1. CHRONIC CONGESTIVE HEART FAILURE American Heart Association in collaboration with Sociedad Española de Cardiologia June, 1999 CHRONIC CONGESTIVE HEART FAILURE American Heart Association in collaboration with Sociedad Española de Cardiologia June, 1999

2. Committee on Post Graduate Education, Council on Clinical Cardiology, American Heart Association Developed in collaboration with the Sociedad Española de Cardiologia Prepared by: Ann F. Bolger, MD José Lopez Sendón, MD The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org). Committee on Post Graduate Education, Council on Clinical Cardiology, American Heart Association Developed in collaboration with the Sociedad Española de Cardiologia Prepared by: Ann F. Bolger, MD José Lopez Sendón, MD The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org).

3. DEFINITION “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return." “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return." E. Braunwald

4. EVOLUTION OF CLINICAL STAGES EVOLUTION OF CLINICAL STAGES NORMAL Asymptomatic LV Dysfunction Asymptomatic LV Dysfunction Compensated CHF Compensated CHF Decompensated CHF Decompensated CHF No symptoms Normal exercise Normal LV fxn No symptoms Normal exercise Normal LV fxn No symptoms Normal exercise Abnormal LV fxn No symptoms Normal exercise Abnormal LV fxn No symptoms Exercise Abnormal LV fxn No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Refractory CHF Refractory CHF Symptoms not controlled with treatment Symptoms not controlled with treatment

5. DETERMINANTS OF VENTRICULAR FUNCTION DETERMINANTS OF VENTRICULAR FUNCTION STROKE VOLUME PRELOAD CONTRACTILITY CARDIAC OUTPUT HEART RATE - Synergistic LV contraction - LV wall integrity - Valvular competence AFTERLOAD

6. Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms TREATMENT OBJECTIVES

7. TREATMENT PHARMACOLOGIC THERAPY TREATMENT PHARMACOLOGIC THERAPY DIURETICS INOTROPES VASODILATORS NEUROHORMONAL ANTAGONISTS OTHERS (Anticoagulants, antiarrhythmics, etc) DIURETICS INOTROPES VASODILATORS NEUROHORMONAL ANTAGONISTS OTHERS (Anticoagulants, antiarrhythmics, etc)

8. Cortex Medulla Thiazides Inhibit active exchange of Cl-Na in the cortical diluting segment of the ascending loop of Henle Thiazides Inhibit active exchange of Cl-Na in the cortical diluting segment of the ascending loop of Henle K-sparing Inhibit reabsorption of Na in the distal convoluted and collecting tubule K-sparing Inhibit reabsorption of Na in the distal convoluted and collecting tubule Loop diuretics Inhibit exchange of Cl-Na-K in the thick segment of the ascending loop of Henle Loop diuretics Inhibit exchange of Cl-Na-K in the thick segment of the ascending loop of Henle Loop of Henle Collecting tubule DIURETICS

9. Volume and preload Improve symptoms of congestion No direct effect on CO, but excessive preload reduction may Neurohormonal activation Levels of NA, Ang II and PRA Exception: with spironolactone Volume and preload Improve symptoms of congestion No direct effect on CO, but excessive preload reduction may Neurohormonal activation Levels of NA, Ang II and PRA Exception: with spironolactone DIURETIC EFFECTS

10. THIAZIDES MECHANISM OF ACTION Excrete 5 - 10% of filtered Na + Elimination of K Inhibit carbonic anhydrase: increase elimination of HCO 3 Excretion of uric acid, Ca and Mg No dose - effect relationship Excrete 5 - 10% of filtered Na + Elimination of K Inhibit carbonic anhydrase: increase elimination of HCO 3 Excretion of uric acid, Ca and Mg No dose - effect relationship

11. LOOP DIURETICS MECHANISM OF ACTION Excrete 15 - 20% of filtered Na + Elimination of K +, Ca + and Mg ++ Resistance of afferent arterioles -  Cortical flow and GFR - Release renal PGs - NSAIDs may antagonize diuresis Excrete 15 - 20% of filtered Na + Elimination of K +, Ca + and Mg ++ Resistance of afferent arterioles -  Cortical flow and GFR - Release renal PGs - NSAIDs may antagonize diuresis

12. K-SPARING DIURETICS MECHANISM OF ACTION Eliminate < 5% of filtered Na + Inhibit exchange of Na + for K + or H + Spironolactone = competitive antagonist for the aldosterone receptor Amiloride and triamterene block Na + channels controlled by aldosterone Eliminate < 5% of filtered Na + Inhibit exchange of Na + for K + or H + Spironolactone = competitive antagonist for the aldosterone receptor Amiloride and triamterene block Na + channels controlled by aldosterone

13. DIURETICS ADVERSE REACTIONS Thiazide and Loop Diuretics Changes in electrolytes: Volume Na +, K +, Ca ++, Mg ++ metabolic alkalosis Metabolic changes: glycemia, uremia, gout LDL-C and TG Cutaneous allergic reactions Changes in electrolytes: Volume Na +, K +, Ca ++, Mg ++ metabolic alkalosis Metabolic changes: glycemia, uremia, gout LDL-C and TG Cutaneous allergic reactions

14. DIURETICS ADVERSE REACTIONS Thiazide and Loop Diuretics DIURETICS ADVERSE REACTIONS Thiazide and Loop Diuretics Idiosyncratic effects: Blood dyscrasia, cholestatic jaundice and acute pancreatitis Gastrointestinal effects Genitourinary effects: Impotence and menstrual cramps Deafness, nephrotoxicity ( Loop diuretics ) Idiosyncratic effects: Blood dyscrasia, cholestatic jaundice and acute pancreatitis Gastrointestinal effects Genitourinary effects: Impotence and menstrual cramps Deafness, nephrotoxicity ( Loop diuretics )

15. DIURETICS ADVERSE REACTIONS K-SPARING DIURETICS DIURETICS ADVERSE REACTIONS K-SPARING DIURETICS Changes in electrolytes: Na +, K +, acidosis Musculoskeletal: Cramps, weakness Cutaneous allergic reactions : Rash, pruritis Changes in electrolytes: Na +, K +, acidosis Musculoskeletal: Cramps, weakness Cutaneous allergic reactions : Rash, pruritis

16. American Heart Association in collaboration with Sociedad Española de Cardiologia CHRONIC CONGESTIVE HEART FAILURE The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org) American Heart Association in collaboration with Sociedad Española de Cardiologia CHRONIC CONGESTIVE HEART FAILURE The content of these slides is current as of June, 1999. Future revisions will be posted on the American Heart Association website (www.americanheart.org)

17. Medical Nutrition Therapy Energy: Moderate 1.3-1.5 x BEE Severe 1.6-1.8 x BEE Protein (variable) 1.0-1.5 Na + Restriction Fluid Restriction (inpatient) Small Frequent Meals Nutrient dense foods/bevs Easy to chew foods