Congestive Heart Failure Hanna Al-Makhamreh, MD FACC Interventional cardiology

Heart Failure Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).

The Vicious Cycle of Congestive Heart Failure

Types of Heart Failure Systolic Heart Failure: decreased cardiac output Decreased Left ventricular ejection fraction Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic pressures May have normal LVEF .

Causes of Low-Output Heart Failure Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM) 50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) peripartum, HIV, connective tissue disease, substance abuse, doxorubicin Hypertension Valvular Heart Disease(MR,AR) Diastolic Dysfunction Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy AS

Clinical Presentation of Heart Failure Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea (PND) Due to reduction in cardiac ouput: Fatigue Weakness

Physical Examination in Heart Failure S3 gallop Low sensitivity, but highly specific Cool, pale, cyanotic extremities Have sinus tachycardia, diaphoresis and peripheral vasoconstriction Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>

Lab Analysis in Heart Failure CBC Since anemia can exacerbate heart failure Serum electrolytes and creatinine before starting high dose diuretics Fasting Blood glucose To evaluate for possible diabetes mellitus Thyroid function tests Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF. Iron studies To screen for hereditary hemochromatosis as cause of heart failure. ANA To evaluate for possible lupus Viral studies If viral mycocarditis suspected

Laboratory Analysis (cont.) BNP With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures Usually is > 400 pg/mL in patients with dyspnea due to heart failure.

Chest X-ray in Heart Failure Cardiomegaly Cephalization of the pulmonary vessels Kerley B-lines Pleural effusions

Cardiomegaly

Pulmonary vessel congestion

Pulmonary Edema due to Heart Failure

Cardiac Testing in Heart Failure Electrocardiogram: May show specific cause of heart failure: Ischemic heart disease Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular block Amyloidosis: pseudo-infarction pattern Idiopathic dilated cardiomyopathy: LVH Echocardiogram: Left ventricular ejection fraction Structural/valvular abnormalities

Further Cardiac Testing in Heart Failure Coronary arteriography Should be performed in patients presenting with heart failure who have angina or significant ischemia Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina. Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.

Classification of Heart Failure New York Heart Association (NYHA) Class I – symptoms of HF only at levels that would limit normal individuals. Class II – symptoms of HF with ordinary exertion Class III – symptoms of HF on less than ordinary exertion Class IV – symptoms of HF at rest

Classification of Heart Failure (cont.) ACC/AHA Guidelines Stage A – High risk of HF, without structural heart disease or symptoms Stage B – Heart disease with asymptomatic left ventricular dysfunction Stage C – Prior or current symptoms of HF Stage D – Advanced heart disease and severely symptomatic or refractory HF

Chronic Treatment of Systolic Heart Failure Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension Lifestyle modification Lower salt intake Alcohol cessation Medication compliance Maximize medications Discontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers)

Order of Therapy Loop diuretics ACE inhibitor (or ARB if not tolerated) Beta blockers Digoxin Hydralazine, Nitrate Potassium sparing diuretcs

Diuretics Loop diuretics Potassium-sparing diuretics Furosemide, buteminide For Fluid control, and to help relieve symptoms Potassium-sparing diuretics Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF

ACE Inhibitor Improve survival in patients with all severities of heart failure. Begin therapy low and titrate up as possible: Enalapril – 2.5 mg po BID Captopril – 6.25 mg po TID Lisinopril – 5 mg po QDaily If cannot tolerate, may try ARB

Beta Blocker therapy Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV. Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma Heart block

Management of Refractory Heart Failure Inotropic drugs: Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin Mechanical circulatory support: Intraaortic balloon pump Left ventricular assist device (LVAD) Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.