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HEART FAILURE

ACUTE AND CHRONIC HEART FAILURE


SYSTOLIC AND DIASTOLIC HEART FAILURE

Ali Aspar
Mappahya
Cardiology Department,
Medical Faculty, Hasanuddin University

INTRODUCTION

Heart failure (HF) is a major health problem, it will be a ma


cause of morbidity and mortality in the future.

HF: Cardiac disorders that impairs the capacity of the


ventricle to fill or to eject the appropriate amount of blood.

HF: The inability of the heart to perfuse metabolizing tissues


adequately.

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.

DEFINITION OF HEART FAILURE (HF)


HF is a clinical syndrome in which patients
have the following features :

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).

bjective evidence of a structural or functional abnorm


f the heart at rest :
cardiomegaly, S3, cardiac murmur, abnormality on the
echocardiogram, raised natriuretic peptide concentration).

PREDISPOSING CAUSES OF HEART FAILURE

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

Relationship between end-diastolic


volume and stroke volume in normal and
failing myocardium

Pathophysiology of

Chronic Heart Failure

Systolic Failure

Diastolic Failure

Pathophysiology of Systolic Heart Failure


Neurohormonal Activation and Imbalance

Vasoconstricting and
growth promoting

Norepinephrine
Angiotensin II
Endothelins
Arginine vasopressin

Worsen hemodynamics,
progressive remodeling

Anand IS, Chugh SS. Curr Opin Cardiol. 1997;12:251-258.

Vasodilating and
growth inhibiting

Natriuretic peptides
Bradykinin
Nitric oxide/EDHF
Prostaglandins

Improve hemodynamics,
prevent remodeling

Neurohormonal Activation in Heart Failure


Plasma
norepinephrine
(pg/mL)
600

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)

The progression from hypertension to CHF

CLINICALFEATURES
OFHEARTFAILURE
forward effects
backward effects
symptoms
signs

NYHA Functional Classification of HF


Severity based on symptoms and physical activity
Class I No limitation of physical activity. Ordinary
physical activity does not cause undue
fatigue, palpitation or dyspnea.
Slight limitation of physical activity.
Class
Comfortable at rest, but ordinary physical
II
activity results in fatigue, palpitation, or
dyspnea.
Marked limitation of physical activity.
Class
Comfortable at rest, but less than ordinary
III
activity results in fatigue, palpitation or
dyspnea.
Unable to carry on any physical activity
Class
without discomfort. Symptoms at rest. If
IV

ACC/AHA Stages of HF
Based on structure and damage to heart muscle
Stage A

Stage B

Stage C
Stage D

At high risk for developing HF. No


identified structural or functional
abnormality; No signs or symptoms.
Developed structural heart disease
that is strongly associated with the
development of HF, but without signs
or symptoms.
Symptomatic HF associated with
underlying structural heart disease.
Advanced structural heart disease and
marked symptoms of HF at rest
despite maximal medical therapy.

ACC / AHA Classification of


CHF2001
STAGE

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

Previous MI, LV Dysfunction,


Valvular Heart Disease

Structural Heart Disease, Dyspnea and


Fatigue, Impaired Exercise Tolerance

Marked Symptoms at Rest Despite


Maximal Medical Therapy

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

COMMON CLINICAL MANIFESTATIONS OF HF


Dominant
clinical
feature

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

Crackles or rales over


lungs, effusion,
tachycardia, tachypnea

Cardiogenic
shock (LOS)

Confusion,
weakness, cold
periphery

Poor peripheral
perfusion, systolic BP
<90 mmHg, anuria or
oliguria

High BP
(Hypertensive

Breathlessness

Usually raised BP, LVH,


and preserved EF

CONDITIONS ASSOCIATED WITH


A POOR PROGNOSIS IN HF
1.DEMOGRAPHICS:
- Advanced aged*
- Ischemic etiology*
- Resuscitatedsudden death*
- Poor compliance
- Renal dysfunction
- Diabetes
- Anemia
- COPD
- Depression
* = powerful predictors

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

AGEMENT OF CHRONIC HEART FAILU


Management of Acute LV failure
Management of Acute RV failure

MAIN STRATEGIES FOR PATIENTS


WITH CHRONIC CONGESTIVE
HEART FAILURE
1. Life style modification.
2. Prevent precipitating and aggravating factors.
3. Essential pharmacologic management with BB,
ACEI/ARB.
4. Complimentary treatment with diuretics or
vasodilators.
5. Reverse structural abnormalities (remodeling
with hypertrophy or dilation).
6. Device therapy including implantable
cardioverter defibrillation (ICD), bi-ventricular
pacing.

Stages in the evolution of HF and recommended


therapy by stage
Stage A
Pts with :

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

Pts who have


marked
symptoms at rest
despite maximal
medical therapy.

THERAPY
All measures
under
stage
A,B and C
Mechanical assist
device
Heart
transplantation
Continuous IV
inotrphic
infusions for
palliation

ACC/AHA Guidelines for the


Evaluation and Management of Chronic Heart Failure in the

PHARMACOLOGIC MANAGEMENT OF PATIENTS


WITH HF AND CORONARY ARTERY DISEASE (CAD)

ACEIs : are recommended in CAD with impaired LVEF (40%).


ARBs : are recommended in patients following MCI with symptoms of
HF or impaired LVEF intolerant to ACEI.

BBs : are recommended for CAD patients with symptoms of HF and


impaired LVEF.
Aldosterone antagonists: are recommended in patients following MCI with
impaired LVEF and/or signs and symptoms of HF.
Nitrates: may be considered to control anginal symptoms.
CCB : may be considered to control anginal symptoms in patients with
reduced LVEF, amlodipine or felodipine are preferable.

Statins: may be considered for all patients with HF and CAD.


No evidence improve survival, but may be reduce the risk of hospitalization.

MANAGEMENT OF PATIENTS WITH HF AND


PRESERVED LVEF (HFPEF)
DIASTOLIC HF

No treatment has yet been shown, convincingly, to reduce


morbidity and mortality in patients with HFPEF.

Diuretics are used to control sodium and water retention


and relieve breathlessness and edema.

Adequate treatment of hypertension and myocardial


ischemia is also important, as is control of the
ventricular rate.

We can use ACEI or ARB

ARRHYTHMIAS IN HF
ATRIAL FIBRILLATION (AF)
A beta-blocker (BB) or digoxin is recommended to control the heart

rate at rest in patient with HF and LV dysfunction.


A combination of digoxin and BB may be considered to control heart
rate at rest and during exercise.
In LV systolic dysfunction, digoxin is the recommended initial
treatment if the patient is hemodynamically unstable.
Intravenous administration of digoxin or amiodarone is recommended
to control the heart rate in patient with AF and HF,
who do not have an accessory pathway.

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.

VENTRICULAR ARRHYTHMIAS (VA)


It is essential to detect, and if possible, correct all potential factors

precipitating ventricular arrhythmias. Neurohumoral blockade with


optimal doses of BB, ACEI, ARB and/or aldosterone blockers is
recommended.
Routine prophylactic use of antiarrhythmic agents in patients with
asymptomatic, non sustained VA is not recommended.
In HF patients, Class Ic agents should not be used

Patients with HF and symptomatic VA :


In patients who survived VF or had a history of hemodynamically
unstable Ventricular tachycardia (VT) or VT with syncope, with reduced
LVEF (< 40%), receiving optimal pharmacological treatment and with
a life expectancy of > 1 year, ICD implantation is recommended.
Amiodarone is recommended in patients with an implanted ICD,
otherwise optimal treated, who continue to have symptomatic VA.
Catheter ablation is recommended as adjunct therapy in patients with
ICD implanted who have recurrent symptomatic VT.

MANAGEMENT OF ARTERIAL HYPERTENSION IN HF

hypertensive patients with evidence of LV dysfunctio

ystolic and diastolic BP should be carefully controlled with a


therapeutic target of 140/90 and 130/80 mmHg in diabetics and
high risk patients.

nti-hypertensive regimens based on renin-angiotensin system antagonists


(ACEI or ARBs) are preferable.

hypertensive patients with HFPEF :

ggressive treatment (often with several drugs with complementary


mechanisms of action) is recommended.

CEI and/or ARBs should be considered the first-line agents.

RENAL DYSFUNCTION IN HF

Renal dysfunction is common in HF and the prevalence


increases with HF severity, age, a history of HTN or DM
In HF renal dysfunction is strongly linked to increased
morbidity and mortality.

The cause of renal dysfunction should always be sought


in order to detect potentially reversible causes such as
hypotension, dehydration, deterioration in renal function
due to ACEI, ARBs or other concomitant medications
(e.g. NSAIDs) and renal artery stenosis.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN HF


COPD is a frequent comorbidity in HF. Restrictive and obstructive
pulmonary abnormalities are common.
There are significant overlap in the signs and symptoms with a relatively
lower sensitivity of diagnostic tests such as Chest X-ray, ECG,
echocardiography and spirometry.
It is essential to detect and treat pulmonary congestion.
Agents with documented effect on morbidity and mortality sych as ACEI,
BB and ARBs are recommended in patients with co-existing pulmonary
disease.
The majority of patients with HF and COPD can safely tolerate BB
therapy. Mild deterioration in pulmonary function and symptoms should
not lead to prompt discontinuation.
A history of asthma should be considered a contraindication to use BB.

ACUTE HEART FAILURE (AHF)

FINITION :

HF is defined as a rapid onset or change in the signs


d symptoms of HF, resulting in the need of urgent
erapy.

may present as new HF or worsening HF in the presen


chronic HF.

may be associated with worsening symptoms or signs


a medical emergency such as
ute Pulmonary Edema.

he patients with AHF will usually presen


in one of 6 clinical categories
1. Worsening or decompensated Chronic HF :
2. Acute pulmonary edema.
3. Hypertensive HF.
4. Cardiogenic shock.
5. Isolated right HF.
6. Acute Coronary Syndrome and HF

USES AND PRECIPITATING FACTORS OF A


ACS, Mechanical complications of AMI, RV Infarction.

Valve stenosis, Valvular regurgitation, Endocarditis, Aortic dissection.


Postpartum cardiomyopathy, Acute myocarditis.
Hypertension, Acute arrhythmias.
Septicemia, Thyrotoxicosis, Anemia, Shunts, Tamponade, Pulmonary
embolism.
Decompensation of preexisting Chronic HF:
Volume overload, Infections (pneumonia), Cerebrovascular insult,
Surgery, Renal dysfunction, Asthma, Drug abuse, Alcohol abuse.

GOALS OF TREATMENT IN AHF

Immediate (ED/ICU/CCU):
Improve symptoms
Restore oxygenation
Improve organ perfusion and hemodynamic
Limit cardiac/renal damage
Minimize ICU length of stay

Intermediate (In hospital):


Stabilize patients and optimize treatment strategy
Initiate appropriate (life-saving) pharmacological therapy
Consider device therapy in appropriate patients
Minimize hospital length of stay

Long-term and predischarge management:


Plan follow-up strategy
Educate and initiate appropriate lifestyle adjustments
Provide adequate secondary prophylaxis
Prevent early readmission
Improve quality of life and survival

The following management options are considered


Appropriate in patients with AHF
o Oxygen : it is recommended to administer O2 as early as possible
in hypoxemic patients to achieve an arterial O2 saturation 95%.
o Non-invasive ventilation (NIV) : (with a sealed face-mask)
NIV with positive end-expiratory pressure (PEEP) should be considered
as early as possible in every patients with Acute cardiogenic pulmonary
edema and hypertensive acute HF.
o Morphine and its analogues in AHF : Morphine relieves dyspnea and
other symptoms in patients with AHF and may be improve cooperation
for the application of NIV (dose: 2,5-5 mg IV line).
o Loop diuretics : Excessive treatment may lead to hypovolemia and
hyponatremia.

The following management options


o Vasodilators : Are recommended at an early stage for HF patients
without symptomatic hypotension .
Vasodilators relieve pulmonary congestion usually without compromising
stroke volume or increasing oxygen demand in AHF, particularly in
patients with ACS.
Hypotension (SBP <90 mmHg) should be avoided, especially in patients
with renal dysfunction

o Inotropic agents : should be considered in patients with low out


in the presence of signs of hypoperfusion or congestion despite the use of
vaso dilators and/or diuretics.
Dopamine, Dobutamine, Milrinone, Enoximone, Levosimendan.
o Vasopressors : Norepinephrine are not recommended as first-line agent
and are only indicated in cardiogenic shock when the combination of an
inotropic agent and fluid challenge fails to restore adequate BP.
o Cardiac glycoside: In AHF, cardiac glycoside produce a small increase
in cardiac output and reduction of filling pressure . It may be useful to
slow ventricular rate in rapid AF

Thank You

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