HEART FAILURE “pump failure”

DEFINITION Heart failure is the inability of the heart to supply adequate blood flow and therefore oxygen delivery to the peripheral tissues and organs

 Cardiac output is about 5 l /min at rest  Increases to upto 25 l/ min  Heart failure occurs when the heart is unable to meet the demand

EPIDEMIOLOGY  Only cardiovascular disease with increasing incidence and prevalance due to  Aging population  Increased survival after MI--thrombolysis  Improvement of medical and surgical treatment

 Important cause of morbidity and mortality  1 yr mortality –10 – 20 %  NYHA class 1V -- > 50 %  4 yr mortality –50 %  Debilitating disease  Significant decrease in quality of life Due to symptoms Decrease functional capabilities Frequent hospitalizations

CLASSIFICATION OF HEART FAILURE This is based on:  How rapid symptoms develop---acute HF ---chronic HF  Which ventricle is involved---right side HF ---left side HF  Over all cardiac output---systolic HF ---diastolic HF

CLASSIFICATION ACCORDING TO ONSET OF SYMPTOMS: Acute heart failure --characterized by a rapid onset of heart failure that may occur following 1- MI 2-myocarditis 3-arrythmias 4- infection 5- PE If it is not fatal may progress to chronic heart failure

Chronic heart failure This results from the heart undergoing adaptive responses to precipitating cause and this cardiac response leads to impaired function. 1- anemia 2-thyrotoxicosis 3-non compliance to medications 4- diet—high salt

ETIOLOGY  Myocardial infarction  Coronary artery disease  Valvular heart disease  Idiopathic cardiomyopathy  Viral or bacterial cardiomyopathy  myocarditis

ETIOLOGY cont.  Pericarditis  Arryhthmias  Hypertension  Thyroid disease  Pregnancy  Septic shock

ETIOLOGY cont.  Toxins—anthracyclines amphetamine cocaine  Metabolic---haemachromatosis wilson,s disease pheochromocytoma

SYMPTOMS cont.{ FACES}  Fatigue  Activity decrease  Cough { specially supine,frothy red sputum  Edema  Shortness of breath { NYHA }

SYMPTOMS NYHA classification of dyspnoe  Class 1—no shortness of breath {SOB}  Class 11—SOB on severe exertion  Class 111—SOB on mild exertion  Class 1v---SOB at rest

Heart failure management issues  High mortality  High readmission rates  Poor Rx adherance  On going symptoms  Reduced quality of life  Dose adjustment in the elderly

Heart failure therapeutic goals  1ry goal = reduce symptoms  Improve quality of life  Reduce hospitalization  Prevent sudden death

DIET approach to the pt. with heart failure  D—diagnose---eteiology ---severity of LV dysfunction  I –initiate---diuretics { thiazide, frusemide } ---beta blockers ---ACEI ---digoxin ---spironolactone

 E—educate----diet ---exercise ---life style  T---titrate---optimize ACEI ---optimize beta blockers

General measures  Correct precipitating causes  Treat ischemia  Control hypertension  D/C smoking  Treat lipid abnormality  Treat and control hypertension

 Low salt diet  Fluid restriction  Regular exercise  Upright position to reduce pulmonary congestion  Prophylactic anticoaggulation  Avoid –ve inatropic drugs

 Identify triggers Acute sudden onsetChronic gradual onset ischemiaanemia arrythmiathyrotoxicosis infectionNon compliance P.Ediet Acute valvular pathology Drugs like NSAID

INVESTIGATION  CBC  U+E  LFT  Cardiac enzymes  CXR  ECG  Echocardiogram

TREATMENT  Diuretics  Digoxin  ACE inhibitors  Vasodilators  Beta blockers

DRUGS  Diuretics ---thiazide diuretic ---frusemide {loop diuretic} ----spironolactone { K sparing}  Titrate to euvolumic state  Maintain ideal body wt ={ dry wt= normal JVP / trace or no pedal edema}

 ACEI  Cornerstone in the Rx of heart failure  Continue indefinitely if EF < 40 %  Rx for all asymptomatic pts with EF < 35%  Rx for all symptomatic pts with EF =35%  Use max. tolerated dose

ACEI cont..  Captopril---capoten  Enalapril----renetic  Lisinopril----zestril  Fosinopril---staril

Angiotensin receptor blockers  Same action and benefits as ACEI  Used in pts who cannot tolerate ACEI due to side effects  Candesartan  Irbesartan  Losartan  Valsartan  Telemisartan

Beta blockers  Titrate to max. tolerated dose  Continue indefinitely  Bisoprolol  Carvidelol  metaprolol

patient selection for successful beta blocker initiation  Stable symptoms  Stable background heart failure medication  No hypotension  No bradycardia  Euvolumic status  Start low and titrate slowly

Patients with heart failure who should NOT be started on beta blockers  Bronchospastic pulmonary disease  Severe bradycardia  High degree A / V block  Sick sinus syndrome  NYHA class 1V  Pts. Who require IV therapy for HF  Hospitalized pts specially for worsening HF  Unstable symptoms

Digoxin  For persisting symptoms in systolic dysfunction  For symptomatic and rate control of AF  To decrease the dose in elderly and pts with renal failure

Aldosterone antagonist  Spironolactone  Add to ACEI, diuretics, beta blockers,+/- digoxin  Used in NYHA class 111 and 1V CHF  EF < 35%  It leads to 30 % ↓ in death from progressive HF

Cardiac resynchronization therapy {CRT}

ACC / AHA guidline summary– management of pts with current or prior symptoms of heart failure and a reduced left ventricular EF  Diuretics and salt restrictions for fluid retention  ACE I in all pts unless CI  Beta blockers in all stable pts, unless CI

Three beta blockers proven to reduce mortality should be used…  Metaprolol  Bisoprolol  Carvidelol  Drugs that adversely affect the pts should be avoided or withdrawn if possible… NSAID Most antiarrythmic drugs Most calcium channel blockers

 Angiotensin 11 receptor blockers are used in pts who cannot tolerate ACEI. Two drugs which are approved are Candesartan larsartan  An implantable cardioverter-defibrillator ICD for 2ry prevention to prolong survival in pts with h/o cardiac arrest, vent. Fib.

Drugs that should be avoided or used with caution  NSAID  Thiozolidindione group  PDE-5 inhibitors—sildenafil  Antiarryhtmics