HEART FAILUREHEART FAILURE

ObjectivesObjectives-:-: DefinitionDefinition EpidemiologyEpidemiology AetiologyAetiology Pathophysiology Pathophysiology StagingStaging Symptoms & Symptoms &

SignsSigns InvestigationsInvestigations TreatmentsTreatments ComplicationsComplications

Definition :-Definition :- Inability to maintain a cardiac Inability to maintain a cardiac

output adequate for the body’s need.output adequate for the body’s need.

It is considered to be a clinical It is considered to be a clinical syndromesyndrome , because despite different , because despite different causes , it is associated with cardiac causes , it is associated with cardiac dilation and impaired cardiac dilation and impaired cardiac contractility .contractility .

Epidemiology :Epidemiology : It is Primarily a disease of old age , It is Primarily a disease of old age ,

affecting 30% of people over 80 affecting 30% of people over 80 years.years.

Improvements in the managements Improvements in the managements of acute MI & chronic heart disease of acute MI & chronic heart disease has led to more heart failure rates , has led to more heart failure rates , because more patients survive to because more patients survive to develop it later in life . develop it later in life .

Aetiology:- Aetiology:- Inadequate LV filling :Inadequate LV filling : -Mitral stenosis .-Mitral stenosis . -LV diastolic dysfunction -LV diastolic dysfunction

(LVH)(LVH) Pressure overload :Pressure overload : -Aortic stenosis .-Aortic stenosis . -Hypertension .-Hypertension . Volume overload :Volume overload : -Aortic or mitral regurgitation -Aortic or mitral regurgitation

.. -High output failure , e.g. -High output failure , e.g.

anemiaanemia LV muscle disease :LV muscle disease : -Myocardial infarction .-Myocardial infarction . -Cardiomyopathy.-Cardiomyopathy. -Myocarditis .-Myocarditis .

-Causes of Left heart failure:

- Causes of Right heart failure :

Any Cause of LHF .Any Cause of LHF .

Pulmonary hypertension (lung Pulmonary hypertension (lung disease) .disease) .

Atrial septal defect . Atrial septal defect .

Pathophysiology :-Pathophysiology :-1 Cardiac

Damage

Cardiac output

Peripheral resistance

Neuroendocrine activation

Fluid retention

2 Ventricular dilatation

Table 1. Stages of HFTable 1. Stages of HFٍ�ٍ�StStageage

DescriptionDescription ExamplesExamples

AAPatients at high risk for developing Patients at high risk for developing HF because of the presence of HF because of the presence of conditions that are strongly conditions that are strongly associated with the development of associated with the development of HF .Such patients have no identified HF .Such patients have no identified structural or functional abnormalities structural or functional abnormalities of the pericardium , myocardium , or of the pericardium , myocardium , or cardiac valves and have never shown cardiac valves and have never shown signs or symptoms of HFsigns or symptoms of HF. .

Systemic hypertension ; coronary Systemic hypertension ; coronary artery disease ; diabetes mellitus; artery disease ; diabetes mellitus; history of cardiotoxic drug therapy history of cardiotoxic drug therapy or alcohol abuse:personal history of or alcohol abuse:personal history of rheumatic fever:family history of rheumatic fever:family history of cardiomyopathycardiomyopathy::

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

Left ventricular hypertrophy or Left ventricular hypertrophy or fibrosis:LV dilatation or fibrosis:LV dilatation or hypocontractility :asymptomatic hypocontractility :asymptomatic valvular heart disease:prevous MIvalvular heart disease:prevous MI . .

CCPatients who have current or prior Patients who have current or prior symptoms of HF associated with symptoms of HF associated with underlying structural heart diseaseunderlying structural heart disease. .

Dyspnea or fatigue due to LV Dyspnea or fatigue due to LV systolic dysfunction ;asymptomatic systolic dysfunction ;asymptomatic patients who are undergoing patients who are undergoing treatment for prior symptoms of HFtreatment for prior symptoms of HF..

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

Patients who are frequantly Patients who are frequantly hospitalized for HF and cannot be hospitalized for HF and cannot be safely discharged from the safely discharged from the hospital;patients in the hospital hospital;patients in the hospital awating heart awating heart transplantation;patients at home transplantation;patients at home receiving continous IV support for receiving continous IV support for symptom relieve or being supported symptom relieve or being supported with mechanical circulatory assist with mechanical circulatory assist devicedevice . .

Symptoms & SignsSymptoms & Signs :: Symptoms :Symptoms : - Shortness of breath .- Shortness of breath .

- Orthopnea.- Orthopnea.

- PND.- PND.

Signs :Signs : - Tachypnoea .- Tachypnoea .

- Tachycardia .- Tachycardia .

- 3- 3rdrd heart sound on aus . heart sound on aus .

- Bibasilar pulmonary crepitations .- Bibasilar pulmonary crepitations .

-Left Heart Failure:

-Right Heart Failure:

Symptoms :Symptoms : Non specific such as :Non specific such as :

- Fatigue .- Fatigue . - Anorexia .- Anorexia .

- Nausea .- Nausea .

Signs :Signs : - JVP .- JVP . - Hepatomegly .- Hepatomegly .

- Pitting edema (an kles and pedal) .- Pitting edema (an kles and pedal) . - Ascites .- Ascites . - Functional tricuspid incompetence .- Functional tricuspid incompetence .

InvestigationsInvestigations: :

ECG .ECG . Echocardiography .Echocardiography . Chest x ray.Chest x ray. Nuclear isotope scanning .Nuclear isotope scanning . 24 hr ECG to investigate 24 hr ECG to investigate

arrhythmiasarrhythmias . .

Treatment

General Measures

MedicalSurgical

General MeasuresGeneral Measures.: .: .: .:

Treat the underlying cause .Treat the underlying cause . Reduce salt and water Reduce salt and water

intake .intake . Daily weight .Daily weight . Treat HTN and CAD Treat HTN and CAD

aggressively.aggressively.

:. :.Medical TreatmentMedical Treatment.: .:

Diuretics.Diuretics. ACE inhibitors .ACE inhibitors . Angiotensin II receptor Angiotensin II receptor

antagonist. antagonist. B- blockers.B- blockers. Digoxin .Digoxin .

(A)(A) Loop diuretics e.g. furosomide , Loop diuretics e.g. furosomide , bumetanide.bumetanide.

- MOA : Inhibit Na reabsorption - MOA : Inhibit Na reabsorption in the in the ascending limb of ascending limb of the loop of Henle.the loop of Henle.

- They are potent .- They are potent .

- S/E : - Marked renal k loss.- S/E : - Marked renal k loss.

- Promote hyperuricemia.- Promote hyperuricemia.

1 DiureticsDiuretics :: -Classified into :

(B)(B) Thiazides e.g. bendroflumethiazide. Thiazides e.g. bendroflumethiazide.

-MOA : Inhibit Na reabsorption in the -MOA : Inhibit Na reabsorption in the distal distal renal tubule. renal tubule.

-Mild diuretics except metolazone which -Mild diuretics except metolazone which causes excess diuresis. causes excess diuresis.

-S/E : -Hypokalemia.-S/E : -Hypokalemia.

- Hyperglycemia & hyperuricemia.- Hyperglycemia & hyperuricemia.

(C)(C) K- sparing diuretics e.g. spironolactone. K- sparing diuretics e.g. spironolactone.

-MOA :Increase Na secretion on the distal-MOA :Increase Na secretion on the distal

nephron and inhibit K secretion.nephron and inhibit K secretion.

-S/E :Gynaecomastia, nausea and -S/E :Gynaecomastia, nausea and abdominal pain. abdominal pain.

E.g. captopril , enalapril , lisinopril .E.g. captopril , enalapril , lisinopril . MOA :MOA : - Inhibit angiotensin II.- Inhibit angiotensin II.

- Increase cardiac output by decreasing preload and - Increase cardiac output by decreasing preload and afterload .afterload .

- Decrease vascular resistance and PCWP .- Decrease vascular resistance and PCWP .

Common S/E :Common S/E : - First dose hypotension .- First dose hypotension .

- the dose of diuretics 24 hr before first dose .- the dose of diuretics 24 hr before first dose .

- Start with low dose followed by gradual increase every - Start with low dose followed by gradual increase every 1-2 weeks . 1-2 weeks .

- Other S/E angioedema and persistant cough.- Other S/E angioedema and persistant cough.

2 ACE Inhibitors:

Studies of LVD (SOLVD) .Enalapril.Studies of LVD (SOLVD) .Enalapril.

- Decrease all cause mortality 16%- Decrease all cause mortality 16%

- Decrease mortality from HF 22% - Decrease mortality from HF 22%

Angiotensin 2 receptor Angiotensin 2 receptor antagonistantagonist: :

e.g. losartan ,valsartan.e.g. losartan ,valsartan. - They block binding of angiotensin 2 with type - They block binding of angiotensin 2 with type

1 receptors.1 receptors. - Do not produce cough.- Do not produce cough.

B – blockersB – blockers: : e.g. metoprolol, bisoprolol, carvedilol.e.g. metoprolol, bisoprolol, carvedilol. - Restricted to patients with chronic stable HF.- Restricted to patients with chronic stable HF. - ACC guidelines recommend that b-blockers - ACC guidelines recommend that b-blockers

should be should be routinely prescribed to routinely prescribed to patients with asymptomatic patients with asymptomatic LV dysfunction LV dysfunction unless they have contraindication.unless they have contraindication.

3

4

5 - Has +ve inotropic effect .- Has +ve inotropic effect . - No mortality benefit. - No mortality benefit.

DigoxinDigoxin : :

:. :.SurgerySurgery.: .: Cardiac transplantationCardiac transplantation . .

Has 90% 1-year survival after surgery .Has 90% 1-year survival after surgery . 75% a live after 5 years. 75% a live after 5 years. Death usually due to :Death usually due to : 1- operative mortality. 1- operative mortality. 2- organ rejection. 2- organ rejection.

ComplicationsComplications: :

ThromboembolismThromboembolism

AFAF

Ventricular arrythmia Ventricular arrythmia

QuestionsQuestions

What is New York HF classification ?What is New York HF classification ?

What are the C/I of ACE inhibitors ?What are the C/I of ACE inhibitors ?