Professional Documents
Culture Documents
Objectives
Definition and Epidemiology Pathophysiology Diagnosis and Classification Treatment of Systolic Dysfunction
Medical Therapy Device Therapy
What is CHF?
Definition
Abnormality of cardiac function that leads to the inability of the heart to pump blood to meet the bodys basic metabolic demands or when it can do so only with an elevated filling pressure
Epidemiology
Prevalence
Cost
Affects nearly 5 million Americans currently, >500,000 new cases diagnosed each year Annual direct cost in >10 billion dollars
Effects 1-2% of patient from 50-59-years-old and 10% of patient over the age of 75
It is the most common inpatient diagnosis in the US for patients over 65 years of age Visits to their family practitioner on average 2-3 times per year Men> women in those between 40 and 75 years of age The sexes are equal over 75 years of age
Gender
Help initially
Vasoconstriction
Redistributes blood to vital organs
Neurohumoral-RAAS
Hurt long-term
Precipitating Causes
Common CAD (70%) Systemic Hypertension Idiopathic Less Common Diabetes Mellitus Valvular Disease
Rare Anemia Connective Tissue Disease Viral Myocarditis Hemochromatosis HIV Hyper/Hypothyroidism Hypertrophic Cardiomyopathy Infiltrative Disease including amyloidosis and sarcoidosis Mediastinal radiation Peripartum cardiomyopathy Restrictive pericardial disease Tachyarrhythmias Toxins Trypanosomiasis (Chagas disease)
Diastolic dysfunction
Systolic dysfunction
EF normal or increased Hypertension Due to chronic replacement fibrosis & ischemia-induced decrease in distensibility EF < 40% Usually from coronary disease Due to ischemia-induced decrease in contractility
High output
Severe anemia AV malformations hyperthyroidism
Biventricular Failure
Systemic and pulmonary congestion
Evaluation
History: risk factors for ischemic heart disease, family history Physical exam: S3, JVD more specific signs of HF than rales, peripheral edema
Exam
Major Criteria
Paroxysmal nocturnal dyspnea Neck Vein Distention Rales Cardiomegaly Pulmonary Edema S3 Gallop Hepatojugular Reflex
Minor Criteria
Ankle edema Nocturnal Cough Dyspnea on ordinary exertion Hepatomegaly Pleural Effusion Tachycardia >120bpm
Electrocardiogram/ECHO
Anterior Q waves, LBBB, LVH
Clinical
Increased Age, Diabetes, Smoking
Laboratory
Hyponatremia, Elevated neurohormones
Hemodynamic
Reduced EF, Increased Pulm Cap Wedge Pressure
Electrophysiological
A-fib, A-flutter, Ventricular ectopy, V-tach
Principles of Treatment
ACE Inhibitors Works to inhibit the over stimulation of the RAS that leads to myocardial hypertrophy and fibrosis Causes balanced vasodilation Decrease the rate of morbidity & mortality in all pts with systolic heart failure -If treating acute HF, can start after BP tolerates and pulmonary edema is relieved
ACE-I
CONSENSUS-Enalapril 2.5-40mg (188 days) vs placebo Pts were already taking digoxin and diuretics 253 Patient with NYHA Class IV Dec mortality at:
6 months -40% 1 Year 27%
All cause mortality dec by 16% Morality rate from HF dec by 16%
Angiotensin-Receptor Blockers
Comparable to ACE inhibitors Reduce all-cause mortality Suitable alternative for patient with adverse events (angioedema, cough, hyperkalemia) occur with ace-i
ACE + ARB
But 23% discontinued due to side effects (increased cr, hypotension, hyperkalemia) Currently Ace + Arb is not recommended
Beta-Blockers
Decrease Cardiac Sympathetic Activity Use in stable, chronic disease (start as early as discharge-IMPACT-HF) Titrate slowly Contraindications-bradycardia, heart block or hemodynamic instability Mild asthma was not a contraindication Work irrespective of the etiology of the heart failure
Three beta-blockers : Bisoprolol (Zebeta) -Trial CIBIS-II Metoprolol (Toprol XL) Trial MERIT-HF (sustained release) Carvedilol (Coreg) Trial-COPERNICUS
6 RCTs with > 9,000 pts already taking ACE-I showed a significant reduction in total mortality and sudden death (NNT 24, and 35 over 1-2 years) regardless of severity
Carvedilol vs. Metoprolol (COMET 2003) 3029 pts; carvedilol 25mg bid vs. metoprolol 50 mg bid Patient with NYHA Classes II-IV Carvedilol greater reduction in mortality (NNT, 18 over 5 years) and cardiovascular mortality (NNT, 16 over 5 years) than metoprolol but hypotension was greater in carvedilol (14 vs 11 percent)
Starting Dose
1.25mg daily 3.125mg bid 12.5-25mg daily
Target Dosage
10mg daily 25mg bid 200mg daily
Aldosterone Antagonists
Digoxin
May relieve symptoms, does not reduce mortality Pts taking digoxin are less likely to be hospitalized (25% reduction) More admissions for suspected digoxin toxicity
Loop Diuretics
Increased risk of Thromboembolic events, 1.6-3.2% per year Antiplatelet therapy (aspirin) in not useful in patient in sinus rhythm Coumadin for patient with atrial fibrillation or a previous thromboembolic event
Nesiritide (Natrecor)
Nonpharmacological Management
Device Therapy
Implantable Cardioverter-Defibrillators (ICD) Cardiac Resynchronization Therapy (CRT) Left Ventricular Assist Devices (LVAD)
ICD
SCD-HeFT (sudden cardiac death) 2521 patients with depressed LV systolic function and Class II-III HF Randomized to standard therapy vs. standard therapy plus ICD vs. standard therapy plus amiodarone 23% reduction in mortality with ICD No difference in mortality with amiodarone Results did not vary based on etiology of LV dysfunction
ICD
Recommended in pts with EF<30% and mild to moderate symptoms of HF Survival with good functional capacity is anticipated for > 1 year
CRT
COMPANION Trial 1520 patients most with Class III-IV HF, QRS duration >120 ms Randomized in 1:2:2 ratio to standard therapy vs standard therapy plus CRT vs standard therapy plus CRT with device that also defibrillated 34% reduction in death or any hospitalization with CRT 40% reduction when combined with ICD
REMATCH Trial1 yr survival 52% (LVAD) vs 24% (rx) 2 yr survival 23% vs 8% End-Stage (Class IV) HF pts ineligible for transplant due to:
>65yo DM with EOD CRI
Diastolic Dysfunction
QUESTIONS?
1. Which one of the following is considered a contraindication to the use of betablockers for congestive heart failure?
A) Mild Asthma B) Symptomatic Heart Block C) New York Heart Association (NYHA) Class III heart failure D) NYHA Class I heart failure in a patient with a history of a previous myocardial infarction E) An ejection fraction <30%
1. Answer B According to several randomized, controlled trial, mortality rates are improved in patient with heart failure who receive beta blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindications to beta blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as them are monitored for potential exacerbations. B-blocker use has been shown to be effective in patient with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction . B-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification
2. Which one of the following serologic tests would be the most helpful for detecting left ventricular dysfunction?
A) B-type natriuetic peptide (BNP) B) Troponin-T C) C-reactive protein (CRP) D) D dimer E) Cardiac interleukin-2
2. Answer A. NP is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the prescence or absence of heart failure.
3. Answer B Significant predictors of intraoperative and perioperative ventricular arrhythmias include preoperative ventricular (not supraventricular) ectopy, CHF, and tobacco use. Age and history of hyperthyroidism are not significant predictors of perioperative ventricular arrhythmias.
4. Which one of the following is preferred for chronic treatment of congestive heart failure due to left ventricular systolic dysfunction?
A) Diuretics B) Digoxin C) Calcium Channel Blockers D) ACE inhibitors E) Hydralazine (Apresoline) plus isosorbide dinitrate (Isordil, Sorbitrate)
4. Answer D
ACE-I are the preferred drugs for CHF due to LV systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether Digoxin affects mortality, although it can help with symptoms.
5. A 72-year-old male with class III CHF due to systolic dysfunction asks if he can take ibuprofen for his aches and pains.
A) NSAIDs are a good choice for pain relief, as they decrease systemic vascular resistance B) NSAIDs are a good choice for pain relief, as they augment the effect of his diuretic C) High-dose aspirin (325mg/day) is preferable to other NSAIDs for patients talking ACE-I D) NSAIDs, including high-dose aspirin, should be avoided in CHF patient because they can cause fluid retention
5. Answer D
If possible, NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. NSAIDs may negate or decrease entirely the beneficial unloading effects of ACE inhibition.
References
REFERENCES : 1 Hunt S.A., Baker D.W., Chin M.H., Cinquegrani M.P., Feldman A.M., Francis G.S., Ganiats T.G., Goldstein S., Gregoratos G., Jessup M.L, ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure) . J Am Coll Cardiol (2001) 38 : pp 2101-2113 . 2 Packer M., Cohn J.N., Consensus recommendations for the management of chronic heart failure . Am J Cardiol (1999) 83 : pp 1A-38A . 3 Pitt B., Williams G., Remme W., Martinez F., LopezSendon J., Zannad F., Neaton J., Roniker B., Hurley S., Burns D, The EPHESUS trial: eplerenone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction Eplerenone Post-AMI Heart Failure Efficacy and Survival Study . Cardiovasc Drugs Ther (2001) 15 : pp 79-87 . 4 Pitt B., Zannad F., Remme W.J., Cody R., Castaigne A., Perez A., Palensky J., Wittes J., The effect of spironolactone on morbidity and mortality in patients with severe heart failure Randomized Aldactone Evaluation Study Investigators . N Engl J Med (1999) 341 : pp 709-717 . 5 SOLVD Investigators Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure The SOLVD Investigators . N Engl J Med (1991) 325 : pp 293-302 .
CONSENSUS Trial Study Group Effects of enalapril on mortality in severe congestive heart failure Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group . N Engl J Med (1987) 316 : pp 14291435 . 7 Hjalmarson A., Goldstein S., Fagerberg B., Wedel H., Waagstein F., Kjekshus J., Wikstrand J., El Allaf D., Vitovec J., Aldershvile J, Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF) MERIT-HF Study Group . JAMA (2000) 283 : pp 1295-1302 . 8 CIBIS-II Investigators The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial . Lancet (1999) 353 : pp 9-13 . 9 Packer M., Bristow M.R., Cohn J.N., Colucci W.S., Fowler M.B., Gilbert E.M., Shust erman N.H., The effect of carvedilol on morbidity and mortality in patients with chronic heart failure U.S. Carvedilol Heart Failure Study Group . N Engl J Med (1996) 334 : pp 1349-1355 . 10 Packer M., Fowler M.B., Roecker E.B., Coats A.J., Katus H.A., Krum H., Mohacsi P., Rouleau J.L., Tendera M., Staiger C, Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study . Circulation (2002) 106 : pp 2194-2199 .
11 Fonarow G., Gheorghiade, M., Abraham, W., Importance of In-Hospital Initiabtion of Evidence-Based Medical Therapies for Heart Failure-A Review. J Am Coll Cardiol (2004) 94 : pp 1155-1159 12 Chavey WE 2nd, The Importance of Beta Blocker in the Treatment of Heart Failure Am Fam Physician - (2000) 62(11): 2453-62