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7/28/2019 Heart Failure Tutorial
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Departemen Kardiologi FK USURSUP. H. Adam Malik
Medan
HEART FAILURE
Dr. Ali Nafiah Nst, SpJP
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Definition
Heart failure is defined as the inability of the
heart to pump blood forward at a sufficient
rate to meet the metabolic demands of thebody (forward failure), or the ability to do so
only if the cardiac filling pressures are
abnormally high (backward failure), or both.
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Pathophysiology
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Frank-Starling Law
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loss of fibers or contractility
reduced cardiac output
reduced renal
perfusion
increased
sympathetic
tone
arteriolar
constriction
increased
resistance
cardiac
hypertrophy
increased renin
secretion
increased
heart rate
incomplete
diastolic
filling
Na+, H2O
retention
increased capillary
hydrostatic pressure
edema
venous
congestion
increasedfilling pressure
cardiac
dilatation
arrhythmia
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PULMONARY CIRCULATION
Blood flows from the right ventricle throughthe pulmonary artery
Blood reaches the capillaries surrounding
alveoli where gas exchange occursOxygenated blood returns by pulmonary
veins to the left ventricle where it is
pumped into systemic circulation
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LV BACKWARD EFFECTS
Decreased emptying of the left ventricle
Increased volume and end-diastolicpressure in the left ventricle
Increased volume (pressure) in the left
atrium
Increased volume in pulmonary veins
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Increased volume in pulmonary capillary bed= increased hydrostatic pressure
Transudation of fluid from capillaries to alveoli
Rapid filling of alveolar spaces
Pulmonary edema
LV BACKWARD EFFECTS cont
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LV FORWARD EFFECTS
Decreased cardiac output
Decreased perfusion of tissues of body
Decreased blood flow to kidneys and glands
Increased reabsorption of sodium and water
and vasoconstriction
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Increased secretion of sodium and
water-retaining hormones
Increased extracellular fluid volume
Increased total blood volume and
increased systemic blood pressure
LV FORWARD EFFECTS cont
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RV BACKWARD EFFECTS
Decreased emptying of the right ventricle
Increased volume and end-diastolic pressure
in the right ventricle
Increased volume (pressure) in right atrium
Increased volume and pressure in the great
veins
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RV Forward Effects
Decreased volume from the RV to the
lungs
Decreased return to the left atrium and
subsequent decreased cardiac output
All the forward effects of left heart failure
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Causes o f lef t ven tr icu lar failure
Volume over load: Regurgitate valveHigh output status
Pressure over load: Systemic hypertensionOutflow obstruction
Loss of musc les : Post MI, Chronic ischemiaConnective tissue diseases
Infection, Poisons(alcohol,cobalt,Doxorubicin)
Rest r icted Fi ll ing : Pericardial diseases, Restrictivecardiomyopathy, tachyarrhythmia
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Diagnosis
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IDENTIFICATIONS OF HF PATIENTS
With a Syndrome of Decrease Exercise
Tolerance
With a Syndrome of Fluid Retention With No Symptoms or Symptoms of Another
Cardiac or Non Cardiac Disorder
(MI, Arrythmias, Pulmonary or SystemicThromboembolic Events)
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SYMPTOMS AND SIGN
Breathlessness, Ankle Swelling, Fatique
Characteristic Symptoms
Peripheral Oedema, JVP , Hepatomegaly
Signs of Congestion of Systemic Veins
S3 , Pulmonary Rales , Cardiac Murmur
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Fram ingham Criter ia
Major Criteria:
PND
JVD
Rales
Cardiomegaly
Acute Pulmonary Edema
S3 Gallop Positive hepatic Jugular reflex
venous pressure > 16 cm H2O
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Minor Criteria:
Extremitas edema
Night cough
Dyspnea on exertion Hepatomegaly
Pleural effusion
vital capacity by 1/3 of normal
Tachycardia
Weight loss 4.5 kg over 5 days management
Fram ingham Criter ia
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Precipitating Factors
Increased metabolic demand
Increased circulating volume
Condition that increased afterload
Condition that impaired contractility
Failure to take prescribe medication
Arrhytmia
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E C G
A low Predictive Value
LAH and LVH maybe Associated wit LV
Dysfunction Anterior Q-wave and LBBB a good predictors
of EF
Detecting Arrhytmias
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CHEST X-RAY
A Part of Initial Diagnosis of HF
Cardiomegaly, Pulmonary Congestion
Relationship Between Radiological Signs and
Haemodynamic Findings may Depend on the
Duration and Severity HF
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HAEMATOLOGY & BIOCHEMISTRY
A Part of Routine Diagnostic
Hb, Leucocyte, Platelets Electrolytes, Creatinine, Glucose, Hepatic Enzyme,
Urinalysis
TSH, C-RP, Uric Acid
ECHOCARDIOGRAPHY
The Preferred Methods
Helpful in Determining the etiology
Follow Up of Patients Heart Failure
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PULMONARY FUNCTIONS
A Little Value in Diagnosis Heart Failure
Usefull in Excluding Respiratory Diseases
EXERCISE TESTING
Focused on Functional, Treatment Assessment andPrognostic
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STRESS ECHOCARDIOGRAPHY
For Detecting Ischaemia
Viability Study
NUCLEAR CARDIOLOGY
Not Recommended as a Routine Use
CMR( CARDIAC MAGNETIC RESONANCE IMAGING)
Recommenmded if Other Imaging Techniques not
Provided Diagnostic Answer
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INVASIVE INVESTIGATION
Elucidating the Cause and Prognostic Informations
Coronary Angiography :
in CADs Patients
Haemodynamic Monitoring :
To Assess Diagnostic and Treatment of HF
Endomyocardial Biopsy :
in Patients with Unexplained HF
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NATRIURETIC PEPTIDES
Cardiac Function (LV Function )
Plasma Natriuretic Peptide Concentration
(Diagnostic Blood Use for HF)
Natriuretic Peptide :
Greatest Risk of CV Events
Natriuretic Peptide :
Improve Outcome in Patients with
Treatment
Identify Pts. With Asymptomatic LV
Dysfunction (MI, CAD)
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Suspected Heart Failure Because
of symptoms and signs
Assess Presence of Cardiac Disease by ECG, X-Rayor NatriureticPeptides (Where Available)
Imaging by Echocardiography (NuclearAngiography or MRI Where Available)
Assess Etiology, Degree, PrecipitatingFactors and Type of Cardiac Dysfunction
Tests Abnormal
Tests Abnormal
Choose Therapy
ALGORITHM FOR THE DIAGNOSIS OF THE HF
If NormalHeart Failure
Unlikely
Additional Diagnosis TestsWhere Appropriate (e.g.Coronary Angiography)
If NormalHeart Failure
Unlikely
(ESC, 2001)
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Aims of treatment
1. Preventiona) Prevention and/or controlling of diseases leading
to cardiac dysfunction and heart failure
b) Prevention of progression to heart failure once
cardiac dysfunction is established2. Morbidity
Maintenance or improvement in quality of life
3. Mortality
Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Treatment opt ion s
Non-pharmacological management
General advice and measures
Exercise and exercise training
Pharmacological therapy
Angiotensin-converting enzyme (ACE) inhibitors
Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
Angiotensin receptor antagonists
Cardiac glycosides Vasodilator agents (nitrates/hydralazine)
Positive inotropic agents
Anticoagulation
Antiarrhythmic agents
Oxygen
Devices and surgery Revascularization (catheter interventions and surgery), other forms of surgery
Pacemakers
Implantable cardioverter defibrillators (ICD)
Heart transplantation, ventricular assist devices, artificial heart
Ultrafiltration, haemodialysis
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560
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Pharmacological therapy
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Angiotens in-Conver t ing Enzyme Inh ib i tors
Recommended as first-line therapy.
Should be uptitrated to the dosages shown to beeffective in the large, controlled trials, and nottitrated based on symptomatic improvement.
Moderate renal insufficiency and a relatively low bloodpressure (serum creatinine 250 mol.l-1 and systolicBP 90 mmHg) are not contraindications.
Absolute contraindications: bilateral renal arterystenosis and angioedema.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Diuret ics
Essential for symptomatic treatment when
fluid overload is present and manifest.
Always be administered in combination
with ACE inhibitors if possible.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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-Blocker
Has been traditionally contraindicated in pts withCHF
Now they are the main stay in treatment on CHF
& may be the only medication that shows
substantial improvement in LV function
In addition to improved LV function multiple
studies show improved survival
Contraindication: decompensated HF,Bradicardia/ AV Block, Asma bronchiale
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Recommended in advanced HF (NYHA III-IV),
in addition to ACE inhibition and diuretics to
improve survival and morbidity
Aldosterone Receptor Antagonists - Spironolactone
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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ARBs could be considered in patients who donot tolerateACE inhibitors for symptomatictreatment.
It is unclear whether ARBs are as effective asACE inhibitors for mortality reduction.
In combination with ACE inhibition, ARBs mayimprove heart failure symptoms and reducehospitalizations for worsening heart failure.
Angiotensin II Receptor Antagonists
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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indicated in atrial fibrillation and any degree ofsymptomatic heart failure.
A combination of digoxin and beta-blockade
appears superior than either agent alone.
In sinus rhythm, digoxin is recommended toimprove the clinical status of patients with
persisting heart failure despite ACE inhibitor anddiuretic treatment.
Cardiac Glycosides
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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No specific role for vasodilators in the treatment of HF
Used as adjunctive therapy for angina or concomitanthypertension.
In case of intolerance to ACE inhibitors ARBs are
preferred to the combination hydralazinenitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE
Hydralazine (up to 300 mg) in combination with ISDN (up to 160
mg) without ACE inhibition may have some beneficial effect on
mortality, but not on hospitalization for HF. Nitrates may be used for the treatment ofconcomitant angina or
relief ofacute dyspnoea.
Vasodilator Agents In Chronic Heart Failure
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Commonly used to limit severe episodes ofHF or as a bridge to heart transplantationin end-stage HF.
Repeated or prolonged treatment with oralinotropic agents increases mortality.
Currently, insuffcient data are available to
recommend dopaminergic agents for heartfailure treatment.
Positive Inotropic Therapy
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Recommendation
1. All pts with HF and AF should be treated with
warfarin unless contraindicated.
2. Patients with LVEF 35% or less.
Anticoagulation
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
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Antiplatelet Drugs
Recommendation
There is insufficient evidence concerning thepotential negative therapeutic interaction
betweenASA and ACE inhibitors.
Antiplatelet agent for pts with HF who haveunderlyingCAD.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
i h h i
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No indication for the use of antiarrhythmic agents in HF
Indications for antiarrhythmic drug therapy include AF(rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS
should be avoided CLASS II ANTIARRHYTHMICS
Beta-blockers reduce sudden death in heart failure
CLASS III ANTIARRHYTHMICS
Amiodarone is the only antiarrhythmic drug withoutclinically relevant negative inotropic effects.
Antiarrhythmics
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Classification of HF
Activity Levels (NYHA Classification)
I asymptomatic at rest
symptoms with heavy exercise
II asymptomatic at restsymptoms with moderate exercise
III asymptomatic at rest
symptoms with activities of daily living
IV symptoms at rest
Exercise testing and O2 consumption
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ACC/AHA A New Approach To The Classification of HF
Stage Descriptions Examples
A Patient who is at high risk fordeveloping HF but has no
structural disorderof the heart.
Hypertension; CAD; DM;rheumatic fever; cardiomyopathy.
B Patient with a structural disorder
of the heart but who has never
developed symptoms of HF.
LV hypertrophy or fibrosis;
LV dilatation; asymptomatic VHD;
MI.
C patient with past or current
symptoms of HF associated with
underlying structural heart
disease.
Dyspnea or fatigue ec LV systolic
dysfunction; asymptomatic
patients with HF.
D Patient with end-stage disease Frequently hospitalized pts ; pts
awaiting heart transplantation etc
ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001
Stages in The Evolution of HF and Recommended Therapy by Stage
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Stage A Stage B Stage C Stage D
Pts with :
Hypertension
CAD
DM
Cardiotoxins
FHx CM
THERAPY Treat Hypertension
Stop smoking
Treat lipid disorders
Encourage regularexercise
Stop alcohol
& drug use
ACE inhibition
Pts with :
Previous MI
LV systolic
dysfunction
Asymptomatic
Valvular disease
THERAPY All measures under
stage A
ACE inhibitor
Beta-blockers
THERAPY All measures under
stage A
Drugs for routine use:
diuretic ACE inhibitor
Beta-blockers
digitalis
THERAPY All measures under
stage A,B and C
Mechanical assist
device Heart transplantation
Continuous IV
inotrphic infusions for
palliation
Pts who have
marked symptoms
at rest despite
maximal medical
therapy.
Pts with :
Struct. HD
Shortness of
breath and fatigue,
reduce exercise
tolerance
Struct.
Heart
Disease
Develop
Symp.of
HF
Refract.
Symp.of
HF at rest
Stages in The Evolution of HF and Recommended Therapy by Stage
ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001
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Chronic Heart FailureChoice ofPharmacological Therapy
LV systolic dysfunction ACE inhibitor Diuretic Beta-blockerAldosterone
Antagonist
Asymptomatic LV
dysfunctionIndicated Not indicated Post MI Not indicated
Symptomatic HF (NYHA II) Indicated Indicated ifFluid retention
Indicated Not indicated
Worsening HF (NYHA III-IV) IndicatedIndicated
comb. diuretic
IndicatedIndicated
End-stage HF (NYHA IV) Indicated Indicatedcomb. diuretic
Indicated Indicated
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
A
Chronic Heart Failure Choice of
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Chronic Heart Failure Choice ofPharmacological Therapy
LV systolic dysfunction
Angiotensin
II receptorantagonists
Cardiac glycosides
Vasodilator
(hydralazine/
isosorbidedinitrate)
Potassium -sparing
diuretic
Asymptomatic LV
dysfunctionNot indicated With AF Not indicated Not indicated
Symptomatic HF (NYHA II)
If ACE inhibitors
are not tolerated
and not on beta-blockade
(a) when AF
(b) when improved
from more severe
HF in sinus
rhythm
If ACE inhibitors
and angiotensin
II antagonists
are not
tolerated
If persisting
hypokalaemia
Worsening HF (NYHA III-IV)
If ACE inhibitors
are not tolerated
and not on beta-
blockade
indicated
If ACE inhibitors
and angiotensin
II antagonists
are not
tolerated
If persisting
hypokalaemia
End-stage HF (NYHA IV)If ACE inhibitors
are not tolerated
and not on beta-
blockade
indicated
If ACE inhibitorsand angiotensin
II antagonists
are not
tolerated
If persisting
hypokalaemia
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
B
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Intervention
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Pts with heart failure ofischaemic origin revascularization
symtomatic improvement.
A strong negative correlation of operative mortality and LVEF,
a low LVEF (
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Algorithm for Management HF
Conclusion
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Conclusion
DIAGNOSIS OF HEART FAILURE
Clinical Signs and Symptoms
Echocardiography (LVEF) The Preferred
Method
Natriuretic Peptide Helpful in The Diagnosis
Process
Additional Test Should be PerfomedWhere Diagnosis Doubt Persist
Conclusion
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Conclusion
Management of HF must be starting fromtheearlier stage (AHA/ACC stage A).
Treatment at each stage can reduce
morbidity and mortality.
Before initiatingtherapy :
Established the correct diagnose. Consider management outline.
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Thank YoU
PREVENTION
IS BETTER THANTREATMENT
NO MATTER WHAT,