2007 Engleza Heart Failure

8/7/2019 2007 Engleza Heart Failure

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CHRONIC CONGESTIVE

HEART FAILURE

2004 - 2005


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BACKGROUND:

HF PREVALENCE o from 3 - 20 at 45 years

to 80-160 over75 years

N.Sharpe, 1998

MORTALITY o with aging

5% deaths throughHF

below 45 years1/3 deaths through HF to 75 years

2/3 deaths through HF above 75 years

Chignon J, 1998

PHARMACOLOGICAL APPROACH

a. medication: intake / abuse / drug associations

b. changes in: - pharmacokinetics- pharmacodinamics

- social, economic, mental context.


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DEFINITION

(after ESC)

SUBJECTIVE:

HF symptoms:

dyspnea/ortopnea/ nocturnal paroxysmal d.

edema

tachycardia

rales

LV gallop

distended neck veins

OBJECTIVE: systolic/diastolic dysfunction

RETROSPECTIVE: response to correct HF treatment


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HF DIAGNOSIS: STEPS

Recognize HFpicture

Etiology

Pathogenesis: systolic/diastolic dysfunction

Recognize decompensation: edema, dyspnea

Assess morbidity/mortality predictive factors


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LV FAILURE

LV FAILURE: asymptomatic at rest, symptomatic at effort

edema

Cardiac asthma

Rest symptomatic LV failure

RV FAILURE

1. RECOGNIZE HF


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2. ETIOLOGY

CORONARY ARTERY DISEASE

- MYOCARDIAL INFARCTION

- CHRONIC ISCHEMIA

Systemic HYPERTENSION

CARDIOMYOPATHIES

- DILATIVE, HYPERTROPHIC, RESTRICTIVE- ACUTE MYOCARDITIS

- OTHER: METABOLIC, ENDOCRINE, NEUROMUSCULARE, TOXIC, etc.

VALVE DISEASES

- SEVERE AORTIC STENOSIS

- MITRALREGURGITATION

- AORTIC REGURGITATION

- MITRALSTENOSIS

OTHER

- ARRHYTHMIAS / BLOCKS

- INCREASED CARDIAC OUTPUT

- CONGENITAL CARDIAC DISEASES

- COR PULMONALE

- CONSTRICTIVE PERICARDITIS


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adapted LV insufficient LV

* dilation

* remodelling

* hemodynamic factors;

neurohumoral factors

3. LV DYSFUNCTION

* POPULATION AT RISK

* CAD

* Hypertension* valvular disease

* cardiomyopathies at onsetLV DYSFUNCTION

DIASTOLIC

-LVHc + EFn

-distensibility

-relaxation

-E/A


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DIASTOLIC DYSFUNCTION

= LV can not be filled at low pressure

Consequences * congestive syndrome pulmonary

peripheral

* EndD LV P > 12 mmHg

CLINIC signsofcongestive HF

cardiac silhouette normal

normal EF

Asymptomatic diastolic dysfunction ECHO

angiography/scintigraphy

Symptomatic: LV failure pulmonary HT right HF congestive syndrome chronic

low cardiac output


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ETIOLOGY:

* PERICARDITIS

* ENDOMYOCARDIALF

IBROSIS* Relaxation and ventricularcompliance deterioration:

concentric LV hypertrophy

CAD

RESTRICTIVE CARDIOPATHIES

* Pulmonary venousreturn decrease: HYPOVOLEMIA

* Secondary tosystolic dysfunction: MITRAL STENOSIS

AGGRAVATING FACTOR: ATRIAL FIBRILLATION


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DYSFUNCTION

SYSTOLIC DIASTOLIC

HISTORY OF

* MI ++ +/-* HTN + + +

ANAMNESIS

* BRUTAL ONSET +/- ++

X-RAY

* CARDIOMEGALY + + -

ECG* Q WAVE ++ +/-

* LV H +/- + +

ECHO EF q EF n

E/A < 1



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4. INVESTIGATIONS

1. HF detection

- Chest X-ray: cardio-thoracic index, pulmonary stasis

- Echocardiography: LV dysfunction- Ergospirometry: VO2 max

2. HF etiology

- ECG: ischemia / infarction, hypertrophy, arrhythmia

- Echocardiography: valve disease, systolic / diastolic dysfunction

- Rare causes: - thyroid dysfunction

- anemias- amiloidosis, sarcoidosis

- Cardiac catheterization

- PBM (myocardial biopsy)

3. HFseverity

- Isotopic ventriculography

- Myocardial scintigraphy- Ergospirometry

4. HFprognosis

- Holtermonitoring

- Assess - renal function

- liverfunction

- hydro-electrolitic equilibrium

- plasma NA peptide (> 900ng/ml)


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Establish diagnosis

Assessments in all cases

Necessary Supports Opposes

History with symptoms +++ Ifabsent

Objective evidence +++ Ifabsent

Response to treatment ++


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Testsfordiagnosis

Test


Electrocardiogram ++ Ifnormal

Echocardiography +++ Ifnormal

Chest x-ray Ifcongestion Ifnormal

Blood count Ifnormal

Blood chemistry Ifnormal


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Aditional tests

Test


Exercise test Ifnormal

Natriuretic peptide Ifelevated Ifnormal

Cardiac cath. Ifnormal


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CLASS I: no activity limitation patients have cardiac

dysfunction, had before HF symptoms and are under medication

for HF

CLASS II: moderate limitation of physical activity:

asymptomatic in resting, but usual effort leads to dyspnoea,

fatigue, palpitations or angina

CLASS III: important limitation of physical activity :

asymptomatic at rest, but an effort below the usual intensity

leads to symptoms.

CLASS IV: HF symptoms are present at rest and aggravated at

minimal effort. The patient is not able to perform any physical

activity without symptoms.

NYHA Classification

( New York Heart Association) 1964


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CLASA A VO2 max > 20 ml/min/kg

CLASA B VO2 max = 16-20 ml/min/kgCLASA C VO2 max = 10-15 ml/min/kg

CLASA D VO2 max < 10 ml/min/kg

CLASA E VO2 max < 6 ml/min/kg

Weber andJanicki Classification 1985


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* HYPERVOLEMIA

* PRIMARY CARDIOMYOPATHY

* CAD + ATRIAL ARRHYTHMIA

* DYSELECTROLYTEMIAS

- alcalosis with hypo-K+

- hypo-Na+

*ALCOHOL

* INADEQUATE TREATMENT

-digitalic toxicity-dysfunction -systolic

-diastolic - diuretics !!!

- antiarrhythmics

5. POTENTIAL REVERSIBLE CONDITIONS

THAT AGGRAVATE HF


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1. ACE inhibitors

- first-line therapy in patients with reduced EF < 45%, with orwithoutsymptoms

- in all HFstages.- fluid retention: ACE-i + Diuretic.

Recommendations:

- avoid excessive diuresis before treatment

- start with a low dose and build up tomaintenance dosage with

weekly monitoring creatinine and plasma ions- avoid potassium-sparing diuretics during therapy initiation

- avoid NSAIDs

If no satisfying response:

- change with anotherACE-i or

- Choose an AT1-receptorinhibitor


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2. Beta-blockade in HF

Indications

-stable mild, moderate and severe HFof ischemic and non-ischemicorigin (ifno contraindications)

-patients with LV dysfunction with/without HFpost-MI forsurvivalbenefit

Initiation and uptitration ofbeta-blockade in HF:

- stable patient on a background therapy with ACE-i + DiureticDigoxin

- nofluid retention

- no hypotension ( SBP < 90 mmHg)

- no bradycardia (HR < 55 / min)

- titrate slowly and carefully from low initial dose to target doses


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BETA-BLOCKERS in HF

-BLOCKER INITIAL DOSE (mg) TITRATION (mg) MAX DAILY DOSE(mg)

BISOPROLOL 1,25 2,5/3,75/5/7,5/10 10CARVEDILOL 3,125 6,25/12,5/25/50 50

METOPROLOL

Succinate CR 12,5/25 25/50/100/200 200

Tartrate 5 10/15/30/50/75/100 150


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Patientsshould be addressed to a specialist if:

Severe HF class III/IV Unknown etiology

Relative CI: bradicardia, low blood pressure

Low dose intolerance

Previous beta-blockeruse with treatment cessation because of

symptoms Suspicion ofasthma orCAD

Beta-blockers: contraindications in HF

Asthma

Severe bronchitis

Symptomatic bradicardia orhypotension


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3. DIURETICS

Loop-diuretics or thiazides

Always togetherwith an ACE-i

If GFR < 30 ml/min (glomerular filtration rate) then nothiazides (exception: if thiazides are adjuvant to loop-diuretics)

Insufficient response:

1. Increase diuretic dose2. Associate loop-diuretics and thiazides

3. Persistent fluid retention: loop-diuretics twice a day

4. Severe HF: monitorcreatinine and electrolytes


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Potassium-sparing diuretics: triamteren, amiloride,

spironolactone

Only if hypo-K+ persists after therapy initiation with ACE-I

and diuretics

Initiate with low dose for 1 week, then assess plasma K+

and creatinine after 5 - 7 days and increase correctly the

dose. Monitor K+ and creatinine every 5 7 days till K+ is

constant.


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MEDICATION INITIAL

DOSE

(mg)

MAX

DOSE

(mg)

SIDE EFFECTS

l.POTASSIUM-SPARING D.

* SPIRONOLACTONE 25 100

* AMILORID 5 40 HYPER-K +

* TRIAMTEREN 50 100

2.THIAZIDES

* HYDROCHLOROTHIAZID 25 50 DYSELECTROLYTEMIA

* METOLAZONE 2,5 10 THIAZIDIC DIABETES

METABOLIC

DISORDERS

3.LOOP-DIURETICS

* FUROSEMID 10 240

* BUMETANID 0,5 10 DYSELECTROLYTEMIA

* TORASEMID 5 100 METABOLIC

DISORDERS

* ETACRINIC ACID 50 200


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4. DIGITALIS GLYCOSIDES are indicated in:

-atrial fibrillation

-any symptomatic HFstage

-sinusrhythm, ifpersistent HF (systolic LVdysfunction) even if treated with ACE-i + Diuretic

Digoxin + Beta-blocker: superiorassociation vs. monotherapy


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5. Vasodilators

May be used as adjunctive therapy in HFforthe reliefof

angina oracute dyspnea (nitrates) orconcomitant

hypertension (DHP calcium antagonists) AT1 bl betterchoice than nitrates /hydralazine when

intolerance to ACE-I

Alpha-blockers are not recommended in HF

DHP calcium antagonists have no effect on survival inHF due to LV systolic dysfunction


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HF WORSENING imposesfollowing associations:

-Spironolactone and / or-Loop-diuretic + thiazide

HF class IV NYHA despite ofoptimal therapy and correct diagnosis

-Continue with mentioned measures

-Add palliative therapy in final stages (opioids)

LV DIASTOLIC DYSFUNCTION

Recommendations

-Beta-blockers

-Calcium antagonists (Verapamil)

-ACE-i

-Diuretics (caution!)-Arrhythmias control sustained VT Amiodarone

Symptomatic A.F. Digitalis


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Documents

2007 Engleza Heart Failure