Upload
maryann-norton
View
212
Download
0
Tags:
Embed Size (px)
Citation preview
Heart FailureHeart Failure
By: Hala M. Al-Khalidi, Pharm.D.By: Hala M. Al-Khalidi, Pharm.D.
Faculty of Pharmacy Faculty of Pharmacy
Clinical Pharmacy Division Clinical Pharmacy Division
KAAU KAAU
EpidemiologyEpidemiology
HF is most commonly diagnosed at ages HF is most commonly diagnosed at ages > > 65 yo, more 65 yo, more frequent frequent in men then women.in men then women.Approximately 400,000 new cases each year.Approximately 400,000 new cases each year.A 4 fold increase in hospitalization over the past 20 A 4 fold increase in hospitalization over the past 20 years. years. The five-year survival rate is about 30-40% for HF The five-year survival rate is about 30-40% for HF patients.patients.Class IV heart failure patients, the 1 year survival rate is Class IV heart failure patients, the 1 year survival rate is only 50%.only 50%.
Definition Definition
Heart failure (HF)Heart failure (HF) is defined as a syndrome in which is defined as a syndrome in which the heart fails to pump sufficient blood to meet the needs of the heart fails to pump sufficient blood to meet the needs of the body the body Ejection fraction (EF)Ejection fraction (EF) = % of the end-diastolic volume that = % of the end-diastolic volume that is ejected during systole (normal > 50%)is ejected during systole (normal > 50%)Preload -Preload - is the volume of blood that fills the ventricle is the volume of blood that fills the ventricle during diastole during diastole (filling of blood)(filling of blood) creating tension or stretch creating tension or stretch on the ventricle on the ventricle Contractility -Contractility - isis the force with which left ventricular the force with which left ventricular ejection occurs, it's independent of preload & afterload ejection occurs, it's independent of preload & afterload effects effects AfterloadAfterload - is the ventricular tension that occurs during - is the ventricular tension that occurs during systole systole (contraction & ejection of blood)(contraction & ejection of blood)
EtiologyEtiologySystolic DysfunctionSystolic Dysfunction
↓↓EF + ↑LVEDVEF + ↑LVEDV - Ischemic diseaseIschemic disease Myocardial Ischemia, & MI. Myocardial Ischemia, & MI.- Non- Ischemic diseaseNon- Ischemic disease ◘◘11ry ry Myocardial muscle dysfunctionMyocardial muscle dysfunction(idiopathic(idiopathic, , alcalc.,.,drug-drug-
iduced, familial).iduced, familial). ◘ ◘ VValvular abnormalities. alvular abnormalities. ◘ ◘ SStructural damage +/- damage to myocardial walls (e.g. tructural damage +/- damage to myocardial walls (e.g.
ventricualr septal defects).ventricualr septal defects). ◘ ◘ Hypertension (plumonary, systemic).Hypertension (plumonary, systemic).
Dilated Cardiomyopathy
EtiologyEtiology
Diastolic DysfunctionDiastolic Dysfunction ↔↔↓↓EF + ↑LVEDVEF + ↑LVEDV
◘ ◘ Hypertension ◘Hypertension ◘ AmyloidosisAmyloidosis ◘ ◘ Myocardial Ischemia ◘Myocardial Ischemia ◘ SarcoidosisSarcoidosis
HypertrophyCardiomyopathy
RestrictiveRestrictiveCardiomyopathyCardiomyopathy
Pathophysiology Pathophysiology
Systolic DysfunctionSystolic Dysfunction IImpaired ventricular contractionmpaired ventricular contraction
Target therapy of systolic dysfunctionTarget therapy of systolic dysfunction
EF < 40%EF < 40%
Diastolic DysfunctionDiastolic Dysfunction IImpaired relaxation/filling of ventriclempaired relaxation/filling of ventricle
((often occurs along with systolic dysfunction)often occurs along with systolic dysfunction)
Target therapyTarget therapy EF EF ≥≥ 45% 45%
Right-sided vs Left-sided HFRight-sided vs Left-sided HF
Right-sidedAbd. pain, anorexia, nausea, constipation Abd. pain, anorexia, nausea, constipation
Peripheral Edema, JVD, hepatojugular Peripheral Edema, JVD, hepatojugular reflex. reflex.
Left-sided
Dyspnea on exertion, Dyspnea on exertion,
PND, orthopnea, CoughPND, orthopnea, Cough
Pulmonary edema, Bibasilar ralesPulmonary edema, Bibasilar rales
Pleural effusion, (+) S3 Gallop. Pleural effusion, (+) S3 Gallop.
Non-specific
Symptoms Fatigue, weaknessFatigue, weakness
Cardiomegaly, Pallor.Cardiomegaly, Pallor.
HF Classification SystemHF Classification System
New York Heart Association Functional New York Heart Association Functional Classification:Classification:
- - Class I No Limitation of physical activity. Class I No Limitation of physical activity.
- Class II ordinary activity results in symptoms - Class II ordinary activity results in symptoms
of HF.of HF.
- Class III Marked limitation of physical activity.- Class III Marked limitation of physical activity.
- Class IV Symptoms of HF at rest. - Class IV Symptoms of HF at rest.
Other Precipitating CausesOther Precipitating Causes
InfectionInfection:: Fever, tachycardia, hypoxemia, and Fever, tachycardia, hypoxemia, and increased metabolic demand place further strain on increased metabolic demand place further strain on heart.heart.Anemia:Anemia: lack of oxygenating RBC demands heart to lack of oxygenating RBC demands heart to increase output-failing heart unable to do so.increase output-failing heart unable to do so.Pregnancy:Pregnancy: For tissue to be adequately perfused, For tissue to be adequately perfused, increased output is needed.increased output is needed.Arrythmias:Arrythmias: Erratic cardiac output.Erratic cardiac output.Physical, dietary, fluid, environmental andPhysical, dietary, fluid, environmental and emotionalemotional excesses:excesses: Any may precipitate heart failure Any may precipitate heart failure that was previously compensated. that was previously compensated.
Drugs that may exacerbate Drugs that may exacerbate HF & Other precipitating causesHF & Other precipitating causes
Negative inotropic effectNegative inotropic effect
- Anti-arrythmics, CCB (non-DHP).- Anti-arrythmics, CCB (non-DHP).
CardiotoxicCardiotoxic
- Doxorubicin, daunomycin, cyclophosphamide.- Doxorubicin, daunomycin, cyclophosphamide.
NaNa++/H/H22O retention O retention
- Glucocorticoids, androgens, estrogens, NSAIDs, - Glucocorticoids, androgens, estrogens, NSAIDs, salicylates(high dose), Nasalicylates(high dose), Na+ + containing drugs. containing drugs.
Morbidity & MortalityMorbidity & Mortality
Number of death due to CHF (1Number of death due to CHF (1ryry & 2 & 2ryry) increased 6-) increased 6-fold during the past 40 yearsfold during the past 40 years
5 year survival is 30-40% once diagnosed5 year survival is 30-40% once diagnosed
1 year survival is 50% for patients in class IV1 year survival is 50% for patients in class IV
3.5 million hospitalization, a3.5 million hospitalization, a 4- 4-fold increase over last fold increase over last 2 decades2 decades
Twice the costs of all forms cancer, up to 50 billion Twice the costs of all forms cancer, up to 50 billion annually annually
Leading cause of hospitalization in pts. > 65 yoLeading cause of hospitalization in pts. > 65 yo
Evaluation of HFEvaluation of HF
A.A. Assign stage of HF based on evaluation & progression of Assign stage of HF based on evaluation & progression of clinical findings clinical findings (ACC/AHA Guidelines for the Evaluation & (ACC/AHA Guidelines for the Evaluation & Management of Chronic Heart Failure)Management of Chronic Heart Failure)
B.B. Obtain LVEF via 2-dimensional echocardiogram Obtain LVEF via 2-dimensional echocardiogram (EF%, systolic, diastolic, & valvular disease)(EF%, systolic, diastolic, & valvular disease)
C.C. Ventricular hypertrophy & chest congestion can be Ventricular hypertrophy & chest congestion can be provided by chest X-ray provided by chest X-ray (cardiomegaly, plural effusion)(cardiomegaly, plural effusion)
D.D. ECG ECG E. liver enzyme elevation (heptomegaly) F.F. Assess fluid status:Assess fluid status:
• • weightweight • Peripheral edema • Peripheral edema • • JVDJVD • Hepato/splenomegaly • Hepato/splenomegaly • • RalesRales
Management of HF Management of HF
Goals of treatment:Goals of treatment: - Improve symptoms, QOL, and prolong life.Improve symptoms, QOL, and prolong life.- Prevention and progression to sever HF & cardiogenic Prevention and progression to sever HF & cardiogenic
shock.shock.
Non-pharmacologic/ Adjunct therapyNon-pharmacologic/ Adjunct therapy 1. 1. Minimize sodium intake (<3gmdaily).Minimize sodium intake (<3gmdaily). 2. Weight loss.2. Weight loss. 3. Smoking cessation. 3. Smoking cessation. 4. EtOH limitation.4. EtOH limitation. 5. A form of exercise. 5. A form of exercise. 6. surgical; correction of valvular disease, revascularization, 6. surgical; correction of valvular disease, revascularization,
heart transplant.heart transplant. 7. Avoide NSAID’s. 8. Flu/Pneumococcoal vac. 7. Avoide NSAID’s. 8. Flu/Pneumococcoal vac.
Management of HFManagement of HF
Pharmacological treatmentPharmacological treatment Most patients with symptomatic LVD should be managed Most patients with symptomatic LVD should be managed
with combination of 4 types of drugs:with combination of 4 types of drugs:
- ACEI,& B-B - ACEI,& B-B (improve EF effecting remodling),(improve EF effecting remodling), Diuretics, +/- Digitals, form the basic core for tx. HF, Diuretics, +/- Digitals, form the basic core for tx. HF,
hydralazine, & isosorbide for pt. who can’t take ACEI. hydralazine, & isosorbide for pt. who can’t take ACEI.
- Oxygination, and hospitalization. - Oxygination, and hospitalization.
- These drugs were established in large-scale clinical - These drugs were established in large-scale clinical trials. trials.
{{Evaluation and management of chronic heart failure in the adult feb.2002.} Evaluation and management of chronic heart failure in the adult feb.2002.}
Dosing of treatment cont.Dosing of treatment cont.
vasodilatorsvasodilatorsHydralazineHydralazine
Isosorbide dinitrateIsosorbide dinitrate
10mg tid10mg tid
10mg tid10mg tid
75mg tid-qid75mg tid-qid
40mg tid40mg tid
100mg 120mg100mg 120mg
SpironolactoneSpironolactone25mg qd25mg qd 25-50mg qd25-50mg qd 100mg100mg
Management HF Management HF
AnticoagulationAnticoagulation is not recommended, only in is not recommended, only in HF patients at risk with; HF patients at risk with; - - AF, DVT, & PE AF, DVT, & PE - EF - EF ≤ 25% may give warfarin≤ 25% may give warfarin
AntiarrhythmicAntiarrhythmic therapy only AF, VT, is the therapy only AF, VT, is the mode of death in up to 50% of HF cases, class mode of death in up to 50% of HF cases, class I antiarrthymic not recommended, amiodarone I antiarrthymic not recommended, amiodarone 11stst line agent (NSR-AF) & dofetilide appear to line agent (NSR-AF) & dofetilide appear to be safe, does not appear to increase mortality.be safe, does not appear to increase mortality.
Clinical studie’s endpointsClinical studie’s endpoints
Significant reduction in HF ProgressionSignificant reduction in HF Progressionimprove (S&S).improve (S&S).Significant reduction in hospitalization.Significant reduction in hospitalization.Improve exercise capacity.Improve exercise capacity.Significant reduction in morbidity & mortality.Significant reduction in morbidity & mortality.
Important Thing To DoImportant Thing To Do
Take your scheduled medications, missing doses Take your scheduled medications, missing doses
may worsen condition.may worsen condition.
A system reminder pill box, calender.A system reminder pill box, calender.
Refill med’s before running out.Refill med’s before running out.
Discuss medications S.E. with your doctor.Discuss medications S.E. with your doctor.
Discuss if less expensive medications would work.oDiscuss if less expensive medications would work.o
Carry an updated list of medications, with each clinic visit, Carry an updated list of medications, with each clinic visit, & include OTC’s.& include OTC’s.
Weigh your self daily & record, if the weight cahnges by 3 Weigh your self daily & record, if the weight cahnges by 3 pounds in a day, or 5pounds in a week , call your doctor.. pounds in a day, or 5pounds in a week , call your doctor..