Heart failure Prepared by: Maha islami. Supervised by : Majda Al-Attas.

outline Definition. Epidemiology. Etiology. Pathophysiology. Symptoms. Classification. Management.

Definition. Heart failure is defined as a syndrome in which the heart fails to pump sufficient blood to meet the needs of the body. Ejection fraction = % of the end-diastolic volume that is ejected during systole (normal > 50 % ).

Epidemiology Heart failure is most commonly diagnosed at ages > 65 yo , more frequent in men than women. Approximately 400,000 new cases each year.

Etiology Systolic Dysfunction : Ischemic disease myocardial ischemia,and MI. Non-Ischemic disease: 1ry myocardial muscle dysfunction (idiopathic , drug induced , familial). Valvular abnormalities. Structural damage +/- damage to myocardial walls (e.g. ventricular septal defects). Hypertension (pulmonary).

Etiology cont….. Diastolic Dysfunction: Hypertrophy cardiomyopathy. Hypertension. Myocardial Ischemia. Restrictive cardiomyopathy. Amyloidosis. Sarcoidosis.

Other precipitating causes Infection: fever, tachycardia, hypoxemia,and increased metabolic demand place further strain on heart. Anemia: lack of oxygenating RBC demands heart to increase output-failing heart unable to do so. Pregnancy: for tissue to be adequately perfused, increased output is needed. Arrythmias: erratic cardiac output. Dietary , and emotional excesses.

Drugs that may exacerbate HF. Negative inotropic effect: anti-arrythmics, CCB (non-DHP). Cardiotoxic : Doxorubicin, cyclophosphamide. Na+/H2O retention: - Glucocorticoids, androgens, estrogens, NSAIDs.

pathophysiology

What Are The Symptoms of Heart Failure? Think FACES... Fatigue. Activities limited. Chest congestion. Edema or ankle swelling. Shortness of breath.

Right-sided vs Left-sided HF. Abd.pain, anorexia, nausea , constipation, peripheral edema, JVD, Hepatojugular reflex. Right-sided Dyspnea on exertion, Prenight dyspnea, orthopnea, cough, pulmonary edema, pleural effusion, (+) S3 Gallop. Left-sided Fatigue, Weakness, Cardiomegaly, Pallor. Non-specific symptoms

HF Classification system New York Heart Association Functional classification: Class I: NO Limitation of physical activity. Class II: ordinary activity result in symptoms of HF. Class III: marked limitation of physical activity. Class IV: symptoms of HF at rest.

Stages of HF based on evolution and progression of clinical findings. examples description stage HTN,CAD,DM,Hx of cardiotoxic drug therapy,Hx of rheumatic fever, family Hx of cardiomyopathy. Pts at ↑risk of developing HF because of the presence of conditions that are strongly associated with the development of HF.such pts have no identified structural abnormalities and have never shown signs or symptoms of HF. A Left ventricular hypertrophy or fibrosis, left ventricular dilation or hypocontractility, asymptomatic valvular heart disease, previous myocardial infarction. Pts who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF. B

Stages of HF based on evolution and progression of clinical findings cont… Examples description stage Dyspnea or fatigue duo to left ventricular systolic dysfunction. pts who have current symptoms of HF associated with underlying structural heart disease, C Pts who are frequently hospitalized for HF and cannot be safely discharged from the hospital receiving continuous IV support for symptom relief or being supported with a mechanical circulatory assist device . Pts with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. D

Evaluation of HF Assign stage of HF based on evaluation and progression of clinical finding( Guidelines ). Obtain LVEF and dimensional echocardiogram. Ventricular hypertrophy and chest congestion can be provided by chest X-ray(cardiomegaly, plural effusion). ECG. Liver enzyme elevation (hepatomegaly). Assess fluid status: -weight. -peripheral edema. -JVD. -hepato/splenomegaly. - Rales.

Management of HF Non-pharmacologic /Adjunct therapy. Minimize sodium intake (< 3 gm daily). Weight loss. Smoking cessation. A form of exercise. Surgical : correction of valvular disease, revascularization, heart transplant. Avoid NSAIDs.

Management of HF cont…. Pharmacological treatment: Most pts with symptomatic should be managed with combination of 4 types of drugs: ACEI +B-B(improve EF duo to effecting remodling)+ Diuretics, +/- Digitals.(basic core ). Hydralazine and isosorbide for pt who can’t take ACEI. Oxygination. Anticoagulation: is not recommended only in HF pts at risk with :AF, DVT, PE,and EF≤25% may give Warfarin.

Management of HF cont…. Anti-arrhythmic: is the mode of death in up to 50% of HF cases.class 1 anti-arrhythmic not recommended. (Amiodarone 1st line agent and Dofetilide appear to be safe ,does not appear to increase mortality.

HF Treatment options ACEI: ↓Preload and afterload,and ↑CO. 1st line agents in the Tx. Showing a beneficial effect on cardiac remodeling. Start at low dose and titrate , dose can be ↑q3-7 days. Elderly pts >75 YO should start ½ recommended starting dose.

ACEI cont….. Dose: SE: Dry cough, angioedema, neutropenia, skin rash, proteinuria, hyperkalemia. Max dose Target dose Starting dose drug 100 mg tid. 20 mg bid. 5 mg bid. 50 mg tid. mg bid. 1-2.5 mg bid. 6.25-12.5 mg tid. 2.5-5 mg qd. 0.5 mg bid. Captopril. enalapril. Cilazapril.

HF Treatment options cont…. B-B: ↓sympathetic stimulation by ↓plasma NE peripheral vasoconstriction and cell death (apoptosis). Dose: Target dose Initial dose drug 10 mg once daily. 1.25 mg once daily. Bisoprolol. 25 mg twice daily , 50 mg twice daily for pts >85 kg. 3.125 mg twice daily. .Carvidolol

HF Treatment options cont…. SE: depression , nightmares , insomnia , bronchospasm , dizziness . Diuretics: ↓edema and congestion (↓preload). IV for pulmonary edema. Oral doses are titrated according to symp and body wt. Thiazid are weak diuretics and are used infrequently in HF.

Diuretics cont…. Loop diuretics (furosemide)most widely used. Dose: ↓K , ↓Mg , DM , HA , jundice , arrythmia. Max dose Starting dose drug 240 mg bid . 20-40 mg qd . furosemide 50 mg qd . 25 mg qd . HCTZ 10 mg qd. 2.5 mg qd . Metalazone

HF Treatment options cont…. digoxin: (+ ve )inotrope ,↑CO , May have beneficial effect on vagal tone and ↓SNS. Used as second line therapy in pt not responding to conventional therapy. Dose: initial dose 0.125-0.25 mg once daily. Target dose : 0.125-0.25 mg once daily. Digitalis Toxicity: Symptoms of toxicity: nausea , vomiting , headache , dizziness , chills , fever, diarrhea , restlessness.

Digitalis Toxicity cont…. Treatment of the toxicity : Hold the medications. Observation. In case of A/V block or severe bradycardia → atropine followed by temporary PM if needed. In life threatening arrhythmia → digoxin-specific fab antibodies. Lidocaine and phenytoin could be used .

HF Treatment options cont…. CCB: Possible ↓in afterload. Amlodipine and Felodipine may have some benefit in HF Pts with angina or HTN. Hydralazine and nitrates combination: Hydralazine :↓afterload. Nitrates:↓ preload. This combination the 1st to ↑survival in sever HF. 1st Tx in mild-moderate systolic HF.

Hydralazine and Nitrates combination cont …. Not studied diastolic HF. Dose: SE: Postural hypotension , sever HA , flushing , SLE . Target dose Starting dose drug 75 mg tid-qid. 40 mg tid-qid. 10 mg tid. Hydralazin and Isosorbide dinitrate

HF Treatment options cont…. Spironolactone: Block aldosterone chronically. Consider in pts with recent or current class IV symptoms. Dose: SE: Gynecomastia , agranulocytosis , N/V , Hyperkalemia. Max dose Target dose Starting dose Drug 100 mg. 25-5o mg qd. 25 mg qd. spironolactone

Stage D Stage C Stage B Stage A Refractory HF requiring specialized interventions. Structural heart disease with prior or current symptoms of HF. Structural heart disease but without symptoms of HF. High risk of developing HF but no structural heart disease or symptoms of HF Therapy All measures under stages A, B,and C. Mechanical assist devices. Heart transplantation. Continuous IV inotropic infusions. All measures under stage A. Drugs for routine use: Diuretics. ACEI. B-B. +/-Digitalis. ACEI in appropriate pts. B-adrenergic blockers in appropriate pts. Treat HTN , encourage smoking cessation , treat lipid disorders , encourage regular exercise,

New Methods: Implantable ventricular assist devices.

New Methods cont… Biventricular pacing (only in patient with left bundle branch block).

References. http://www.nlm.nih.gov/mdlineplus/heartfailure.htm. http://www.emedicinehealth.com/congestive_heart_failure/article_em.htm.

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