Professional Documents
Culture Documents
Ali Aspar
Mappahya
Cardiology Department,
Medical Faculty, Hasanuddin University
INTRODUCTION
INTRODUCTION.
The risk factors for HF among HTN subjects included
MCI (5-6 fold risk), LVH (2-3 fold risk), DM (2-3 fold
risk)
and valvular heart disease ( two-fold risk).
In developed countries, there are two principal risk
factors
for HF : hypertension (HTN) and myocardial
infarction
(MCI)
Early and adequate treatment of HTN may
substantially
reduce the burden of heart failure in the
community.
Symptoms typical of HF :
(breathlessness at rest or on exercise, fatigue, tiredness,
ankle swelling).
Signs typical of HF :
(tachycardia, tachypnea, pulmonary rales, pleural effusion
raised jugular venous pressure, peripheral edema,
hepatomegaly).
Hypertension
Diabetes Mellitus
Dyslipidemia
Valvular heart disease
Coronary artery disease
Myopathy
Rheumatic fever
Mediastinal radiation
Sleep apnea disorders
Exposure to cardiotoxin
agents
Alcohol abuse
Smoking
Collagen vascular
disease
Thyroid disorder
Pheochromocytoma
Old age
Metabolic
syndrome
PRECIPITATING FACTORS OF
HEART FAILURE
1. Infections
2. Brady-or tachyarrhythmia
3. Myocardial ischemia or infarction (MI)
4. Physical or emotional stress
5. Pulmonary embolism
6. High-output states such anemia,
thyrotoxicosis, Pagets disease, pregnancy,
beriberi and A-V fistula
7. Cardiac infection and inflammation
(myocarditis, infective endocarditis)
8. Comorbidities (renal, liver, thyroid, respiratory
insufficiency)
9. Cardiac toxin (chemotherapy, cocain, alcohol
Pathophysiology
of Heart Failure
Pathophysiology of
Systolic Failure
Diastolic Failure
Vasoconstricting and
growth promoting
Norepinephrine
Angiotensin II
Endothelins
Arginine vasopressin
Worsen hemodynamics,
progressive remodeling
Vasodilating and
growth inhibiting
Natriuretic peptides
Bradykinin
Nitric oxide/EDHF
Prostaglandins
Improve hemodynamics,
prevent remodeling
12
400
100
Cohn 1997.
150
NL HF
NL HF
100
2
0
200
50
NL
HF
Endothelin-1
(pg/mL)
250
200
Atrial natriuretic
peptide
(pg/mL)
300
300
Arginine
vasopressin
(pg/mL)
12
15
500
Levels
Plasma renin
activity
(ng/mL/h)
NL HF
NL HF
Obesity
Diabetes
LVH
Diastolic
Dysfunction
Hypertension
CHF
Smoking
Dyslipidemia
Diabetes
Normal LV
structure and function
MI
Systolic
Dysfunction
LV
remodelling
Subclinical
LV dysfunction
Time (decades)
Death
Overt HF
Time (months)
CLINICALFEATURES
OFHEARTFAILURE
forward effects
backward effects
symptoms
signs
ACC/AHA Stages of HF
Based on structure and damage to heart muscle
Stage A
Stage B
Stage C
Stage D
A
High Risk For
Developing Heart
Failure
B
Asymptomatic
Heart Failure
C
Symptomatic
Heart Failure
D
Refractory End-stage
Heart Failure
DESCRIPTION
Hypertension, Diabetes Mellitus, CAD,
Family History of Cardiomyopathy
FORWARD
EFFECTS
Poor renal perfusion predisposing to
prerenal failure.
Poor perfusion of extremities resulting in
cold extremities.
Increased lactic acid production in underperfused skeletal muscle leading to
weakness and fatigue.
Hypotension
BACKWAR
D EFFECTS
The peripheries subcutaneous edema is
felt in the legs and other dependents part.
The liver tender hepatomegaly is a result
of hepatic congestion and may lead to
cirrhotic changes.
The abdominal cavity resulting in ascites
Symptoms
Signs
Peripheral
edema/
congestion
Breathlessness,
tiredness, fatigue,
anorexia
Peripheral edema,
raised JVP, pulmonary
edema, hepatomegaly,
ascites, fluid overload,
cachexia
Pulmonary
edema
Severe
brathlessness at
rest
Cardiogenic
shock (LOS)
Confusion,
weakness, cold
periphery
Poor peripheral
perfusion, systolic BP
<90 mmHg, anuria or
oliguria
High BP
(Hypertensive
Breathlessness
2. CLINICAL:
- Hypotension*
- NYHA class III_IV*
- Recent HFhospitalization*
- Tachycardia
- Pulmonary rales
- Aortic stenosis
- Low BMI
- Sleep related
breathing disorders
CONDITIONS ASSOCIATED
3. ELECTROPHYSIOLOGICAL:
- Tachycardia
4.
- Q-waves
- Wide QRS*
- LVH
- Complex ventriculararrhythmias*
- Low HR variability
- T-wave alternans
- Atrial fibrillation (AF)
* = powerful predictors
FUNCTIONAL/
EXERTIONAL:
- Reduced work
- Low peak VO2*
- Poor 6 minuteswalk distance
- High VE/VCO2slope
- Periodic breathing
CONDITIONS ASSOCIATED
5. LABORATORY:
6.
- Marked elevation of BNP/
NT-pro BNP*
- Hyponatremia*
- Elevated troponin*
- Elevated biomarkers,
neurohumoral activation*
- Elevated creatinine/
BUN
- Elevated bilirubin
- Anemia
- Elevated uric acid
* = powerful predictors
IMAGING:
- Low LVEF*
- Increased LV vol.
- Low cardiac index
- High LV fillingpressure
- Restrictive mitralfilling pattern
- Pulmonary htn.
- Impaired RV function
EVOLUTION OF
CLINICAL STAGES
NORMAL
NORMAL
Asymptomati
Asymptomati
No
No symptoms
symptoms
Normal
Normal exercise
exercise c
c LV
LV
Normal
Normal LV
LV fxn
fxn
Dysfunction
Dysfunction
No
symptoms
No symptoms
Normal
Normal
exercise
exercise
Abnormal
AbnormalLV
LVNo
No symptoms
symptoms
fxn
fxn
Exercise
Exercise
Abnormal
Abnormal LV
LV
Symptoms
fxn
fxn
Symptoms
Exercise
Exercise
Abnormal
Abnormal LV
LV
fxn
fxn
Compensate
Compensate
d
d CHF
CHF
Decompensat
Decompensat
ed
ed CHF
CHF
Refracto
Refracto
ry
ry CHF
CHF
Symptoms
Symptoms not
not
controlled
controlled with
with
treatment
treatment
MANAGEMENTOFCARDIACFAILURE
Hypertension
CAD
DM
Cardiotoxins
FHx CM
Stage B
Struct.
Heart
Disease
THERAPY
Treat
Hypertension
Stop smoking
Treat lipid
disorders
Encourage
regular
exercise
Stop alcohol
& drug use
ACE inhibition
Pts with :
Previous MI
LV systolic
dysfunction
Asymptomatic
Valvular
disease
THERAPY
All measures
under
stage
A
ACE inhibitor
Beta-blockers
Stage C
Stage D
Pts with :
Struct. HD
Develo
p
Symp.
of
HF
Shortness of
breath and fatigue,
reduce exercise
tolerance
Refract.
Symp.of
HF at
rest
THERAPY
All measures
under
stage A
Drugs for routine
use:
diuretic
ACE
inhibitor
Betablockers
digitalis
THERAPY
All measures
under
stage
A,B and C
Mechanical assist
device
Heart
transplantation
Continuous IV
inotrphic
infusions for
palliation
ARRHYTHMIAS IN HF
ATRIAL FIBRILLATION (AF)
A beta-blocker (BB) or digoxin is recommended to control the heart
Prevention of thromboembolism :
Antithrombotic therapy to prevent thromboembolism is recommended
to all patients with AF, unless contra-indicated.
In patients with AF at highest risk of stroke/thromboembolism, chronic
oral anticoagulant therapy with a vitamin K antagonist
is recommended unless contra-indicated.
Rhythm control :
Electrical cardioversion is recommended when the rapid ventricular
response does not respond promptly to appropriate pharmacological
measures, especially in patients with AF causing myocardial ishemia,
symptomatic hypotension or symptom of pulmonary congestion.
RENAL DYSFUNCTION IN HF
FINITION :
Immediate (ED/ICU/CCU):
Improve symptoms
Restore oxygenation
Improve organ perfusion and hemodynamic
Limit cardiac/renal damage
Minimize ICU length of stay
Thank You