2. HEART FAILURE “pump failure”

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

5. 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

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

7. 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

8. 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

9. 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

10. 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

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

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

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

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

15. 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

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

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

18. 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

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

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

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

22. Identify triggers
Acute sudden onset
Chronic gradual onset
ischemia
anemia
arrythmia
thyrotoxicosis
infection
Non compliance
P.E
diet
Acute valvular pathology
Drugs like NSAID

23. INVESTIGATION
CBC
U+E
LFT
Cardiac enzymes
CXR
ECG
Echocardiogram

24. TREATMENT
Diuretics
Digoxin
ACE inhibitors
Vasodilators
Beta blockers

25. 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}

26. 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

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

28. 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

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

31. 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

32. 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

33. 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

34. 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

35. Cardiac resynchronization therapy {CRT}

36. 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

37. 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

38. 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.

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