Heart Failure Rev UKRIDA

8/13/2019 Heart Failure Rev UKRIDA

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DR. Med. Dr. Tike Ha ri Prati kto, SpJP, FIHA,FICA


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The situation when the heart is incapable of maintaining a cardiac

output adequate to accommodate metabolic requirements and the

venous return. (E. Braunwald)

The inability of the heart to pump blood forward at a sufficient rate to

meet the metabolic demands of the body (forward failure), or the

ability to do so only if the cardiac filling pressure are abnormally high

(backward failure), or both. (Pathophysiology of Heart Disease 4 thed,

Liily, Leonard S)

DEFINITION


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Heart Failure is a clinical syndrome in which patients have the following

features :

DEFINITION

Symptoms typical of HF

(breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling

And

Signs typical of HF

(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raisedjugular venous pressure, peripheral oedema, hepatomegaly)

And

Objective evidence of a structural or functional abnormality of the heartat rest (cardiomegaly, third heart soud, cardiac murmurs, abnormality onthe echocardiogram, raised natriuretic peptide concentration)


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Symptoms


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ACC/AHA A New Approach To The

Classification of HF

2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

Stage AAt high risk of HF but

without structural heartdisease or symptoms of

HF

Stage Bstructural heart disease

but withoutsigns/symptoms of HF

Stage CStructural heart disease

with prior or currentsymptoms of HF

Stage DRefractory HF requiring

specializedinterventions

e.g. patient with-Hypertension-Atherosclerosisdisease-Diabetes

-Obesity-Metabolic syndr-Using cardiotoxin-with Familialhistory

e.g. patient with-Previous MI-LV remodeling:including LVH, lowEF-Asymptomaticvalvular disease

e.g. patient with-Known structuralheart disease-Shortness ofbreath and fatigue,reduced exercisetolerance

e.g. patient with-Who have markedsymptoms at restdespite maximalmedical therapy(recurrentlyhospitalized/cannot be safelydischarged fromhospital withoutspecializedinterventionStructural heart

diseaseDevelopment of HF

symptoms

Refractory symptomsof HF at rest

At Risk For Heart Failure Heart Failure


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Determinant of ventricular function

STROKEVOLUME

PRELOAD

CONTRACTILITY

CARDIAC OUTPUT

HEARTRATE

- Synergistic LV contraction- LV wall integrity- Valvular competence

AFTERLOAD


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The goal of treatment : relieve symptoms and signs

prevent hospital admission

improve survival

Treatment strategy for the use of drugs in patients with HR-REF

Three neurohumoral antagonist

ACE inhibitor (or Angiotensin Receptor Blocker (ARB))

Beta-blocker

MRA (Mineralocorticoid Receptor Blocker)

The aforementioned drugs commonly used in conjunction witha diuretic given to relieve the symptoms and signs ofcongestion

TREATMENT


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Evaluation of acutely decompensatedchronic HF


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THANK YOU


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Diagnosis of heart failure

The diagnosis of HF-REF requiresthree conditions to be satisfied :


Signs typical of HF

Reduced LVEF

The diagnosis of HF-PEF requiresfor conditions to be satisfied :


Signs typical of HF

Normal or only mildly reduced

LVEF and LV not dilated

Relevant structural heart disease(LV hypertrophy/LA

enlargement) and/or diastolicdysfunctions


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Patients who should get ACEI

LVEF 40%, irrespective of symptoms

Initiation of an ACEI :

Check renal function and serum electrolytes

Consider dose up-titration after 2-4 weeks

Do not increase dose if worsening renal function or hyperkalaemia

It is common to up-titrate slowly but more rapid titration is possiblein closely monitored patients

ACE inhibitors


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Starting dose (mg) Target dose (mg)

ACE Inhibitors

Captopril 6.25 mg t.i.d 50 t.i.d

Enalapril 2.5 b.i.d 10-20 b.i.d

Lisinopril 2.5- 5 o.d 20-35 o.d

Ramipril 2.5 o.d 5 o.d

Trandolapril 0.5 o.d 4 o.d

ACE Inhibitors (Dosage)


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Patients who should get an ARB

LVEF 40% and either

As an alternative in patients with mild to severe symptoms (NYHA fc II-IV) whoare intolerant of an ACEI

Or in patients with persistent symptoms (NYHA fc IV) despite treatment withan ACEI and beta blocker

Initiation of an ARB

Check renal function and serum electrolytes Consider dose up-titration after 2-4 weeks

Do not increase dose if worsening renal function or hyperkalaemia

It is common to up-titrate slowly but more rapid titration is possible in closelymonitored patients

ARBs


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ARBs (dosage)


ARB

Candesartan 4 or 8 mg o.d 32 o.d

Valsartan 40 b.i.d 160 b.i.d

Losartan 50 o.d 150 o.d


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Patients who should get a beta-blocker LVEF 40%

Mild to severe symptoms (NYHA fc II-IV)

Optimal dose level of an ACEI or/and ARB

Patients should be clinically stable(e.g. no recent change in dose of diuretic)

Initiation of a beta-blocker

Beta-blocker may be initiated prior to hospital discharge in recently

decompensated patients with caution

Visits every 2-4 weeks to up-titrate the dose of beta-blocker (slower dose up-titration may be needed in some patients). Do not increase dose if signs ofworsening HF, symptomatic hypotension (e.g. dizziness) or excessivebradycardia (pulse rate


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Beta-blockers (dosage)


Beta blockers

Bisoprolol 1.25 mg o.d 10 o.d

Carvedilol 3.125 b.i.d 25-50 b.i.d

Metoprolol (CR/XL) 12.5/25 o.d 200 o.d

Nebivolol 1.25 o.d 1o.d


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Patients who should get an MRA

LVEF 35%

Moderate to severe symptoms (NYHA fc II-IV)

Optimal dose of beta-blocker and an ACEI or an ARB (but not an ACEI and

an ARB)

Initiation of spironolactone (eplerenone)

Check renal function and serum electrolytes

Consider up-titration after 4-8 weeks. Do not increase dose if worseningrenal function or hyperkalaemia

Mineralocorticoid receptor antagonist(MRA)


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Diuretics and MRAs (dosage)


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Potential adverse effect Hyperkalemia

K > 5.5 halve dose

K > 6.0stop

Worsening renal function

Cr > 220 umol/L (~2.5 mg/dl) halve dose

Cr > 310 umol (~3.5 mg/dl)stop

Breast tenderness and/ enlargement

Switch from spironolactone to eplerenone

MRA (potential adverse effects)


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Ivabradine is a drug that inhibits the I fchannel in the sinusnode. Its only known pharmacological effect is to slowheart rate in patients in sinus rhythm (it does not slow theventricular rate in AF)

Patients who should get an Ivabradine

Mild to severe symptoms (NYHA fc II-IV)

Sinus rhythm with a rate 70 bpm

LVEF 35%

Ivabradine


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In patients in sinus rhythm with symptomatic HF andLVEF 40%, this treatment improve patient well-beingand reduce hospital admission for worsening HF

Patients in AF with ventricular rate at rest >80, and at

exercise >110-120 beat/minute should get digoxin

In patients with sinus rhythm and left ventricularsystolic dysfunction (LVEF 40%) receiving optimaldoses of diuretic, ACEI or/and ARB, beta-blocker and

aldosterone antagonist if indicated, who aresymptomatic, digoxin may be considered)

Digoxin


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Patients who should get H-ISDN

An alternative to an ACEI/ARB where both of the latter are not tolerated

As add-on, therapy to an ACEI if ARB or aldosterone antagonist is nottolerated or if significant symptoms persist despite therapy with an ACEI,ARB, beta-blocker, and aldosterone antagonist

Initiation of H-ISDN

Consider dose up-titration after 2-4 weeks. Do not increase dose withsymptomatic hypotension

Hydralazine and ISDN


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A h th i b d di d t i t i l


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Atrial Fibrillation

The most common arrhythmia in HF

increases the risk of thrombo-embolic complications (particularly stroke)and may lead to worsening of symptoms

The following issues need to be considered in patients with HF and AF,especially a first episode of AF or paroxysmal AF:

Identification of correctable causes (e.g. hyperthyroidism, electrolytedisorders, uncontrolled hypertension, mitral valve disease).

Identification of potential precipitating factors (e.g. recent surgery, chest

infection or exacerbation of chronic pulmonary disease/asthma, acutemyocardial ischaemia, alcohol binge) as this may determine whether arhythm-control strategy is preferred to a rate-control strategy.

Assessment for thromboembolism prophylaxis.

Arrhythmia, bradycardia, and atrioventricular

block in patients with heart failure with reduced EFand heart failure with preserved EF


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Atrial Fibrillation

Thrombo-embolism prophylaxis


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Ventricular arrhythmia in HF


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Chronic obstructive pulmonary disease and Asthma

may cause diagnostic difficulties, especially in HF-PEF

Beta-blockers are contraindicated in asthma but not in

COPDselective beta-1 adrenoceptor antagonist (i.e.bisoprolol, metoprolol succinate, or nebivolol) Preferred

Oral corticosteroids cause sodium and water retentionworsening of HF


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Diabetes Melitus

Associated with poorer functional status and worse prognosis

Prevented by treatment with ARBs and possibly ACE inhibitors.

Beta-blockers are NOTcontraindicated in diabetes and are aseffective in improving outcome in diabetic patients as in non-diabetic individuals

Thiazolidinediones (glitazones)sodium and water retention andincreased risk of worsening HF and hospitalization

Metformin is NOTrecommended in patients with severe RENAL

or HEPATIC IMPAIRMENT

HYPERTENSION


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HYPERTENSION


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Acute Heart Failure


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Defined as the rapid onset of, or change in,symptoms and signs of HF. It may occur withor without previous cardiac disease.

ESC guidelines for the Diagnosis & Treatment of Acute and Chronic Heart Failure 2012


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Precipitants and causes


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Clinical classification

Worsening or decompensated chronic HF There is usually a history of progressive worsening of known chronic HF

on treatment and evidence of systemic and pulmonary congestion

Pulmonary oedema

Present with severe respiratory distress, tachypnoea and orthopnoeawith rales over on lung fields. Artery O2 saturation is usually


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Oxygen

Given to treat hypoxemia (SpO2


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Vasodilators


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Positive Inotropes or vasopressors or both


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Goals of treatment in acute heart


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Immediate (ED/ICU/ICCU) Treat symptoms

Restore oxygenation

Improve haemodynamics and organ

perfusion Limit cardiac and renal damage

Prevent thrombo-embolism

Minimize ICU length of stay

Goals of treatment in acute heartfailure


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Most of the knowledge about the epidemiology, riskfactors,prognosis, treatment, and prevention of HF is based onNorth American and European studies

EPIDEMIOLOGY

(ESC Guidelines for the Diagnosis andTreatment of Acute and Chronic Heart

Failure ,2008)

ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure

in the Adult 2001

Europe

The prevalence of symptomatic HFrange from 2-3%

Prevalence in 70- to 80-year-oldpeople is between 10 and 20%.

15 million HF pts in 900 million totalpopulation

Overall 50% of patients are dead at 4

years. Forty per cent of patientsadmitted to hospital with HF aredead or readmitted within 1 year

USA

Nearly 5 million HF pts. 500,000 pts are HF for the 1st time

each year.

Last 10 yearsnumber ofhospitalizations has increased.

Nearly 300,000 patients die of HFeach year.

Terminology related to the time-course


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A patient who/whose Never exhibited the typical signs or symptoms of HFasymptomatic LV

systolic dysfunction

Have had HFchronic HF

Chronic stable HF conditions deteriorates

decompensated Chronic stable HF resolves from acute conditioncompensated

HFs condition presents acutelyNew (de novo) HF

Terminology related to the time courseof heart failure


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Suspected Heart Failure

Acute onset

ECGChest x-ray

Echocardiography BNP/NT-pro BNP

ECG normaland

NT-proBNP


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MRA

Eplerenone 25 mg o.d 50 o.d

Spironolactone 25 o.d 25-50 o.d

Documents

Heart Failure Rev UKRIDA