HEART FAILURE

CAUSES Coronary artery diseases (in 2/3rds) o Hypertension and diabetes are contributing factors Dilated cardiomyopathy o Viral infections o Alcohol abuse o Genetic o Chemotherapy (doxorubicin) PATHOPHYSIOLOGY Injury to myocytes (often ischaemic) Maladaptive changes in surviving myocytes Lead to pathological remodelling of the left ventricle o Dilation o Impaired contractility Exacerbated by additional injury (further ischaemia) Worsened by systemic responses o Sympathetic o Renin-angiotensin-aldosterone system Results in o Development and worsening of symptoms o Decline in functional capacity o Myocardial electrical instability pump arrhythmia DIAGNOSIS Clinically o Symptoms (exertional dyspnea, fatigue, orthopnea, PND) o Signs (peripheral edema, pulmonary edema, jugular venous distention, enlarged heart, S3) Cardiac investigations o ECG (look for AF, bundle branch block, bradycardia) o Chest radiography (pulmonary congestion, cardiomegaly, other causes of dyspnea) o Echocardiography (valvular structure, thrombus, EF) o Cardiac MRI as an alternative to echo or need for important tissue characterization o Natriuretic peptides Investigate other factors o Hemoglobin (anaemia) o Electrolytes (sodium and potassium)

TREATMENT Pharmacological Diuretics o Symptom relief only o Target a dry weight o Combine diuretics (thiazide + loop +/- aldosterone antagonists) in severe cases o IV diuretics if severe edema (oral diuretics will not be fully absorbed) ACEi o First-line therapy o Should be promptly initiated after diagnosis o Reduce ventricular size and increase EF o Improves survival, improves symptoms, decreases MI rates ARBs

o Efficacy similar to ACEi o Often used as an alternative in patients developing cough on ACEi o Added to ACEi and BB if symptoms persist Beta-blockers o First-line therapy o Improves systolic function, increases EF by 5-10% o Bisoprolol, carvedilol and metoprolol XR o Should be initiated once acute symptoms are over o Should not be withdrawn unless severe systemic underperfusion Aldosterone antagonists o Used in severe systolic heart failure (remains NYHA III/IV despite ACEi+diuretic+BB) o Either aldosterone antagonists or ARB, but not both Hydralazine and isosorbide dinitrate o Used in black patients who have less response to ACEi Other drugs o Digoxin if very poor function o Aspirin, statins and darbopoietin have uncertain effects in heart failure o Warfarin in AF o Pneumococcal and influenza vaccines o DVT prophylaxis in hospital o Be careful of NSAIDs (inhibition of renal prostaglandin natreuritic effect fluid retention)

Lifestyle modification Restrict sodium intake Aerobic exercise Devices Implantable cardioverter-defibrillators o 50% of deaths in heart failure are attributed to ventricular arrhythmias (especially in milder symptoms) o ICD reduces risk of sudden death o Primary prevention: NYHA II/III + EF <35% despite optimal meds for 1 year o Secondary prevention: After unprovoked VF/VT Cardiac resynchronization therapy o 30% HF patients have intraventricular conduction delays (bundle branch blocks, QRS >120ms Leads to dyssynchronous contractions and impaired emptying o Also, some have heart block (AV conduction delay, PR >200ms) o Cardiac resynchronization therapy is recommended for: Severe symptoms (NYHA III/IV) EF <35% Sinus rhythm QRS >120ms

CHRONIC HEART FAILUR E MANAGEMENT GUIDELI NES 1. Non-Drug Treatment Salt restriction 2g/day Fluid restrict 1.5L per day Regular exercise as tolerated Daily weighs to detect worsening (gain 2kg in 2 days) Quit smoking Be careful of NSAIDs 2. Chronic Heart Failure Management Level 1: Thiazide + ACEi Level 2: Frusemide (40mg OD) + ACEi (double dose) + Beta blocker (carvedilol 3.125mg)

Level 3: Spironolactone/eplerenone Level 4: Digoxin