Heart Failure Halmat M. Jaafar (MSc. Clinical pharmacy) Hawler Medical University/ College of Pharmacy Department of Pharmacology Halmat.jaafar@pha.hmu.edu.iq

Outline of this lecture: What is Heart Failure? Epidemiology. Etiology And Pathophysiology. Classification of Heart Failure. Sign and symptoms dignosis Prognosis. Complications. Assessment of Heart Failure patient, treatment and management (nonpharmacological, medical and surgery).

What is Heart failure? is the pathological process in which the systolic or/and diastolic function of the heart is impaired, and as a result, cardiac output decreases and is unable to meet the metabolic demands of the body.

What is Heart failure? A pathophysiologic state in which an abnormality of cardiac function and/or strucure is responsible for failure of the heart to pump blood at a rate commensurate with metabolic requirements of the tissues.

What is Heart failure? Heart Failure- Clinical syndrome … can result from any structural or functional cardiac disorder that impairs ability of ventricle to fill with or eject blood. -It is commonly termed congestive heart failure (CHF) since symptoms of increase venous pressure are often prominent.

EPIDEMIOLOGY More than 20 million people affected worldwide Affects 10% of people over 65 year It is the most common condition for which patients 65 + require admission to hospital with an estimated 772,000 new HF cases projected in the year 2040. The incidence of HF is greater in men and in the elderly Prevalence- 2% in developed countries Affects over 50% of people with 85+ years Approx. 10% of patients with HF die each yr.

Heart Failure Final common pathway for many cardiovascular diseases whose natural history results in symptomatic or asymptomatic left ventricular dysfunction Risk of death is 5-10% annually in patients with mild symptoms and increases to as high as 30-40% annually in patients with advanced disease

Etiology And Pathophysiology Hemodynamic changes Neurohormonal changes Cellular changes

Ventricular Remodeling Ventricular remodeling after acute infarction Ventricular remodeling in diastolic and systolic heart failure Initial infarct Expansion of infarct (hours to days) Global remodeling (days to months) Normal heart Hypertrophied heart (diastolic heart failure) Dilated heart (systolic heart failure) Ventricular Remodeling

Risk factors

Classification of heart failure According to the course of disease Acute HF Chronic HF According to the cardiac output (CO)  Low-output HF   High-output HF According to the location of heart failure Left -side heart failure (LHF) Right-side heart failure (RHF) Biventricular failure (whole heart failure) According to the function impaired Systolic failure Diastolic failure

Classification of heart failure According to the course of disease Acute HF Chronic HF According to the cardiac output (CO)  Low-output HF   High-output HF According to the location of heart failure Left -side heart failure (LHF) Right-side heart failure (RHF) Biventricular failure (whole heart failure) According to the function impaired Systolic failure Diastolic failure

Chronic heart failure

Chronic Heart Failure

JVP = jugular venous pressure

Edema

Ascites

HF—lab test Brain natriuretic peptide (BNP) >100 pg/ml Heart failure

Heart Failure Normal

Pulmonary edema Butterfly sign

Heart Failure Diagnostic Tests Initial Lab workup includes Glucose Fasting lipid profile (FLP) liver function tests (LFT) Thyroid-stimulating hormone (TSH) Cardiac Troponins Beta naturetic peptide (BNP) Arterial Blood gas (ABG) ECG Chest X ray Complete blood count (CBC) Urinalysis Serum electrolytes (including calcium and magnesium) Blood urea nitrogen (BUN) and serum creatinine (Cr)

Chest xray Normal Pulmonary edema

Heart Failure Diagnostic Tests 2-dimensional echocardiogram (2-D echo) with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function

But

Framingham Criteria for Dx of Heart Failure Major Criteria: PND JVD Rales Cardiomegaly Acute Pulmonary Edema S3 Gallop Positive hepatic Jugular reflex ↑ venous pressure > 16 cm H2O

Framingham Criteria for Dx of Heart Failure Minor Criteria LL edema, Night cough Dyspnea on exertion Hepatomegaly Pleural effusion ↓ vital capacity by 1/3 of normal Tachycardia 120 bpm Weight loss 4.5 kg over 5 days management

Heart Failure Complications Pleural effusion Atrial fibrillation (most common dysrhythmia) Loss of atrial contraction – necessary for 20-25% of cardiac output Reduce CO by 20% to 25% Promotes thrombus/embolus formation Increase risk for stroke

Heart Failure Complications High risk of fatal dysrhythmias (e.g., sudden cardiac death, ventricular tachycardia) with HF and an EF <35% HF lead to severe hepatomegaly, especially with RV failure Fibrosis and cirrhosis (cardiac cirrhosis) - develop over time Renal insufficiency or failure (cardiorenal syndrome)

MANAGEMENT OF HF

Goals of treatment To improve symptoms and quality of life To decrease the disease progression To reduce the risk of death and need for hospitalization

TREATMENT Correction of reversible causes Ischemia Valvular heart disease Thyrotoxicosis and other high output status Arrhythmia A fib, flutter Medications Ca channel blockers, some antiarrhythmics

Non Pharmacological Activity- Diet- Routine modest exercise for class I-III For euvolemic patients- regular isotonic exercise such as walking or riding a stationary-bicycle ergometer Diet- Restriction of sodium (2-3 g daily) is recommended in all patients, Extra < 2g reduction in moderate to severe cases. Fluid restriction (<2 L/day) if hyponatremia (<130 meq/L) Caloric supplementation- with advanced HF and unintentional weight loss or muscle wasting Three things for preventing heart diseases are – Eat less fried food, less butter. Second, exercise daily for around 45 minutes. And third, reduce stress in life

Non Pharmacological Activity- Diet- Routine modest exercise for class I-III For euvolemic patients- regular isotonic exercise such as walking or riding a stationary-bicycle ergometer Diet- Restriction of sodium (2-3 g daily) is recommended in all patients, Extra < 2g reduction in moderate to severe cases. Fluid restriction (<2 L/day) if hyponatremia (<130 meq/L) Caloric supplementation- with advanced HF and unintentional weight loss or muscle wasting Three things for preventing heart diseases are – Eat less fried food, less butter. Second, exercise daily for around 45 minutes. And third, reduce stress in life

Pharmacological measures DRUGS FOR ACUTE DECOMPENSATED HF Drug Therapy for Chronic HF Due to Systolic Dysfunction DIURETICS-furosemide / hydrochlorthiazide ACE-INHIBITORS*-captopril ARBs*- losartan Neprilysin inhibitor: *(sacubitril + valsartan) HYDRALAZINE + ISOSORBIDE*-when ACE-I or ARB contraindicated or not fully effective BETA BLOCKERS* SPIRONOLACTONE* DIGOXIN * = SURVIVAL BENEFIT DIURETICS- Furosemide /hydrochlorthiazide VASODILATORS- Nitroprusside, Nitroglycerin, Nesiritide INOTROPIC AGENTS- dobutamine, dopamine, milrinone,

Surgical measures Cardiac Resynchronization Implantable Cardiac Defibrillators Intraaortic balloon counter pulsation Percutaneous and surgically implanted LV assist devices Cardiac transplantation

ESC Guidelines

Surgical measures Cardiac Resynchronization Implantable Cardiac Defibrillators Intraaortic balloon counter pulsation Percutaneous and surgically implanted LV assist devices Cardiac transplantation

Patient Selection and Treatment Congestion at Rest No Yes Warm & Dry PCWP normal CI normal (compensated) Warm & Wet PCWP elevated CI normal Natriuretic Peptide Nesiritide or No Low Perfusion at Rest Vasodilators Nitroprusside Nitroglycerin Cold & Dry PCWP low/normal CI decreased Cold & Wet PCWP elevated CI decreased Yes Normal SVR High SVR Inotropic Drugs Dobutamine Milrinone Calcium Sensitizers

Heart Failure Therapies Stage A At high risk for developing heart failure. Includes people with: Hypertension Diabetes mellitus CAD (including heart attack) History of cardiotoxic drug therapy History of alcohol abuse History of rheumatic fever Exercise regularly Quit smoking Treat hypertension Treat lipid disorders Discourage alcohol or illicit drug use If previous heart attack/ current diabetes mellitus or HTN, use ACE-I Stage B Those diagnosed with “systolic” heart failure- have never had symptoms of heart failure (usually by finding an ejection fraction of less than 40% on echocardiogram Care measures in Stage A + Should be on ACE-I Add beta -blockers Surgical consultation for coronary artery revascularization and valve repair/replacement (as appropriate

Heart Failure Therapies Stage C Patients with known heart failure with current or prior symptoms. Symptoms include: SOB, fatigue, Reduced exercise intolerance All care measures from Stage A apply, ACE-I and beta-blockers should be used + Diuretics, Digoxin, Dietary sodium restriction Weight monitoring, Fluid restriction Withdrawal drugs that worsen condition Maybe Spironolactone therapy

Heart Failure Therapies Stage D Presence of advanced symptoms, after assuring optimized medical care All therapies -Stages A, B and C + evaluation for: Cardiac transplantation, surgical options, research therapies, Continuous intravenous inotropic infusions/ End-of-life care

Heart Failure Therapies