1. Heart Failure Halmat M. Jaafar (MSc. Clinical pharmacy)
Hawler Medical University/ College of Pharmacy
Department of Pharmacology

2. 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).

3. 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.

4. 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.

5. 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.

6. EPIDEMIOLOGY More than 20 million people affected worldwide
Affects 10% of people over 65 year
It is the most common condition for which patients 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.

7. 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

8. Etiology And Pathophysiology
Hemodynamic changes
Neurohormonal changes
Cellular changes

9. 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

10. Risk factors

11. 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

12. 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

13. Chronic heart failure

14. Chronic Heart Failure

15. JVP = jugular venous pressure

16. Edema

17. Ascites

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

19. Heart Failure
Normal

20. Pulmonary edema
Butterfly sign

21. 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)

22. Chest xray
Normal
Pulmonary edema

23. 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

24. But

25. 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

26. 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

27. 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

28. 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)

29. MANAGEMENT OF HF

30. 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

31. 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

32. 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

33. 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

34. 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,

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

36. ESC Guidelines

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

38. 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

39. 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

40. 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

41. 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

42. Heart Failure Therapies