preloadInc.preload

Maintains perfusion of Maintains perfusion of

vital organsvital organs

inc,.HR & EFinc,.HR & EF

VasodilationVasodilation

Unloads individualUnloads individual

muscle fibrsmuscle fibrs

May reduce dilationMay reduce dilation

Pul.congestion,anasar Pul.congestion,anasar

ca,inc.pumpca,inc.pump

dysfunction,inc.cardiadysfunction,inc.cardiac energy expenditure.c energy expenditure.

Inc. energyInc. energy

expenditue & impairedexpenditue & impaired

contraction, lvcontraction, lv

remodelingremodeling

Deterioration & deathDeterioration & death

of cardiac cellsof cardiac cells

Impairs relaxationImpairs relaxation



LV RemodellingLV Remodelling

StimulusStimulus

Mechanical stretch of myocyteMechanical stretch of myocyte

Circulating neurohormonesCirculating neurohormones Inflammatory cytokinesInflammatory cytokines

Reactive oxygen speciesReactive oxygen species



Structural/functional changesStructural/functional changes

Myocyte hypertrophyMyocyte hypertrophy

Alterations in contractile properties of Alterations in contractile properties of myocytemyocyte

Progressive loss of myocyteProgressive loss of myocyte

Beta adrenergic desensitisationBeta adrenergic desensitisationReorganisation of extracellular matrixReorganisation of extracellular matrix

which doesn¶t provide supportwhich doesn¶t provide support



All these lead toAll these lead to

Decreased cardiac outputDecreased cardiac output

Inc lv dilationInc lv dilation Inc hemodynamic overloadigInc hemodynamic overloadig



MECHANISMS OF REMODELLINGMECHANISMS OF REMODELLING

& HF& HF

CELL CELL

GROWTHGROWTH

FIBROSISFIBROSIS APOPTOSISAPOPTOSIS

COUNTERCOUNTER

REGULATORREGULATOR

Y HOMONESY HOMONES

ANGIOTENSIN ANGIOTENSIN--IIII

CATECHOLAMINCATECHOLAMIN

ESES

ENDOTHELINENDOTHELIN

TNFTNF--ALPHA ALPHA

GROWTHGROWTH

HORMONEHORMONEIGFIGF

CARDIOTROPHICARDIOTROPHI

NN--II

MECHANICALMECHANICAL

STRETCHSTRETCH

ANGIOTENSIN ANGIOTENSIN--IIII

ENDOTHELINENDOTHELIN

ALDOSTERONE ALDOSTERONE

TGFTGF--BB

TNFTNF--ALPHA ALPHA

Fas LIGANDFas LIGAND

ANP ANP

BNPBNP

BRADYKININBRADYKININ

NONO



Pathogenesis of HF

with normal EF



CRITERIA FOR DIASTOLIC HFCRITERIA FOR DIASTOLIC HF

Definitive evidence of CHFDefinitive evidence of CHF

Objective evidence of normal LV systolicObjective evidence of normal LV systolic

functionfunctionObjective evidence of LV diastolicObjective evidence of LV diastolic

dysfunctiondysfunction

MEDICINE UPDATE 2010



DIFFERENCESDIFFERENCES

DHFDHF SHFSHF

EFEF normalnormal decreaseddecreased

Regional wallRegional wall

thicknessthickness

increasedincreased decreaseddecreased

EDVEDV NormalNormal increasedincreased

MEDICINE UPDATE 2010



SYMPTOMSSYMPTOMS

MAJORMAJOR

DysneaDysnea

OrthopneaOrthopnea

PndPnd Bil pedal edemaBil pedal edema

FatigueFatigue

Pulmonary edemaPulmonary edema

Exercise intoleranceExercise intolerance

cachexiacachexia

MINORMINOR

Wt.lossWt.loss

CoughCough

NocturiaNocturia

PalpitationsPalpitations

Peripheral cyanosisPeripheral cyanosis

depressiondepression



SIGNSSIGNS

MAJORMAJOR

TachycardiaTachycardia

Inc.venouspressureInc.venouspressure

Positive hepatojugular reflexPositive hepatojugular reflexRalesRales

TacypneaTacypnea

S3S3

HepatomegalyHepatomegaly

Ankle edema Ankle edema

Ascites Ascites

Pleural effusionPleural effusion

MINORMINOR

MRMR

CardiomegalyCardiomegaly

HypotensionHypotension

Pulsus alternansPulsus alternans

ExtrasystolesExtrasystoles

AF AF

Wt.lossWt.loss



FRAMINGHAM CRITERIAFRAMINGHAM CRITERIA

MAJOR CRITERIAMAJOR CRITERIA PND or orthopneaPND or orthopnea

neck vein distensionneck vein distension

RalesRales

CardiomegalyCardiomegaly

Acute pulmonary Acute pulmonary

edema,s3 gallopedema,s3 gallop

Hepatojugular Hepatojugular reflexreflex

IcreasedIcreased venous pressurevenous pressure

MINOR CRITERIAMINOR CRITERIA Ankle edema Ankle edema

ExertionalExertional dysneadysnea

HepatomegalyHepatomegaly

Pleural effusionPleural effusion

Decreased vital capacityDecreased vital capacity

Tachycardia[>120/min]Tachycardia[>120/min]



MAJOR OR MINOR CRITERIAMAJOR OR MINOR CRITERIA

Wt.loss > 4.5 kg in 5 days in response toWt.loss > 4.5 kg in 5 days in response to

treatmenttreatmentDIAGNOSISDIAGNOSIS

2 MAJOR2 MAJOR

1MAJOR + 2 MINOR1MAJOR + 2 MINOR



DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Pulmonary diseasePulmonary disease

pneumonia,asthma,copdpneumonia,asthma,copd

Sleep disordered breathingSleep disordered breathing

ObesityObesity

Renal failureRenal failure

Hepatic failureHepatic failure

HypoalbuminemiaHypoalbuminemia

Venous stasisVenous stasis



EVALUATION OF PTÙS WITH HFEVALUATION OF PTÙS WITH HF

Routine lab testingRoutine lab testing Cbp,sr.cr,electrolytes,ck,troponin,LFT,Cbp,sr.cr,electrolytes,ck,troponin,LFT,

TSH,urine analysisTSH,urine analysis

ChestChest--xx--rayray yesyes

ecgecg yesyes

2d2d--echoecho yesyes

Holter monitoringHolter monitoring No,unless symptoms of arrythmiaNo,unless symptoms of arrythmia

Exercise testingExercise testing yesyes

Coronary angiographyCoronary angiography Selected pt¶s with CADSelected pt¶s with CAD

biomarkersbiomarkers YesYes

CTCT

MRIMRI

FOLLOWFOLLOW--UPUP ClinicalClinical

examination,electrolytes,bnp,ecg,2examination,electrolytes,bnp,ecg,2

dd--echo when indicatedecho when indicated



ECGECG

Normal ecg excludes systolic dysfunction.Normal ecg excludes systolic dysfunction.

To asessTo asess

Rhythm abnormalitiesRhythm abnormalitiesHypertrophyHypertrophy

MIMI



CHEST XCHEST X--RAYRAY

Inc. calibre ul vesselsInc. calibre ul vessels

Septal linesSeptal lines

Small pl. effusionsSmall pl. effusions

Thickened interlobar Thickened interlobar

fissuresfissures

Bats wingBats wing

Vascular pedicle inc.Vascular pedicle inc. CardiomegalyCardiomegaly



KERLEYKERLEY--B LINESB LINES BasesBases

11--2 cm long2 cm long

Horizontal in directionHorizontal in direction

Perpendicular toPerpendicular topleural surfacepleural surface

KERLEYKERLEY--C LINESC LINES

Near hilumNear hilum Run obliquelyRun obliquely

Longer than BLonger than Blineslines



2d2d--echoecho

To assesTo asses

Lv functionLv function

Valvular abnormalitiesValvular abnormalitiesRegional wall motion abnormalitiesRegional wall motion abnormalities

Severity of lv remodellingSeverity of lv remodelling



BIOMARKERSBIOMARKERS

Provide diagnostic & prognosticProvide diagnostic & prognostic

information.information.

Predicts response to treatmentPredicts response to treatmentCommonly used are BNP & ProCommonly used are BNP & Pro--BNPBNP

Increased in both systolic & diastolicIncreased in both systolic & diastolic

dysfuction.dysfuction.Normal BNP excludesNormal BNP excludes HF.HF.



BNPBNP

32 AA polypeptide32 AA polypeptide

SourceSource ± ± ventricleventricle

Predictor of high LVPredictor of high LV

EDPEDP

Increases with ageIncreases with age

Women have highWomen have high

BNP than men[in nonBNP than men[in non--chf]chf]

Cut off point 80 pg/mlCut off point 80 pg/ml

1

81

55 -

64

65 -

74

75+

non - chf n

non- chf omen

CARDIOLOGY CLINICSCARDIOLOGY CLINICS--by JAMES B. YOUNGby JAMES B. YOUNG



THERAPEUTIC THERAPEUTIC

MONITORING MONITORING

U seful to evaluate longtermU seful to evaluate longterm

effects of short term Rx effects of short term Rx

ENDPOINTS ENDPOINTS-- death &death &

readmission ratesreadmission rates

Pt¶s with more BNP during Pt¶s with more BNP during

hosp & prehosp & pre-- discharge hasdischarge has

more end pointsmore end points

Final BNP < 430pg/ml is strong Final BNP < 430pg/ml is strong NPV for re admissionNPV for re admission 0

1600

END

N

N N

END

N

b f r Rx

ft r Rx




S EVERITY ASS E S MENT S EVERITY ASS E S MENT

M ore BNP levels at timeM ore BNP levels at time

of admission moreof admission more

severity severity NYHANYHA -- IV has moreIV has more

BNP compared to NYHABNP compared to NYHA

--I I

0

1000

I II III IV




ROLE IN ACUTE HF ROLE IN ACUTE HF

to differentiate acute hf to differentiate acute hf

from other causes of from other causes of

dyspneadyspnea

To predict outcomeTo predict outcome

M ore bnp levels indicateM ore bnp levels indicate

more symptomsmore symptoms

0

100

200

300

400

500

600700

800

900

1000

N N-

CH

V D CH




THERAPEUTIC THERAPEUTIC

MONITORING MONITORING

U seful to evaluate longtermU seful to evaluate longterm

effects of short term Rx effects of short term Rx

ENDPOINTS ENDPOINTS-- death &death &readmission ratesreadmission rates

Pt¶s with more BNP during Pt¶s with more BNP during

hosp & prehosp & pre-- discharge hasdischarge has

more end pointsmore end points

Final BNP < 430pg/ml is strong Final BNP < 430pg/ml is strong NPV for re admissionNPV for re admission 0

1600

END

IN

N N

END

IN

b f r Rx

ft r Rx




DIFFERNTIATION DIFFERNTIATION

Other conditionsOther conditions

Cor pulmonaleCor pulmonale

Pul.embolismPul.embolism

HTNHTN

LvhLvh

Acute or chronic Acute or chronic

ischemiaischemia0

10

20

30

40

50

60

H N D C D




Other biomarkersOther biomarkers

CRPCRP

TNFTNF--alphaalphaUric acid levelsUric acid levels

Surfectant proteinSurfectant protein--BB

Growth differentiating factor[gdf Growth differentiating factor[gdf--15]15]



MANAGEMENTMANAGEMENT

ACUTE HF ACUTE HF

CHRONIC HFCHRONIC HF

NEWER THERAPIESNEWER THERAPIES ACC GUIDELINES ACC GUIDELINES



ACUTE HF ACUTE HF



PRECIPITANTS OF HFPRECIPITANTS OF HF

POTENTIALLYPOTENTIALLYPRE ENTABLEPRE ENTABLE

NOTREADILYNOTREADILYPRE ENTABLEPRE ENTABLE

Poor dietary compliancePoor dietary compliance

Poormedical compliancePoormedical compliance

Use of drugs precipitatingUse of drugs precipitating

HFHF

inadequate HTN treatmentinadequate HTN treatment

Anemia Anemia

Excess alcohol consumptionExcess alcohol consumption

Acute MI Acute MI

Arrythmias Arrythmias

InfectionInfection

Acute valvular insufficiency Acute valvular insufficiency

Endocrine abnormalitiesEndocrine abnormalities



TREATMENT GOALSTREATMENT GOALS

Stabilize hemodynamic derangements thatStabilize hemodynamic derangements that

provoked symptomsprovoked symptoms

Identify & treat reversible factors thatIdentify & treat reversible factors thatprecipitated HFprecipitated HF

ReRe--establish effective OP regimen toestablish effective OP regimen to

prevent relapse & disease progressionprevent relapse & disease progression

Educate pt & familyEducate pt & family



CRITERIA FOR ADMISSIONCRITERIA FOR ADMISSION

E IDENCE OF SE ERELY E IDENCE OF SE ERELY DECOMPENSATED HFDECOMPENSATED HF

HypotensionHypotension

worsening renal functionworsening renal function

altered mentationaltered mentation

DYSPNEA AT RESTDYSPNEA AT REST

reflected by tachypnea at restreflected by tachypnea at rest

o2 sat < 90%o2 sat < 90% HEMODYNAMICALLY SIGNIFICANT HEMODYNAMICALLY SIGNIFICANT ARRYTHMIASARRYTHMIAS

including new onset AFincluding new onset AF

ACUTE CORONARY SYNDROMESACUTE CORONARY SYNDROMESHFSA GUIDE LINES



Immediate resuscitation

Pt distressed or in pain

Arterial o2 saturation>95%

Normal HR & Rhythm

Mean BP>70 mm hg

yes

no

no

yes

yes

yes

yes

No

no

no

Fluid challengeAdeqate preload

Inc.fio2,consider cpap,nippv

Pacing,antiarrythmics,etc

asodilators,consider diuresis

If volume overload

Analgesia or sedation

If moribund bls,als

Adeqate CO,reversal of metabolic

Acidosis ,svo2>65%,signs of Adeqate perfusion

no

yes

Consider inotropes or further

After load manipulation

Reasses freqently



HEMODYNAMIC PROFILES IN HEMODYNAMIC PROFILES IN

ACUTE HFACUTE HF

Elevated lv filling pressuresElevated lv filling pressures

PROFILE APROFILE A

Warm & dryWarm & dry

PROFILE BPROFILE B

Warm &wetWarm &wet

PROFILE LPROFILE L

Cold& dryCold& dry

PROFILE CPROFILE C

Cold&wetCold&wet



Hemodynamic classification provides useful guide for Hemodynamic classification provides useful guide for selecting initial optimal therapiesselecting initial optimal therapies

ProfileProfile--B[ to decrease lv filling pressures]B[ to decrease lv filling pressures]

DiureticsDiuretics

Vasodilators[ntg,nitropruside,nesiritide]Vasodilators[ntg,nitropruside,nesiritide]

ProfileProfile--c[to inc. CO & dec.lv filling press]c[to inc. CO & dec.lv filling press]

dobutaminedobutamine

dopaminedopamine

milrinonemilrinone ProfileProfile--LL

fluid therapy/dopaminefluid therapy/dopamine

TREATMENT STRATEGIES OF HFTREATMENT STRATEGIES OF HF



TREATMENT STRATEGIES OF HFTREATMENT STRATEGIES OF HF

olume Volume

over loadover load

Worsening Worsening

renal renal

functionfunction

SystolicSystolic

>100mm of >100mm of

hghg

Blood Blood

9090--100100

PressurePressure

<90<90

yesyes yesyes Vasodilator Vasodilator

diureticsdiuretics

vasodilator/invasodilator/in

otropeotrope

diureticsdiuretics

Inotrope/dopaInotrope/dopa

minemine

diureticdiuretic

yesyes nono Vasodilator Vasodilator diureticsdiuretics

Vasodilator/inVasodilator/inotropeotrope

Recheck vol.Recheck vol.statusstatus

Inotrope/dopaInotrope/dopa

minemine

diureticsdiuretics

nono yesyes Vasodilator for Vasodilator for

hyprtnsve HFhyprtnsve HF

Vasodilator/inVasodilator/in

otropeotrope

Rechck volRechck vol

statusstatus

Inotrope/dopInotrope/dop

Nor Nor--e/vpe/vp

nono nono vasodilator vasodilator treat astreat as

CardiogenicCardiogenic

shockshock

same assame as

aboveabove



INITIATING DOSEINITIATING DOSE MAXIMUM DOSEMAXIMUM DOSE

VASODILATORSVASODILATORS

NitroglycerinNitroglycerin

NitroprussideNitroprusside

NesiritideNesiritide

2020 mcg/minmcg/min

1010 mcg/minmcg/min

Bolus 2Bolus 2 mcg/kgmcg/kg

4040 ± ± 400400 mcg/minmcg/min

3535 ± ± 350350 mcg/minmcg/min

0.010.01 ± ± 0.030.03 mcg/kg/minmcg/kg/min

INOTROPESINOTROPES

DobutamineDobutamine

MilrinoneMilrinone

DopamineDopamine

levosimendanlevosimendan

11 ± ± 2 mcg/kg/min2 mcg/kg/min

Bolus 50 mcg/kgBolus 50 mcg/kg


Bolus 12 mcg/kgBolus 12 mcg/kg

22-- 10 mcg/kg/min10 mcg/kg/min

0.10.1 ± ± 0.75 mcg/kg/min0.75 mcg/kg/min


0.10.1 ± ± 0.2 mcg/kg/min0.2 mcg/kg/min

VASOCONSTRICTORVASOCONSTRICTOR

SS

DopamineDopamine

epinephrineepinephrine

5 mcg/kg/min5 mcg/kg/min

0.5 mcg/kg/min0.5 mcg/kg/min


50 mcg/kg/min50 mcg/kg/min



CRITERIA FOR DISCHARGECRITERIA FOR DISCHARGE

At least 24 hr stable fluid status,BP,renal At least 24 hr stable fluid status,BP,renal

function on oral regimen planned for homefunction on oral regimen planned for home

Should be free of dyspnea,symptomaticShould be free of dyspnea,symptomatic

hypotension while at rest & walking smallhypotension while at rest & walking small

distancesdistances

HFSA GUIDE LINES



CHRONIC HFCHRONIC HF



High Risk: Hypertension, coronary artery disease, diabetes, family

history of cardiomyopathy

Asymptomatic LVD: Previous MI, LV systolic dysfunction,

asymptomatic valvular disease

Symptomatic HF: Known structural

heart disease, shortness of breath and

fatigue, reduced exercise tolerance

Refractory

End-Stage HF:

Marked symptoms

at rest despite maximalmedical therapy

AA

BB

CC

DD

Heart Failure Disease Progression:Heart Failure Disease Progression:

ACC/AHA Heart Failure StagesACC/AHA Heart Failure Stages

Heart Failure Disease Progression:Heart Failure Disease Progression:

ACC/AHA Heart Failure StagesACC/AHA Heart Failure Stages

ACC/AHA = American College of Cardiology/American Heart Association; LVD = left ventricular

dysfunction; MI = myocardial infarction. Adapted from Yancy CW et al. Prim Care Spec Ed. 2002;6:15-19.



STAGESTAGE--A A STAGESTAGE--BB STAGESTAGE--CC STAGESTAGE--DD

High risk for High risk for developmentdevelopment

of HF,noof HF,no

structuralstructural

abnormalityabnormality

HaveHavestructuralstructural

abnormality,abnormality,

no symptomsno symptoms

HaveHavestructuralstructural

abnormality,abnormality,

symptomssymptoms

RefractoryRefractoryHF requiringHF requiring

specialisedspecialised

interventionsinterventions

Pt¶s withPt¶s with

HTN,CAD,DHTN,CAD,D

M or usingM or using

cardiotoxinscardiotoxinswith familywith family

h/o CMh/o CM

Pt¶s withPt¶s with

Previous MI,Previous MI,

Lv systolicLv systolic

dysfunction,dysfunction,

Asymptomati Asymptomati

c valvular c valvular

diseasedisease

Pt¶s with str.Pt¶s with str.

HeartHeart

disease,withdisease,with

sob,fatigue,resob,fatigue,reducedduced

exerciseexercise

intoleranceintolerance

Have markedHave marked

symptoms atsymptoms at

rest &rest &

refractory torefractory tomedicalmedical

treatmenttreatment



TREATMENT OF CHRONIC HFTREATMENT OF CHRONIC HF

STAGESTAGE--A A STAGESTAGE--BB STAGESTAGE--CC STAGESTAGE--DD

Treat HTN,Treat HTN,

EncourageEncourage

smoking cessation,smoking cessation,

Treat lipidTreat lipid

disorders,disorders,

Discourage alcoholDiscourage alcoholintake,intake,

Control metabolicControl metabolic

syndrome,syndrome,

ACE ACE-- I in appr. Pt¶sI in appr. Pt¶s

All measures All measures

under stageunder stage--aa

DRUGSDRUGS--

ACE ACE--II

ARB¶S ARB¶S

BB-- blockersblockersDevices inDevices in

selected pt¶sselected pt¶s

ICD¶SICD¶S

All measures All measures

under stageunder stage--a,a,

stagestage--b.b.

Drugs routine useDrugs routine use

Diuretics for fluidDiuretics for fluid

retentionretention

ACE ACE--II

In selected pt¶sIn selected pt¶s

Aldosterone ant Aldosterone ant

agonistsagonists

ARB¶S ARB¶S

DigitalisDigitalisHydralazine/nitrateHydralazine/nitrate

DevicesDevices

Biventricular Biventricular

pacingpacing

ICD¶SICD¶S

All measures under All measures under

stagestage ± ±a,b,ca,b,c

DECCISIONDECCISION

REGARDINGREGARDING

HEARTHEART

TRANSPLACENTATTRANSPLACENTAT

ION,ION,

ChronicChronic

INOTROPES,INOTROPES,

PermanentPermanent

mechanical supportmechanical support

etcetc



STEPPED THERAPY OF HF



TREATMENT OF CHFTREATMENT OF CHF



TREATMENT OF CHFTREATMENT OF CHF

Asses for fluid retention

Fluid retention No fluid retention

diuretic ACE-I

B-BLOCKER

If persistent symptoms ARB¶S

ALDOSTERONE ANTAGONISTHYDRALAZINE + ISOSORBIDE/DIGOXIN



DIURETIC S;DIURETIC S; Pt¶ s require chronic diuretic therapy often at lower dosesPt¶ s require chronic diuretic therapy often at lower doses

Decrease or discontinue if significant improvement in clinical status ocursDecrease or discontinue if significant improvement in clinical status ocurs

Consider following when congestion fails to improve with diuretic theraphyConsider following when congestion fails to improve with diuretic theraphy

--Na+ & fluid restrictionNa+ & fluid restriction--increase dose of loop diureticincrease dose of loop diuretic

--continuos infusioncontinuos infusion

--add orally[metalozone or spironolactone] or iv [chlorthiazide]add orally[metalozone or spironolactone] or iv [chlorthiazide]

--consider ultrafiltration finallyconsider ultrafiltration finally

Aldosterone antagonist¶s contraindication; Aldosterone antagonist¶s contraindication;--Sr.cr..>2.5mg/dlSr.cr..>2.5mg/dl

--sr.K+ >.5mmol/lsr.K+ >.5mmol/l

--in addition to othr K+ sparing diureticsin addition to othr K+ sparing diuretics

HFSA GUIDE LINES



Hydralazine/oral nitrate;Hydralazine/oral nitrate;

ConsiderationsConsiderations

in pt¶s intolerant to ACEin pt¶s intolerant to ACE--I/ARB¶S due toI/ARB¶S due tohyperkalemia ,renal insufficiencyhyperkalemia ,renal insufficiency

In pt¶s with LV dysfunction,remainIn pt¶s with LV dysfunction,remain

symptomatic despite standard therapysymptomatic despite standard therapy



BB--BLOCKERS BLOCKERS -- RECOMMENDATIONSRECOMMENDATIONS

GeneralGeneral initiate lower dosesinitiate lower doses

UptitrateUptitrate gradually,nogradually,no sooner sooner than at 2 week intervalsthan at 2 week intervals

Maintain at max. dosesMaintain at max. doses

Consideration if symptom worse or Consideration if symptom worse or

side effects occur side effects occur

Adjust dose of diuretic Adjust dose of diuretic

Titrate to target dose onceTitrate to target dose once

symptoms resolvesymptoms resolve

If uptitration difficultIf uptitration difficult Prolong titration intervalProlong titration interval

Reduce target doseReduce target dose

Ref to HF specialistRef to HF specialist

Acute exacerbation of chronic HF Acute exacerbation of chronic HFoccursoccurs

Maintain therapy if possibleMaintain therapy if possible

Reduce dose if necessaryReduce dose if necessary

Avoid abrupt discontinuation Avoid abrupt discontinuation

If stoped/red restart graduallyIf stoped/red restart gradually

before dischargebefore discharge



DIGOXINDIGOXIN

RecommendationsRecommendations

Pt¶s with symptomatic LV dysfunction whoPt¶s with symptomatic LV dysfunction whohave AFhave AF

For pt¶s with symptoms & signs of HFFor pt¶s with symptoms & signs of HF

while receiving standard therapywhile receiving standard therapy

DOSE DOSE

0.1250.125-- 0.25mg/day0.25mg/day



ANTICOAGULATION ;[ANTICOAGULATION ;[WARFARINWARFARIN]]

RecommendationRecommendation Pt¶s with chronic or paroxysmal AFPt¶s with chronic or paroxysmal AF

With h/o systemic/pulmonary emboli [stroke/TIA]With h/o systemic/pulmonary emboli [stroke/TIA]

Recent large anterior MI or recent mi with LVRecent large anterior MI or recent mi with LV

thrombus[treated for initial 3 months]thrombus[treated for initial 3 months]

INRINR------22--33

ASPIRINASPIRIN

Used in low doses in HF with IHDUsed in low doses in HF with IHD



CARDIAC RESYNCHRONISATIONCARDIAC RESYNCHRONISATION

THERAPHY/BIVENTRICULAR PACINGTHERAPHY/BIVENTRICULAR PACING

RecommendationsRecommendations Pt¶s in sinus rhythm with EF < 35%,andPt¶s in sinus rhythm with EF < 35%,and

QRS>120msQRS>120ms

Who remain symptomatic despite medicalWho remain symptomatic despite medicaltherapytherapy



ICD¶SICD¶S

Used to reduce sudden cardiac deathUsed to reduce sudden cardiac death

Considered for pt¶s of classConsidered for pt¶s of class--II,III HF withII,III HF withEF <30EF <30--35% on optimal medical therapy35% on optimal medical therapy



ANEMIA ANEMIA

Look for reversible causes & treatLook for reversible causes & treat

Role of erythropoitin under investigationRole of erythropoitin under investigationRENAL DY S FUNCTION RENAL DY S FUNCTION

Poor prognosisPoor prognosis

Treated with standard medical therapyTreated with standard medical therapy

Fluid restrictionFluid restriction

Hemofiltration & CRRT consideredHemofiltration & CRRT considered

VITAMIN DEFICIENCY VITAMIN DEFICIENCY

Abstinence from alcohol Abstinence from alcohol

Rx thiamine deficiencyRx thiamine deficiency

COR PULMONALE COR PULMONALE

Rx underlying pulmonary disorder [bronchodilators,steroids,AB¶s,NIMV]Rx underlying pulmonary disorder [bronchodilators,steroids,AB¶s,NIMV]

DiureticsDiuretics

Digoxin has less roleDigoxin has less role



NEUTRAL ENDOPEPTIDASE INHIBITORSNEUTRAL ENDOPEPTIDASE INHIBITORS

Useful in chronic HFUseful in chronic HF

MOA; inhibition of NEP which degradeMOA; inhibition of NEP which degradenariuretic peptidesnariuretic peptides

Example;Example;candoxatril,ecadotril candoxatril,ecadotril

ISTAROXIMEISTAROXIME

MOA;inhibition of Na+/K+ ATPase &MOA;inhibition of Na+/K+ ATPase &stimulation of sarcolemmal ca+ pumpstimulation of sarcolemmal ca+ pumpwhich improves myocardial relaxationwhich improves myocardial relaxation



VASOPRESSIN ANTAGONISTSVASOPRESSIN ANTAGONISTS

MOA;MOA;V1aV1a--receptor receptor--mediate vasoconstrictionmediate vasoconstriction

V2V2--mediate water reabsorptionmediate water reabsorptionDrugs;Drugs;

conivaptanconivaptan--v1a & v2 receptor antagonistv1a & v2 receptor antagonist

tolvaptan &tolvaptan & lixivaptanlixivaptan--v2 antagonistsv2 antagonists



OTHER THERAPIESOTHER THERAPIES

Natriuretic peptidesNatriuretic peptides

Cardiac myosin activatorsCardiac myosin activators

Adenosine antagonists Adenosine antagonists

Cytokine targeting therapyCytokine targeting therapy

Immunomodulation therapyImmunomodulation therapy

Immunoglobulin or interferon therapyImmunoglobulin or interferon therapy

Matrix modulation therapyMatrix modulation therapy



ACC 2009 GUIDE LINES ACC 2009 GUIDE LINES



ACCF/AHA practice guidelinesACCF/AHA practice guidelines are are intended tointended to

assist healthcare providers in clinicalassist healthcare providers in clinical

decision makingdecision making by describing a range of generallyby describing a range of generally

acceptable approachesacceptable approaches

for the diagnosis, management, andfor the diagnosis, management, andprevention of specific diseases or prevention of specific diseases or conditions.conditions.



Classification of RecommendationsClassification of Recommendations

CLASSCLASS--

11benifit >>> benifit >>>

riskrisk

CLASSCLASS--

2a 2a benefit>>riskbenefit>>risk

CLASSCLASS--

2b2b benefit > benefit >

risk risk

CLASSCLASS--

33Risk > Risk >

benifitbenifit

ProcedureProcedure

or or

treatmenttreatment

should beshould be

performedperformed

//

administer administer

eded

It isIt is

reasonablreasonabl

e toe to

performperform

ProcedureProcedure

/treatment/treatment

ProcedureProcedure


may bemay be

considereconsidere

dd

ProcedureProcedure


not to benot to be

performedperformed

,it may be,it may be

harmfulharmful

R OF HF WITH PRESERVED EFR OF HF WITH PRESERVED EF



Rx OF HF WITH PRE S ERVE D EF Rx OF HF WITH PRE S ERVE D EF STAGESTAGE--AA

ClassClass--11 Control of HTNControl of HTN

Treat lipid disordersTreat lipid disorders

Control blood sugar Control blood sugar

Avoid smoking,alcohol Avoid smoking,alcohol

Control rate or restore sinus rhythm in svt¶sControl rate or restore sinus rhythm in svt¶s

Treat thyroid disordersTreat thyroid disorders Perform periodic evaluation for signs &Perform periodic evaluation for signs &

symptoms of HFsymptoms of HF



ClassClass--22

ACE ACE--I or ARB¶S in pt¶s with h/oI or ARB¶S in pt¶s with h/o

atherosclerotic vascular atherosclerotic vascular disease,diabetes,or HTN with cvs riskdisease,diabetes,or HTN with cvs risk

factorsfactors



ClassClass--33

Nutritional supplements to preventNutritional supplements to prevent

development of structural heart disease.development of structural heart disease.



STAGESTAGE--BB

ClassClass--11 Apply All class Apply All class--1 recommendations as of stage1 recommendations as of stage--aa

BB--blocker&ACEblocker&ACE--I with h/o MI regardles of EF or I with h/o MI regardles of EF or

HF symptomsHF symptoms BB--blockr without h/o MI but with decreasd EF butblockr without h/o MI but with decreasd EF butno HF symptomsno HF symptoms

ACE ACE--I in all pt¶s with reducd EF with or withoutI in all pt¶s with reducd EF with or withouth/o MIh/o MI

Recommend coronary revascularisationRecommend coronary revascularisation Valvular replacement if hemodynamicalyValvular replacement if hemodynamicaly

significantsignificant



STAGESTAGE--BB

ClassClass--22

ACE ACE--I/ARB¶S for pt¶s with HTN & LVHI/ARB¶S for pt¶s with HTN & LVH

Placement of ICD in ischemic ³2a´/nonPlacement of ICD in ischemic ³2a´/nonischemic cardiomyopathy ³2b´ with EFischemic cardiomyopathy ³2b´ with EF

lessthan 30% &have reasonable lifelessthan 30% &have reasonable life

expectancy more than 1 yr expectancy more than 1 yr



ClassClass--33

Use of digoxin in pt¶s with lowUse of digoxin in pt¶s with low

EF,sinus rhythm,no h/o HF symptomsEF,sinus rhythm,no h/o HF symptomsUse of nutritional supplements to treatUse of nutritional supplements to treat

or prevent HFsymptomsor prevent HFsymptoms

Use of CCB¶S with negative inotropicUse of CCB¶S with negative inotropiceffect in asymptomatic pt¶s with loweffect in asymptomatic pt¶s with lowEF aftr MIEF aftr MI



STAGESTAGE--CC

ClassClass--11 Apply all clas Apply all clas--1 recommendations for stage1 recommendations for stage--aa

Diuretics&salt restriction in pt¶s of fluid retentionDiuretics&salt restriction in pt¶s of fluid retention ACE ACE--I in all unless contraindicatedI in all unless contraindicated

Avoid NSAID¶S,CCB¶S,anti Avoid NSAID¶S,CCB¶S,anti--arrythmicsarrythmics

exercise trainingexercise training

Placement of ICD in pt¶s with h/o cardiacPlacement of ICD in pt¶s with h/o cardiac

arrest,VF,VTarrest,VF,VT



ClassClass--2a2aDigitalis to decrease hospitalisationsDigitalis to decrease hospitalisations

Add combination of hydralazine & nitrate Add combination of hydralazine & nitratewith persistent symptoms inspite of takingwith persistent symptoms inspite of taking ACE ACE--I/BI/B--blockr blockr

ClassClass--2b2bUse of hydralazine/nitrate in pt¶s intolerantUse of hydralazine/nitrate in pt¶s intolerant

of ACEof ACE--I/ARB¶SI/ARB¶S



ICD therapy in pt¶s of IHD postICD therapy in pt¶s of IHD post--MI/non ischemicMI/non ischemic

cardiomyopathy with EF less than 30% withcardiomyopathy with EF less than 30% with

NYHA classNYHA class--2,3 symptoms to prolong survival2,3 symptoms to prolong survival

CRT in pt¶s of cardiac dyschrony,LVEF less thanCRT in pt¶s of cardiac dyschrony,LVEF less than30% in sinus rhythm,with NYHA class30% in sinus rhythm,with NYHA class--3,43,4

symptomssymptoms

Addition of aldosterone antagonist in selected Addition of aldosterone antagonist in selected

pt¶s if Sr.CR less than 2.5[men]/2 [women] &pt¶s if Sr.CR less than 2.5[men]/2 [women] &potassium less than 5mg/dlpotassium less than 5mg/dl



CLASSCLASS--33

Use of combination of ACEUse of combination of ACE--

I/ARB¶S/aldosterone antagonistsI/ARB¶S/aldosterone antagonistsUse of CCB¶SUse of CCB¶S

Longterm use of inotropic agentsLongterm use of inotropic agents



STAGESTAGE--DD

ClassClass--11

Meticulous identification &control of fluidMeticulous identification &control of fluid

retentionretentionRefer for cardiac transplantationRefer for cardiac transplantation

Offer pt¶s with implantable defibrillatorsOffer pt¶s with implantable defibrillators



ClassClass--2a2a Consider left ventricular assist device in highlyConsider left ventricular assist device in highly

selected pt¶s with refractory end stage failureselected pt¶s with refractory end stage failure

classclass--2b2b

Pulmonary artery catheter placement to guidePulmonary artery catheter placement to guide

therapytherapy

Mitral valve repair/replacementMitral valve repair/replacement

Continuous infusion of inotropic agentsContinuous infusion of inotropic agents



ClassClass--33

Partial left ventriculectomy not indicate inPartial left ventriculectomy not indicate in

pt¶s of non ischemic cardiomyopathypt¶s of non ischemic cardiomyopathyRoutine intermittent infusions of inotropicRoutine intermittent infusions of inotropic

agents not recommendedagents not recommended



Treatment of HF with normal EFTreatment of HF with normal EF

ClassClass--11 Control HTNControl HTN

Control Ventricular rate in pt¶s of AFControl Ventricular rate in pt¶s of AF

Diuretics to control congestive symptomsDiuretics to control congestive symptomsClassClass--2a2a Coronary revascularisation in pt¶s of CADCoronary revascularisation in pt¶s of CAD

ClassClass--2b2b Restoration & maintanence of sinus rhythm in af Restoration & maintanence of sinus rhythm in af Use of bUse of b--bckr/acebckr/ace--i/arb¶s not wel establishedi/arb¶s not wel established

Use of digoxin not establishedUse of digoxin not established



REFERENCESREFERENCES

HARRISON¶S 17HARRISON¶S 17 thth editionedition

BRAUNWALD¶S HEART DISEASE 8BRAUNWALD¶S HEART DISEASE 8 thth editionedition

HURST¶S Manual of cardiology 12HURST¶S Manual of cardiology 12thth editionedition


CARDIOLOGY UPDATE 2009CARDIOLOGY UPDATE 2009-- AMAL KUMAR AMAL KUMAR

BENERJEEBENERJEE

HEART FAILURE comprehensive guideHEART FAILURE comprehensive guide ± ± bybyG.WILLIAM DECG.WILLIAM DEC

Ravi Kanth Heart Failure

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