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 onsetChronic gradual onset ischemiaanemia arrythmiathyrotoxicosis infectionNon compliance P.Ediet 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