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Heart Failure SyndromeHeart Failure Syndrome with with
Preserved Systolic FunctionPreserved Systolic Function
Dr. Asadullah SoomroDr. Asadullah Soomro
CardiologistCardiologistKing Fahad Hospital, HofufKing Fahad Hospital, HofufKingdom of Saudi ArabiaKingdom of Saudi Arabia
IntroductionIntroduction
Heart failure is an enormous and rapidly Heart failure is an enormous and rapidly growing public health problem all over the growing public health problem all over the world and in Kingdom of Saudi Arabia world and in Kingdom of Saudi Arabia indeed.indeed.Recent estimates suggest that more than Recent estimates suggest that more than 5 million patients carry this diagnosis in 5 million patients carry this diagnosis in USA alone 75% are older than 65 years.USA alone 75% are older than 65 years.More than 550,000 new cases of CHF are More than 550,000 new cases of CHF are diagnosed each year.diagnosed each year.
It remain primary cause of death and It remain primary cause of death and disability despite advances in modern disability despite advances in modern treatment.treatment.
It is the most common cause of hospital It is the most common cause of hospital admission and readmission indeed.admission and readmission indeed.
Over a period of 3-6 months, 20-50% Over a period of 3-6 months, 20-50% patients are readmitted and the cost of patients are readmitted and the cost of these hospitalization was $5.45 billion these hospitalization was $5.45 billion compared to $3.2 billion for cancer and compared to $3.2 billion for cancer and $3.2 billion for MI.$3.2 billion for MI.
Two-year mortality rate in patients with Two-year mortality rate in patients with newly diagnosed CHF is 35% and 6-year newly diagnosed CHF is 35% and 6-year mortality is 67% in women and 82% in mortality is 67% in women and 82% in men.men.
DefinitionDefinition
Heart failure is a progressive and Heart failure is a progressive and debilitating clinical syndrome debilitating clinical syndrome characterized by an inability of the heart to characterized by an inability of the heart to deliver enough Odeliver enough O22 and nutrient to meet the and nutrient to meet the
body’s metabolic needs at normal filling body’s metabolic needs at normal filling pressurepressure
To most physician, the typical image of To most physician, the typical image of patients with heart failure is one of a patients with heart failure is one of a “dilated/ischaemic cardiomyopathy” and “dilated/ischaemic cardiomyopathy” and “low left ventricular ejection fraction”.“low left ventricular ejection fraction”.
This is certainly the case when one is This is certainly the case when one is considering the “end stage” or “refractory considering the “end stage” or “refractory heart failure”.heart failure”.
Patients with heart failure and preserved Patients with heart failure and preserved systolic function are surprisingly common systolic function are surprisingly common representing 20-50% of all patients with representing 20-50% of all patients with diagnosis of CHF, yet despite the diagnosis of CHF, yet despite the frequency of this syndrome, we know frequency of this syndrome, we know relatively little about regarding its morbidity relatively little about regarding its morbidity and mortality. and mortality.
Heart Failure ClassificationHeart Failure Classification
SystolicSystolic Diastolic Diastolic MixedMixed 60%60% 40% 40% CAD CADCAD esp. MICAD esp. MI Hypertension Amyloido- Hypertension Amyloido-Dilated cardio- LVHDilated cardio- LVH sissis myopathymyopathy Age Age1 year mortality Amyloidosis1 year mortality Amyloidosis 19%19% 1 year mortality 1 year mortality 8%8%
Heart Failure ClassificationHeart Failure Classification
Acute heartAcute heart Chronic heart Acute onChronic heart Acute on
failurefailure failure failure (most common)(most common) chronic chronic- Acute MIAcute MI - Old infarction- Old infarction heart heart
failurefailure- Mechanical - RHDMechanical - RHD
complications - CHDcomplications - CHD- Arrhythmias - PericardialArrhythmias - Pericardial
- HTN- HTN
Heart failureHeart failure
with enlarged heart sizewith enlarged heart size
Chronic MR, ARChronic MR, AR
Old myocardial infarctionOld myocardial infarction
Chronic atrial fibrillationChronic atrial fibrillation
Cardiomyopathy (D)Cardiomyopathy (D)
Congenital heart defectsCongenital heart defects
Long standing severe Long standing severe hypertensionhypertension
Heart failure Heart failure
with normal heart sizewith normal heart size
Mitral stenosisMitral stenosis
Acute infarction, shockAcute infarction, shock
Acute AR, MRAcute AR, MR
Infective endocarditisInfective endocarditis
Aortic stenosis or HCM Aortic stenosis or HCM with atrial fibrillationwith atrial fibrillation
Pericardial constrictionPericardial constriction
Heart FailureHeart Failure
Low ejection fractionLow ejection fraction Normal/high ejection Normal/high ejectionfractionfraction
Normal EnlargedNormal Enlarged Normal EnlargedNormal Enlargedheart size heartheart size heart heart size heartheart size heart- Acute MI - Old MI - Aortic -ThyrotoxicosisAcute MI - Old MI - Aortic -Thyrotoxicosis stenosis - MRstenosis - MR-Myocarditis - Dilated CMP -Mitral - AR-Myocarditis - Dilated CMP -Mitral - AR stenosis w/stenosis w/ atrial fibrillationatrial fibrillation
HCMHCM
King Fahad Hospital, HofufKing Fahad Hospital, Hofuf
Cardiac admission in month 1/1423Cardiac admission in month 1/1423Total admissions = 140Total admissions = 140
Male 61% Female 39%Male 61% Female 39%
Heart failureHeart failure :: 70 (50%)70 (50%)Myocardial infarctionMyocardial infarction :: 22 (15%)22 (15%)AnginaAngina :: 19 19 ArrhythmiasArrhythmias :: 1717HypertensionHypertension :: 4 4RHDRHD :: 7 7CHDCHD :: 1 1
Heart Failure at KFHHHeart Failure at KFHH
Total = 70 (50%)Total = 70 (50%)
Male 48 (68%) Female 22 (31%)Male 48 (68%) Female 22 (31%)
≤ ≤ 45 yrs.45 yrs. 46-59 46-59 ≥ 60 years ≥ 60 years
99 2222 3939
(13%)(13%) (31%) (31%) (55%) (55%)
Heart Failure AuditHeart Failure Auditat Dow Medical College & Civil Hospital, Karachiat Dow Medical College & Civil Hospital, Karachi
DemographyDemography
Total NumberTotal Number 372 patients372 patients
PeriodPeriod 15/07/1995 to 15/11/199715/07/1995 to 15/11/1997
MenMen 243 (65.3%)243 (65.3%)
WomenWomen 129 (34.6%)129 (34.6%)
≥ ≥ 50 years of age50 years of age214 (57.5%)214 (57.5%)
< 50 years of age< 50 years of age 158 (42.4%)158 (42.4%)
Causes of Heart Failure Causes of Heart Failure at Dow Medical College & Civil Hospital, Karachiat Dow Medical College & Civil Hospital, Karachi
CoronaryCoronary 164164RheumaticRheumatic 88 88HypertensionHypertension 31 31CardiomyopathiesCardiomyopathies 19 19CongenitalCongenital 15 15PericardialPericardial 12 12MiscellaneousMiscellaneous 43 43
CAD with Heart FailureCAD with Heart Failure
No. 164/372No. 164/372
Men: 131 (80%)Men: 131 (80%) Women: 33 Women: 33 (20%)(20%)
> 50 years: 108> 50 years: 108 > 50 years: 29 > 50 years: 29
< 50 years: 23< 50 years: 23 < 50 years: 04 < 50 years: 04
Classified in Four GroupsClassified in Four Groups
1.1. Old myocardial infarction with heart Old myocardial infarction with heart failure. 92 (56%)failure. 92 (56%)
2.2. Acute myocardial infarction with heart Acute myocardial infarction with heart failure. 29 (18%)failure. 29 (18%)
3.3. Unstable angina with heart failure Unstable angina with heart failure (without old/acute MI). 21 (12.8%)(without old/acute MI). 21 (12.8%)
4.4. Primarily symptom of heart failure (no Primarily symptom of heart failure (no myocardial infarction and angina). myocardial infarction and angina). 22 (13%)22 (13%)
Rheumatic Heart Disease and Heart FailureRheumatic Heart Disease and Heart Failure
Men = 36Men = 36 Women = Women = 5252
≤ ≤ 50 years = 72 (82%)50 years = 72 (82%)< 50 years = 16 (18%)< 50 years = 16 (18%)
Isolated mitral stenosisIsolated mitral stenosis 43 (49%)43 (49%)MS + MRMS + MR 15 (17%)15 (17%)ARAR 07 (08%)07 (08%)MRMR 04 (4.5%)04 (4.5%)MS + ARMS + AR 04 (4.5%)04 (4.5%)MR + ARMR + AR 04 (4.5%)04 (4.5%)ASAS 02 (2%)02 (2%)AS + ARAS + AR 01 (1%)01 (1%)AS + MRAS + MR 01 (1%)01 (1%)MixedMixed 07 (8%)07 (8%)
Heart Failure with Preserved Systolic FunctionHeart Failure with Preserved Systolic FunctionPrevalence, Morbidity and MortalityPrevalence, Morbidity and Mortality
At least 30 different studies have At least 30 different studies have examined the magnitude of this problem, examined the magnitude of this problem, which vary tremendously with regard to which vary tremendously with regard to patient population. patient population.
Framingham criteria for CHF diagnosis Framingham criteria for CHF diagnosis and normal LV systolic function defined as and normal LV systolic function defined as EF >50% on echocardiogramEF >50% on echocardiogram
Median prevalence was 36% with range Median prevalence was 36% with range from 13-74%. There was no significant from 13-74%. There was no significant difference in rate of readmission, 51% for difference in rate of readmission, 51% for low EF and 56% for preserved systolic low EF and 56% for preserved systolic function.function.
However mortality was 18% in low EF and However mortality was 18% in low EF and 9% for preserved systolic function.9% for preserved systolic function.
The first response to the findings of normal The first response to the findings of normal or “preserved ejection fraction” is to or “preserved ejection fraction” is to consider alternative diagnosis.consider alternative diagnosis.The main focus on systolic dysfunction The main focus on systolic dysfunction (low EF%) has left many physicians (low EF%) has left many physicians confused and uncomfortable in treating the confused and uncomfortable in treating the patient with CHF and preserved systolic patient with CHF and preserved systolic function.function.In recent years, however, there has been In recent years, however, there has been a growing recognition of magnitude and a growing recognition of magnitude and importance of this problem.importance of this problem.
Causes of CHF and Preserved Causes of CHF and Preserved Systolic FunctionSystolic Function
1. Inaccurate diagnosis of CHF (e.g. COPD)1. Inaccurate diagnosis of CHF (e.g. COPD)
2. Inaccurate measurement of LV ejection fraction.2. Inaccurate measurement of LV ejection fraction.
3. LV systolic function overestimated by EF 3. LV systolic function overestimated by EF (e.g. mitral regurgitation)(e.g. mitral regurgitation)
4. Episodic LV systolic dysfunction with 4. Episodic LV systolic dysfunction with improvement at time of evaluation.improvement at time of evaluation.
e.g.: - Severe hypertensione.g.: - Severe hypertension
- Myocardial ischaemia- Myocardial ischaemia
- Tachy or bradyarrhythmias- Tachy or bradyarrhythmias
- Volume overload- Volume overload
- Infections, Drugs- Infections, Drugs
Patients with heart failure and preserved Patients with heart failure and preserved systolic function are surprisingly common systolic function are surprisingly common representing 20-50% of all patients with representing 20-50% of all patients with diagnosis of CHF, yet despite the diagnosis of CHF, yet despite the frequency of this syndrome, we know frequency of this syndrome, we know relatively little about regarding its morbidity relatively little about regarding its morbidity and mortality. and mortality.
5. Pericardial diseases (constriction/ 5. Pericardial diseases (constriction/ tamponade)tamponade)
6. Obstruction to LV inflow6. Obstruction to LV inflow- Mitral stenosis- Mitral stenosis- Left atrial myxoma- Left atrial myxoma
7. Diastolic dysfunction7. Diastolic dysfunctionA. IschaemiaA. Ischaemia
HypertrophyHypertrophy HypertensionHypertensionHypertrophic Hypertrophic cardiomyopathy cardiomyopathyAortic stenosisAortic stenosis
AgingAgingCardiomyopathiesCardiomyopathiesHigh output statesHigh output states Infection Infection
ThyrotoxicosisThyrotoxicosisoverloadoverload Anaemia Anaemia
Beri-beriBeri-beriPressurePressure VolumeVolume AV shunt AV shunt
(ESRD)(ESRD)
B. Altered passive elastic propertiesB. Altered passive elastic properties
DiabetesDiabetes
Infiltrative myocardial diseases Infiltrative myocardial diseases (amyloidosis, sarcoidosis)(amyloidosis, sarcoidosis)
Storage myocardial diseases Storage myocardial diseases (haemochromatosis)(haemochromatosis)
Endomyocardial fibrosisEndomyocardial fibrosis
RadiationRadiation
Diastolic DysfunctionDiastolic Dysfunction
1907 – Henderson first describe 1907 – Henderson first describe importance of ventricular relaxation.importance of ventricular relaxation.
1960-1970s – recognized that altered 1960-1970s – recognized that altered diastolic properties of the left ventricular diastolic properties of the left ventricular filling pressures that result in clinical filling pressures that result in clinical presentation of CHF despite the presence presentation of CHF despite the presence of normal systolic function.of normal systolic function.
DefinitionDefinition
There is no standard definition for diastolic There is no standard definition for diastolic dysfunction, however, it is characterized dysfunction, however, it is characterized by:by:
““Abnormally elevated ventricular Abnormally elevated ventricular filling filling pressures despite normal or pressures despite normal or modestly modestly increased ventricular volume increased ventricular volume and and preserved systolic function”.preserved systolic function”.
Heart failure with normal systolic Heart failure with normal systolic functionfunction
““Diastolic dysfunction is not the only Diastolic dysfunction is not the only mechanism”.mechanism”.
There are several circumstances in which There are several circumstances in which a patient present with apparent CHF and a patient present with apparent CHF and normal systolic function but does not normal systolic function but does not actually have diastolic dysfunction indeed.actually have diastolic dysfunction indeed.
First and most obviously, the diagnosis of CHF First and most obviously, the diagnosis of CHF may be erroneous. The findings of dyspnea, may be erroneous. The findings of dyspnea, cough, tachycardia, pulmonary crackles and cough, tachycardia, pulmonary crackles and peripheral edema are non specific for CHF and peripheral edema are non specific for CHF and can occur in many non-cardiac conditions such can occur in many non-cardiac conditions such as chronic obstructive pulmonary diseases or as chronic obstructive pulmonary diseases or pulmonary fibrosis.pulmonary fibrosis.
Chest X-ray can be misleading in patients with Chest X-ray can be misleading in patients with acute respiratory distress syndrome or acute respiratory distress syndrome or pulmonary infections.pulmonary infections.
Second, diagnosis of CHF with preserved Second, diagnosis of CHF with preserved systolic function is dependent on accurate systolic function is dependent on accurate measurement of ejection fraction, however, EF measurement of ejection fraction, however, EF measurement can differ substantially by different measurement can differ substantially by different techniques and even same technique can vary techniques and even same technique can vary widely (e.g. obese patients, ICU patients on widely (e.g. obese patients, ICU patients on ventilator).ventilator).
Third, the commonly used index of LV ejection Third, the commonly used index of LV ejection fraction may overestimate the true status of LV fraction may overestimate the true status of LV systolic function particularly in setting of valvular systolic function particularly in setting of valvular regurgitation, e.g. patient with EF 45% with regurgitation, e.g. patient with EF 45% with significant MR may have severe dysfunction.significant MR may have severe dysfunction.
Fourth, circumstance is episodic LV Fourth, circumstance is episodic LV systolic dysfunction that has improved at systolic dysfunction that has improved at the time of evaluation, e.g. myocardial the time of evaluation, e.g. myocardial ischaemia, severe hypertension can often ischaemia, severe hypertension can often quickly recover by medical treatment.quickly recover by medical treatment.Myocarditis, tachycardia-related Myocarditis, tachycardia-related cardiomyopathy, peripartum cardiomyo-cardiomyopathy, peripartum cardiomyo-pathy and alcoholic cardiomyopathy pathy and alcoholic cardiomyopathy sometimes improve dramatically over a sometimes improve dramatically over a period of several weeks with resolution of period of several weeks with resolution of infection or conversion to sinus rhythm.infection or conversion to sinus rhythm.
Diagnosis of heart failure with Diagnosis of heart failure with preserved systolic functionpreserved systolic function
““Can diastolic dysfunction be differentiated?”Can diastolic dysfunction be differentiated?”
A variety of clinical criteria have been used to A variety of clinical criteria have been used to diagnose CHF (Framingham, Duke and Boston diagnose CHF (Framingham, Duke and Boston investigations) but non of these criteria is highly investigations) but non of these criteria is highly sensitive or specific.sensitive or specific.
““20% of patients with low ejection fraction did not 20% of patients with low ejection fraction did not have criteria for CHF and 51% of patients with have criteria for CHF and 51% of patients with criteria for CHF had a normal ejection fraction”.criteria for CHF had a normal ejection fraction”.
It is important to note that neither history, It is important to note that neither history, physical examination or X-ray with physical examination or X-ray with enlarged heart are able to reliably enlarged heart are able to reliably determine whether a patient with CHF has determine whether a patient with CHF has normal or abnormal systolic function.normal or abnormal systolic function.
Diastolic Dysfunction AssessmentDiastolic Dysfunction Assessment
The specific diagnosis of diastolic dysfunction The specific diagnosis of diastolic dysfunction require measurement of LV pressure and require measurement of LV pressure and volume simultaneously during diastole to volume simultaneously during diastole to generate pressure-volume curves which can generate pressure-volume curves which can only be done by cardiac catheterization. This only be done by cardiac catheterization. This approach is not only invasive but time approach is not only invasive but time consuming indeed.consuming indeed.
As a result, indirect assessment such as As a result, indirect assessment such as echocardiography doppler to determine LV filling echocardiography doppler to determine LV filling velocity pattern at MV level and radionuclide velocity pattern at MV level and radionuclide angiography has provided an alternative angiography has provided an alternative approach for assessing diastolic dysfunction.approach for assessing diastolic dysfunction.
Unfortunately, none of these methods are Unfortunately, none of these methods are specific for diagnosis of diastolic specific for diagnosis of diastolic dysfunction because:dysfunction because:
1. Doppler method measures only velocity 1. Doppler method measures only velocity and not volumetric flow.and not volumetric flow.
2. Doppler parameters can be altered 2. Doppler parameters can be altered dramatically by changes in heart rate dramatically by changes in heart rate preload, afterload, valve regurgitation preload, afterload, valve regurgitation and medications.and medications.
Thus without a specific diagnostic tool, the Thus without a specific diagnostic tool, the diagnosis of CHF caused by diastolic diagnosis of CHF caused by diastolic dysfunction is difficult to determine with dysfunction is difficult to determine with any degree of certainty.any degree of certainty.
Hence at present, diastolic dysfunction Hence at present, diastolic dysfunction remains a diagnosis of exclusion.remains a diagnosis of exclusion.
Systolic vs Diastolic Heart FailureSystolic vs Diastolic Heart Failure
HistoryHistory SystolicSystolic DiastolicDiastolic
Coronary artery Coronary artery diseasedisease
++++++ ++++
HypertensionHypertension ++++ ++++++++
DiabetesDiabetes ++++ ++++
Valvular heart Valvular heart diseasedisease
++++++++ ++
Paroxysmal dyspneaParoxysmal dyspnea ++++ ++++++
Physical exam.Physical exam. SystolicSystolic DiastolicDiastolic
CardiomegalyCardiomegaly ++++++ ++
Soft heart soundsSoft heart sounds ++++++++ ++
S3 gallopS3 gallop ++++++ ++
S4 gallopS4 gallop ++ ++++++
HypertensionHypertension ++++ ++++++++
Mitral regurgitationMitral regurgitation ++++++ ++
RalesRales ++++ ++++
EdemaEdema ++++++ ++
Raised JVPRaised JVP ++++++ ++
X-ray ChestX-ray Chest SystolicSystolic DiastolicDiastolic
CardiomegalyCardiomegaly ++++++ ++
Pulmonary congestionPulmonary congestion ++++++ ++++++
Electrocardiogram and Electrocardiogram and echocardiogramechocardiogram
Left ventricular hypertrophyLeft ventricular hypertrophy ++++ ++++++++
Q wavesQ waves ++++ ++
Low voltageLow voltage ++++++ --
Left ventricular hypertrophyLeft ventricular hypertrophy ++++ ++++++++Left ventricular dilatationLeft ventricular dilatation ++++ --
Left atrial dilatationLeft atrial dilatation ++++ ++++Reduced ejection fractionReduced ejection fraction ++++++++ --
Cardiac CatheterizationCardiac Catheterization
NormalNormal Systolic Systolic DysfunctionDysfunction
Diastolic Diastolic DysfunctionDysfunction
End diastolic volume End diastolic volume (ml/m(ml/m22))
8080 135135 7070
End systolic volume End systolic volume (ml/m(ml/m22))
4040 105105 3030
Stroke volume (ml/mStroke volume (ml/m22)) 4040 3030 4040
Ejection fraction (%)Ejection fraction (%) 5050 2020 5656
End diastolic pressure End diastolic pressure (mmHg)(mmHg)
1010 2525 2525
Mean diastolic Mean diastolic pressure (mmHg)pressure (mmHg)
55 -- 1818
Myocardial hypertrophy without failureMyocardial hypertrophy without failure
Diastolic complianceDiastolic compliance
LessLess MoreMore
Concentric hypertrophyConcentric hypertrophy Eccentric hypertrophyEccentric hypertrophy
Pressure overloadPressure overload Volume overloadVolume overload
- Aortic stenosis- Aortic stenosis - Mitral regurgitation- Mitral regurgitation
- Systemic HTN- Systemic HTN - Aortic regurgitation- Aortic regurgitation
- Hypertrophic CMP- Hypertrophic CMP
Preload depen-dent
Require high LVEDPRequire high LVEDP Increase in end diastolicIncrease in end diastolicfor normal fillingfor normal filling volume with relatively volume with relatively
diastolic pressure, often diastolic pressure, often significantly significantly
myocardial myocardial dysfunctiondysfunction
Diastolic dysfunctionDiastolic dysfunction Normal stroke volumeNormal stroke volumecharacterized bycharacterized by Normal end diastolic Normal end diastolic
volumevolumeHence normal ejectionHence normal ejection
Fraction (50-75%)Fraction (50-75%)
Hypertrophy and delayed ventricular relaxation mayHypertrophy and delayed ventricular relaxation mayLimit time for diastolic filling and elevate filling pressure.Limit time for diastolic filling and elevate filling pressure.
Pulmonary congestionPulmonary congestion Pulmonary edemaPulmonary edema
Both are amplified by tachycardia + salt & water retentionBoth are amplified by tachycardia + salt & water retention
Compensated Heart FailureCompensated Heart Failure
It is a state in which the symptom of heart It is a state in which the symptom of heart failure are relieved and signs of pulmonary failure are relieved and signs of pulmonary and peripheral congestion have been and peripheral congestion have been relieved by therapy, although the LVEDV relieved by therapy, although the LVEDV and LVEDP often elevated and ejection and LVEDP often elevated and ejection fraction remain reduced. fraction remain reduced.
Decompensated Heart FailureDecompensated Heart Failure
Sudden or progressive appearance of symptoms Sudden or progressive appearance of symptoms of heart failure and signs of pulmonary and of heart failure and signs of pulmonary and peripheral congestion are usually due to:peripheral congestion are usually due to:
A. CVS factorsA. CVS factors– Superimposed ischemia/infarctionSuperimposed ischemia/infarction– Uncontrolled hypertensionUncontrolled hypertension– Unrecognized primary valve diseaseUnrecognized primary valve disease– Worsening secondary MRWorsening secondary MR– New onset or uncontrolled atrial fibrillationNew onset or uncontrolled atrial fibrillation– Excessive tachy, bradycardiaExcessive tachy, bradycardia– Pulmonary embolismPulmonary embolism
B. Systemic factorsB. Systemic factors– Inappropriate Inappropriate
medicationsmedications– Superimposed Superimposed
infectionsinfections– AnaemiaAnaemia– Uncontrolled diabetesUncontrolled diabetes– Thyroid dysfunctionThyroid dysfunction– Electrolyte imbalanceElectrolyte imbalance– PregnancyPregnancy
C. Patient-related C. Patient-related factorsfactors– Medication non-Medication non-
compliancecompliance– Dietary indiscretionDietary indiscretion– Alcohol Alcohol
consumptionconsumption
Prevention of Heart FailurePrevention of Heart Failure
Primary and secondary prevention of Primary and secondary prevention of coronary artery syndrome.coronary artery syndrome.
CAD being a major cause of heart failure CAD being a major cause of heart failure demands risk factors modification.demands risk factors modification.– Cigarette smokingCigarette smoking– Control of blood pressureControl of blood pressure– Control of diabetesControl of diabetes– Lowering of hyperlipidemiaLowering of hyperlipidemia
Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Myocardial infarction is the most common Myocardial infarction is the most common cause of heart failure syndrome. cause of heart failure syndrome. Requires:Requires:
1.1. Myocardial salvage (early thrombolysis).Myocardial salvage (early thrombolysis).2.2. Prevention of another MI.Prevention of another MI.3.3. Prevention, early recognition and timely. Prevention, early recognition and timely.
management of mechanical complication of management of mechanical complication of MI.MI.
4.4. Active myocardial ischaemia: needs timely Active myocardial ischaemia: needs timely revascularization for enhancing L.V. function.revascularization for enhancing L.V. function.
Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Atrial fibrillation – early reversion and rate Atrial fibrillation – early reversion and rate control is main objective. control is main objective. Rheumatic heart disease: emphasis Rheumatic heart disease: emphasis should be given onshould be given on– Mass education for prevention of R.F.Mass education for prevention of R.F.– Prevention of recurrent attacks of R.F.Prevention of recurrent attacks of R.F.– Control progression of disease.Control progression of disease.– Timely correction of underlying defects.Timely correction of underlying defects.– Prevention and effective treatment of infective Prevention and effective treatment of infective
endocarditis.endocarditis.
Prevention of Heart Failure cont.Prevention of Heart Failure cont.
Timely correction of congenital heart Timely correction of congenital heart defects.defects.Comprehensive search for systemic Comprehensive search for systemic disease responsible.disease responsible.– ThyrotoxicosisThyrotoxicosis– AnaemiaAnaemia– Myocardial depressant drugsMyocardial depressant drugs– AlcoholAlcohol– NSAIDNSAID
Suggested Indications for CHF Suggested Indications for CHF AdmissionAdmission
1.1. Symptomatic arrhythmias (syncope, Symptomatic arrhythmias (syncope, presyncope, cardiac arrest)presyncope, cardiac arrest)
2.2. New myocardial infarction or ischaemiaNew myocardial infarction or ischaemia
3.3. Rapid onset of new symptoms of CHFRapid onset of new symptoms of CHF
4.4. Decompensation of CHFDecompensation of CHF
A. Need for immediate hospitalizationA. Need for immediate hospitalization– Pulmonary edema or dyspnoea in sitting Pulmonary edema or dyspnoea in sitting
positionposition– Arterial desaturation < 90%Arterial desaturation < 90%– Heart rate > 120/minHeart rate > 120/min– Systolic BP < 75 mmHgSystolic BP < 75 mmHg– Symptoms of mental hypoperfusionSymptoms of mental hypoperfusion
B. Need for urgent hospitalizationB. Need for urgent hospitalization– Decompensation due to acutely worsening Decompensation due to acutely worsening
non cardiac conditions such as pulmonary non cardiac conditions such as pulmonary disease and worsening renal failure.disease and worsening renal failure.
– New development of liver congestion, tense New development of liver congestion, tense ascites or anasarca.ascites or anasarca.
– New evidence of simultaneous congestion New evidence of simultaneous congestion and hypoperfusion.and hypoperfusion.
C. Consider hospitalizationC. Consider hospitalization– Rapid fall in serum Na < 130 mEqRapid fall in serum Na < 130 mEq– Rising s. creatinine > 2.5 mg/dlRising s. creatinine > 2.5 mg/dl– Persistent symptoms at rest despire repeated Persistent symptoms at rest despire repeated
OPD visits.OPD visits.
MortalityMortality
Most of the studies indicated that CHF Most of the studies indicated that CHF with systolic dysfunction had a worse with systolic dysfunction had a worse prognosis than CHF caused by normal prognosis than CHF caused by normal systolic function (19% vs 8.9% annual systolic function (19% vs 8.9% annual mortality).mortality).
TreatmentTreatment
Unfortunately, unlike the treatment of CHF Unfortunately, unlike the treatment of CHF resulting from systolic dysfunction which is resulting from systolic dysfunction which is based on evidence gathered in well designed based on evidence gathered in well designed clinical trials (ACE inhibitors, digoxin) there are clinical trials (ACE inhibitors, digoxin) there are virtually no controlled studies of therapy for virtually no controlled studies of therapy for diastolic dysfunction.diastolic dysfunction.
As a result, treatment is directed at instigating or As a result, treatment is directed at instigating or reversing the presumed underlying or reversing the presumed underlying or exacerbating conditions e.g., coronary exacerbating conditions e.g., coronary revascularization/PTCA or medical drugs for revascularization/PTCA or medical drugs for myocardial ischaemia may improve LV diastolic myocardial ischaemia may improve LV diastolic and systolic function.and systolic function.
Effective treatment of hypertension will cause Effective treatment of hypertension will cause regression in LV hypertrophy which may improve regression in LV hypertrophy which may improve myocardial compliance.myocardial compliance.
Tachyarrhythmias such as atrial fibrillation can Tachyarrhythmias such as atrial fibrillation can be converted to sinus rhythm by be converted to sinus rhythm by electrical/chemical cardioversion restoring the electrical/chemical cardioversion restoring the atrial contribution to ventricular filling.atrial contribution to ventricular filling.
Surgery and balloon dilatation have proven to be Surgery and balloon dilatation have proven to be effective in treating valvular disease.effective in treating valvular disease.
Treatment of HCM with Verapamil has been Treatment of HCM with Verapamil has been mildly successful.mildly successful.
Hemochromatosis, thyrotoxicosis, Hemochromatosis, thyrotoxicosis, anaemia and beri-beri are all treatable anaemia and beri-beri are all treatable medical conditions.medical conditions.
Surgery can also strip the pericardium in Surgery can also strip the pericardium in patients with pericardial constriction.patients with pericardial constriction.
Surgery by resecting left atrial myxoma is Surgery by resecting left atrial myxoma is curable cause of CHF.curable cause of CHF.
Thus, the principal objectives of treating Thus, the principal objectives of treating diastolic dysfunction are to:diastolic dysfunction are to:– Aggressively control of hypertension.Aggressively control of hypertension.– Recognize and timely treatment of significant Recognize and timely treatment of significant
myocardial ischaemia.myocardial ischaemia.– Reduce symptoms related to fluid retention Reduce symptoms related to fluid retention
and elevated filling pressure.and elevated filling pressure.
Without data from clinical trials, drug Without data from clinical trials, drug therapy is essentially empiric and usually therapy is essentially empiric and usually involved careful combination of agents.involved careful combination of agents.
e.g. Diuretic for fluid retention and nitrates for e.g. Diuretic for fluid retention and nitrates for elevated ventricular filling pressures. Calcium elevated ventricular filling pressures. Calcium antagonists to improve LV filling and relaxation. antagonists to improve LV filling and relaxation. ββ-blockers are also attractive in slowing heart -blockers are also attractive in slowing heart rate and improve diastolic filling. Digoxin cannot rate and improve diastolic filling. Digoxin cannot be recommended routinely for patients with be recommended routinely for patients with preserved function. The empiric and paradoxical preserved function. The empiric and paradoxical effects found with digoxin are poorly understood effects found with digoxin are poorly understood and require further study. Which of these agents and require further study. Which of these agents beneficial in patients with diastolic dysfunction is beneficial in patients with diastolic dysfunction is perhaps the major challenge in clinical perhaps the major challenge in clinical management of CHF.management of CHF.
ConclusionConclusion
Heart failure is an epidemic with high Heart failure is an epidemic with high morbidity and mortality. CAD is morbidity and mortality. CAD is commonest cause of heart failure with commonest cause of heart failure with systolic dysfunction.systolic dysfunction.
However, CHF with preserved systolic However, CHF with preserved systolic function and diastolic dysfunction is function and diastolic dysfunction is perhaps the next major challenge in the perhaps the next major challenge in the clinical management of heart failure.clinical management of heart failure.
CHF is common and costly clinical entity CHF is common and costly clinical entity with high rate of OPD and ER visits and with high rate of OPD and ER visits and longest hospital stay and is commonest longest hospital stay and is commonest cause of death indeed.cause of death indeed.
Prevention of CHF and frequent Prevention of CHF and frequent decompensation is best achieved through decompensation is best achieved through multidisciplinary approach like introduction multidisciplinary approach like introduction of “heart failure education” at community of “heart failure education” at community level.level.
