Systolic Heart Failure Eugene Yevstratov MD http www

Systolic Heart Failure Eugene Yevstratov MD http: //www. ctsnet. org/home/eyev stratov

Definition Inability to pump an adequate volume of blood and/or to do so only from an abnormally elevated filling pressure, is that heart failure, can be caused by an abnormality in systolic function leading to a defect in the expulsion of blood i. e. Systolic Heart Failure http: //www. ctsnet. org/home/eyev stratov

Causes • Coronary artery disease • Valvular heart disease • Hypertension and aging • Diabetes • Dilated cardiomyopathy http: //www. ctsnet. org/home/eyev stratov

NYHA classification of heart failure symptoms • Class 1: No limitations, ordinary physical activity does not cause undue fatige, dyspnoea or palpitation (asymptomatic LVD) • Class 2: Slight limitation of physical activity, such patients are comfortable at rest (symptomatically ¨mild¨heart failure) • Class 3: Marked limitation od physical activity, less then ordinary physical activity will lead to symptoms (symptomatilcally ¨moderade¨heart failure) http: //www. ctsnet. org/home/eyev stratov

Echo Morphological Classification • Segmental dysfunction Focal scarring/dyskinesis most likely ischemic origin, but significant regional asymmetry (even without LBBB) often seen in DCM • Global dysfunction May be due to any of the causes of systolic dysfunction, including CAD http: //www. ctsnet. org/home/eyev stratov

SHF vs Normal Heart Value • • • End diastolic volume 135 m. Vm 2 (N 80) End Systolic volume 105 ml/m 2 (N 40) Stroke volume 30 ml/m 2 (N 40) Ejection fraction 20 % (N 50) End diastolic pressure 25 mm. Hg (N 10) http: //www. ctsnet. org/home/eyev stratov

Left ventricular systolic dysfunction is defined as an ejection fraction of less than 40% http: //www. ctsnet. org/home/eyev stratov

Clinical Symptoms • • • Dyspnoea Hallmark Fatigue symptoms Periferal oedema Orthopnoea Spesific Paroxysmal nocturnal dyspnoea symptoms http: //www. ctsnet. org/home/eyev stratov

Nearly 50% of patients with heart failure die within five years of the onest of symptoms http: //www. ctsnet. org/home/eyev stratov

Identification of SHF http: //www. ctsnet. org/home/eyev stratov

CAD producing ischemic cardiomyopathy is the most common cause of left ventricular systolic dysfunction http: //www. ctsnet. org/home/eyev stratov

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Physiology http: //www. ctsnet. org/home/eyev stratov

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Preload http: //www. ctsnet. org/home/eyev stratov

Afterload http: //www. ctsnet. org/home/eyev stratov

LV remodeling Pressure overload Volume overload normal Increased DP Increased SP Icreased Sσ Icreased Dσ + - Series addition of new safcomeres Parallel addition of new myofibrils Wall thickening - Chamber enlargement http: //www. ctsnet. org/home/eyev stratov Concentric hypertrophy Eccentric hypertophy

Ventricular Hypertrophy 3 1 5 2 4 http: //www. ctsnet. org/home/eyev stratov 3

Systolic vs Diastolic Dysfunction http: //www. ctsnet. org/home/eyev stratov

Treatment of SHF • • Diuretics Positive Inotropics Drugs Direct-Acting Vasodilators Neurohormonal Antagonists http: //www. ctsnet. org/home/eyev stratov

Treatment of SHF http: //www. ctsnet. org/home/eyev stratov

Tailored Therapy for Advanced Heart Failure • IV nitroprusside and diuretics tailored to hemodynamics goals PCW <15 mm. Hg • Measurment of baseline hemodynamics SVR< 1200 dynes/s/cm-5 RA < 8 mm. Hg http: //www. ctsnet. org/home/eyev stratov SBP > 80 mm. Hg

• Definition of optional hemodynamics by 23 – 48 hours • Titration of high-dose oral vasodilators as nitroprusside weaned (combination of captopril, ISDN, hydralazine as needed as alternative or addition) • Monitored ambulation and diuretic adjustment for 24 – 48 hours • Maintain digoxin levels 1. 0 – 2. 0 ng/dl if no contraindication http: //www. ctsnet. org/home/eyev stratov

Eugene Yevstratov MD http: //www. ctsnet. org/home/eyev stratov