Heart Failure Objectives 1 to know the common

Heart Failure Objectives 1 - to know the common causes of heart failure. 2 - Types of heart failure. differentiation between systolic & diastolic failure. Staging of H. F 3 - Clinical signs of heart failure & lab tests &their findings in diagnosis of H. F. 4 - Treatment of systolic & diastolic failure.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Pathophysiology Hemodynamic changes Neurohormonal changes Cellular changes

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Neurohormonal changes in CHF Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Initial fall in LV performance, wall stress Activation of RAAS and SNS Remodeling and progressive worsening of LV function Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity Morbidity and mortality Arrhythmias Pump failure RAS, renin-angiotensin system; SNS, sympathetic nervous system. Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Fatigue Activity altered Chest congestion Edema Shortness of breath

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Neurohormonal changes N/H changes Favorable effect Unfavor. effect HR , contractility, vasoconst. V return, filling Arteriolar constriction After load workload O 2 consumption Renin-Angiotensin – Aldosterone Salt & water retention VR Vasoconstriction after load Vasopressin Same effect interleukins &TNF May have roles in myocyte hypertrophy Apoptosis Vasoconstriction VR After load Sympathetic activity Endothelin

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Causes of CHF • Volume overload: Regurgitate valve High output status • Pressure overload: Systemic hypertension Outflow obstruction—AS • Loss of muscles: Post MI, Chronic ischemia Connective tissue diseases Infection, Poisons (alcohol, cobalt, Doxorubicin) • Restricted Filling: Pericardial diseases, Restrictive cardiomyopathy Tachyarrhythmia

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Types of CHF • Systolic & Diastolic • High Output Failure Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagets disease • Low Output Failure • Acute • large MI, aortic valve dysfunction-- • Chronic

CLINICAL STAGES OF HEART FAILURE. �STAGE A: risk factors , no structural disease or symptoms. �STAGE B : structural disease but no symptoms. �STAGE C : structural disease with prior or current symptoms. �STAGE D : refractory disease with severe symptoms.

Precipitants of H F: � 1 - Myocardial ischemia. As ACS. � 2 - Hypertension. � 3 - Arrhythmias. � 4 - Infections. � 5 - Drugs & Toxins. � 6 - Diet. � 7 - Noncompliance. � 8 - acute pulmonary embolism. � 9 - Anaemia.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Rhythm problems leading to CHF

DIAGNOSIS OF HEART FAILURE

Signs & Symptomes Of H F �Dyspnea on exertion & later on at rest. NYHA 1 – 4. �Orthopnea & PND. �Fatigue & poor exercise tolerance. �Plapitation & syncope. �Cough specialy at night. �Leg swelling. �Raised JVP. �Basal rales. �S 3 gallop.

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Framingham Criteria for CHF Major Criteria: • • PND JVD Rales Cardiomegaly Acute Pulmonary Edema S 3 Gallop Positive hepatic Jugular reflex ↑ venous pressure >16 cm H 2 O

Minor Criteria 1 - Bilateral leg odema. 2 - Dyspnea on exertion. 3 - Pleural effusion. 4 - Hepatomegaly. 5 - Heart rate more than 120 per min.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF EKG Old MI or recent MI Arrhythmia Some forms of Cardiomyopathy are tachycardia related LBBB→may help in management Heart Block

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Chest X-ray Look for Heart size Pulmonary vascular markings COPD, pneumonia, Pneumothorax, widened mediastinum Pleural effusions

Chest X- ray

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Echocardiogram Function of both ventricles Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pericardial effusion Restrictive pericarditis Pulmonary hypertension

Diagnostic tests: � 4 - B-type natriuretic peptide ( BNP ). � Cutoff level 150 pg / ml. senstivity =90 % � specificity 70%. Use in acute setting only. �Affected by age , renal function & BMI. � 5 - other tests : BUN, s. electrolytes, CBC, thyroid function test, s. iron & s. ferritin.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Cardiac Catheterization Coronary artery disease Dilated ventricle Hyperdynamic small ventricle Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts Pulmonary hypertension

Systolic versus diastolic failure SYSTOLIC DYSFUNCTION DIASTOLIC DYSFUNCTION �Dilated cardiac chambers. �Normal size or LVH. �Cardiomegaly on CX-ray. �Pulmonry congestion +normal cardiac size. �Low EF < 40 %. �Worse prognosis. �Normal EF > 40 % , E/A< 1 �Good prognosis.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Goals for CHF management in a hospital 1. Relieve symptoms rapidly 2. Reverse hemodynamic abnormalities 3. Prevent end-organ dysfunction 4. Initiate patient education and survival-enhancing medications before discharge 5. Optimize survival-enhancing oral medications (ACE inhibitor, beta blocker, aldosterone receptor antagonist) 6. Optimize patient education and HF disease management

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Management-long term

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Diet and Activity Salt restriction (2 grams per day) Fluid restriction (Less than 1 -2 liters per day) Daily weight (tailor therapy) Gradual exercise programs Blood sugar monitoring

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Treatment of CHF Correction of reversible causes • Medications Diuretics, ACE inhibitors, beta blokers etc. • Ischemia • Arrhythmia: A fib, flutter, PJRT • Valvular heart disease • Thyrotoxicosis and other high output status • Shunts

SUGAR LAND HEART CENTER Congestive Heart Failure CHF treatment-Acute Pharmacological Morphine sulfate Nitrates Diuretics ACE inhibitors Beta blockers Aspirin therapy statins Vasodilators Neurohormonal antagonists – Anticoagulant therapy – Antiarrhymics

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Diuretics Loop diuretics for more severe heart failure • • • Lasix Bumex Torsemide (20 – 320 mg QD), Furosemide (Bumetanide 1 -8 mg) (20 -200 mg) Mechanism of action: Inhibit chloride reabsortion in ascending limb of loop of Henle results in natriuresis, kaliuresis and metabolic alkalosis Adverse reaction: pre-renal azotemia Hypokalemia Skin rash Ototoxicity

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Diuretics K sparing diuretics Triamterene Amiloride – acts on distal tubules to ↓ K secretion Spironolactone (Aldosterone inhibitor) Recent evidence suggests that it may improve survival in CHF patients due to the effect on renin-angiotensin-aldosterone system with subsequent effect on myocardial remodeling and fibrosis

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Renin, angiotensin, aldasterone blockers Renin-angiotensin-aldosterone system is activation early in the course of heart failure and plays an important role in the progression of the syndrome: • Angiotensin converting enzyme inhibitors (ACE inhibitors) • Angiotensin receptors blockers (ARBS) • Spironolactone

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Renin-angiotensin blockers They block the R-A-A system by inhibiting the conversion of angiotensin I to angiotensin II: → Vasodilation → Na retention ↓ → Decreased Bradykinin degradation ↑ its level → ↑ PG secretion & nitric oxide Ace Inhibitors improve survival in CHF patients • Delay onset & progression of HF in pts with asymptomatic LV dysfunction • ↓ cardiac remodeling

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Beta Blockers • Has been traditionally contraindicated in pts with CHF • 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 • The only contraindication is severe decompensated CHF

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Inotropic agents-Digoxin The role of digitalis has declined somewhat because of safety concern Recent studies have shown that digitals does not affect mortality in CHF patients but causes significant • • • Reduction in hospitalization Reduction in symptoms of HF Rate control in At fib.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Inotropic agent-Digoxin action +ve inotropic effect by ↑ intracellular Ca & enhancing actin-myosin cross bride formation (binds to the Na-K ATPase → inhibits Na pump → ↑ intracellular Na → ↑ Na-Ca exchange Vagotonic effect Arrhythmogenic effect

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Inotropic agent-Digitalis toxicity Narrow therapeutic to toxic ratio Non cardiac manifestations Anorexia, Nausea, vomiting, Headache, Xanthopsia sotoma, Disorientation Treatment: Digibind (Fab antibody)

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Antiarrhythmics Most common cause of SCD in these patients is ventricular tachyarrhythmia Patients with h/o sustained VT or SCD → ICD implant Patients with CHF with an ejection fraction of less than 30% may receive ICD implant Amiodarone for patients with frequent VPCs and at fib Dranedone for patients with recurrent paroxysmal at fib.

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Anticoagulation Atrial fibrillation H/o embolic episodes Left ventricular apical thrombus Low LV ejection fraction

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Inotropic Agents These are the drugs that improve myocardial contractility (β adrenergic agonists, dopaminergic agents, phosphodiesterase inhibitors), Dopamine Dobutamine Milrinone, Aamrinone Several studies showed ↑ mortality with oral inotropic agents So the only use for them now is in acute sittings such as cardiogenic shock

SUGAR LAND Congestive Heart Failure CHF HEART CENTER New Treatment Choices Implantable ventricular assist devices Biventricular pacing (only in patient with LBBB & CHF) Artificial Heart

SUGAR LAND Congestive Heart Failure CHF HEART CENTER Achieving Cardiac Resynchronization Mechanical Goal: Atrial-synchronized bi-ventricular pacing • • • Standard pacing lead in RA Standard pacing or defibrillation lead in RV Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right Atrial Lead Right Ventricular Lead Left Ventricular Lead

SUGAR LAND HEART CENTER Pacing Congestive Heart Failure CHF

SUGAR LAND Congestive Heart Failure CHF HEART CENTER CHF treatment-Acute • • • NTG- SL and IV infusion Morphine sulfate: 2 -6 mg IV Lasix 40 -80 mg IV O 2—High flow O 2 CPAP Foley catheter

SUGAR LAND HEART CENTER Congestive Heart Failure CHF Differential Diagnosis of CHF Pericardial diseases Liver diseases Nephrotic syndrome Protein losing enteropathy