HEART FAILURE

Dr. dr. Teuku Heriansyah, Sp.JP(K)-FIHA

 Introduction
Heart Failure Clinical Syndrome
...... can result from any structural or functional
cardiac disorder that impairs ability of ventricle to fill
with or eject blood.

leading cause for hospital admission among

patients > 65 years old in Western countries
About 1 million hospital admissions per year
About 0,3% in Indonesian Population
300,000 deaths/year
Yancy CW. Et al. Circulation 2013 Oct 15;128(16):e240; Indonesian Ministry of Health. Riskesdas. 2013
 Introduction
The Cardiovascular Continuum:
Targeting Mechanisms and Mediators

Oxidative Target Organ

Stress/ Tissue Injury Pathological Damage
(MI, Stroke) Remodeling
Inflammation
Vascular Disease Target Organ
Dysfunction (CHF,
Vascular Renal)
Dysfunction
End-stage
Organ Failure
Risk Factors:
Diabetes
Hypertension Death
Adapted from Dzau V, Braunwald E. Am Heart J. 1991.
 Introduction

http://watchlearnlive.heart.org
 Definitions
Key Concepts CO = SV x HR

Lilly LS. Pathophysiology of Heart Disease. LLW: 2015

 Definitions
Key Concepts Ejection Fraction (EF)

Lilly LS. Pathophysiology of Heart Disease. LLW: 2015; http://www.heart.org/HEARTORG/Conditions/HeartFailure

 Epidemiology

>
The prime candidates for the
European development ofstudies
population-based heartoffailure
LVSD show: in whom death from stroke
are patients with hypertension
Prevalence of 23%.
has been prevented by antihypertensive therapy and
Increasing to 7% in the elderly.
survivors of acute myocardial infarction who have been
spared death from arrhythmia.
Eugene Braunwald, Shattuck Lecture 1997-
primary diagnosis of heart failure in
about 1 million hospital admissions per
23%
year of the worlds population is
affected
hospital admissions by symptomatic
due to acute HF
decompensated heart failure have
(~ 22 million
tripled in last 30 years people worldwide)
incidence and prevalence increases
with age
Korczyk D. Fast Fact Heart Failure. 2012
 Epidemiology

>
European population-based studies
of LVSD show:
Prevalence of 23%.
Increasing to 7% in the elderly.

HF prevalence has increased

from 5.7 million (2009 to 2012)
to 6.5 million (2011 to 2014) in
Americans 20 years of age.

Gadner RS. Heart Failure. Oxford: 2014; Emelia J et al. Circulation. 2017;135:e-e458
 Epidemiology
Based on Symptoms:
0,3% from total population
(absolute count : 229.696 people)
Based on doctors dx:
0,13% from total population
(absolute count: 530.068)

Based on Symptoms
0,3% (9.531 people)
Based on doctors dx:
0,10%(3.117 people)

Indonesian Ministry of Health. Riset Kesehatan Dasar. 2013

 Classifications
Types of HF
Diastolic versus Systolic
Acute versus Chronic
Right versus Left (and Biventricular)
High versus Low Output.
American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) staging of development of heart failure

Stage A At high risk for heart failure but without structural heart
disease or symptoms of heart failure
Stage B Structural heart disease but without signs or symptoms of
heart failure
Stage C Structural heart disease with prior or current symptoms of
heart failure
Stage D Refractory heart failure requiring specialized interventions
Mckelvie RS et al. Can J Cardiol 2013 Feb; (29) 2: 168-181; Yancy CW. Et al. Circulation 2013 Oct 15;128(16):e240
 Classifications
NYHA Functional Classification:
NYHA Class Patient Symptoms
No limitation of physical activity
Class I (mild) Ordinary physical activity does not cause symptoms
of heart failure (undue fatigue, palpitations, and
dyspnea)
Slight limitation of physical activity
Class II (mild) Comfortable at rest, but ordinary physical activity
results in symptoms of heart failure
Significant limitation of physical activity
Class III (moderate) Comfortable at rest, but less than ordinary activity
causes symptoms of heart failure
Unable to carry out any physical activity without
Class IV (severe) symptoms of heart failure or symptoms of heart
failure at rest
Yancy CW. Et al. Circulation 2013 Oct 15;128(16):e240
 Risk Factors
Coronary artery disease Congenital heart disease

Past heart attack Severe lung disease

Abnormal heart valves Diabetes

Heart muscle disease Obesity

High blood pressure

Sleep Apnea
(hypertension)

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319

 Etiology
Heart Failure

Reduced EF Preserved EF
(Systolic Dysfunction) (Diastolic Dysfunction)

Impaired Contractility Afterload Impaired Diastolic Filling

1.Coronary artery disease (Chronic Pressure Overload) 1. LVH
- Myocardial infarction 1. Advance d aortic 2. Restrictive
- Transient myocardial stenosis Cardiomiopathy
ischemia 2. Uncontrolled severe 3. Myocardial Fibrosis
2.Chronic volume hypertension 4. Transient Myocardial
overload Iscemia
- Mitral regurgitation 5. Pericardial
- Aortic regurgitation constriction or
3.Dilated Tamponade
cardiomyopathies
Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Pathophysiology

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Pathophysiology
Compensatory mechanisms in heart failure

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Clinical Manifestation

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Clinical Manifestation

Left Ventricular Failure

Signs and symptoms
dyspnea
orthopnea PND
Cheyne Stokes
fatigue
Anxiety
rales

NOTE L FOR LEFT AND L FOR LUNGS

Why does this occur??
Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Clinical Manifestation
Right Heart Failure
Signs and Symptoms
fatigue, weakness,
lethargy
wt. gain, inc. abd. girth,
anorexia, RUQ pain
elevated neck veins
Hepatomegaly +HJR
may not see signs of LVF

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Physical Examination
S3 gallop
Low sensitivity, but highly specific
Cool, pale, cyanotic extremities
Have sinus tachycardia, diaphoresis and peripheral
vasoconstriction
Crackles or decreased breath sounds at bases (effusions) on
lung exam
Elevated jugular venous pressure
Lower extremity edema
Ascites
Hepatomegaly
Splenomegaly
Displaced PMI
Apical impulse that is laterally displaced past the midclavicular
line is usually indicative of left ventricular enlargement>
Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Physical Examination
Measuring Jugular Venous Pressure

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Criteria for heart failure
Framingham: requires the simultaneous presence of at least two major criteria or
one major criterion in conjunction with two minor criteria

Major criteria Minor criteria

Nocturnal dyspnea Tachycardia

Venous distension Crackles
Hepatojugular reflux Bilateral ankle edema
Pulmonary edema Exertional dyspnea
Cardiomegaly on chest Nocturnal cough
radiography Hepatomegaly
S3 gallop (a third heart Reduction of vital
sound) capacity
Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Hemodynamic clinical profiles of acute heart failure

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Lab Analysis in Heart Failure
CBC
Since anemia can exacerbate heart failure
Serum electrolytes and creatinine
Before starting high dose diuretics
Fasting Blood glucose
To evaluate for possible diabetes mellitus
Thyroid function tests
Since thyrotoxicosis can result in A. Fib and hypothyroidism can
results in HF.
Iron studies
To screen for hereditary hemochromatosis as cause of heart failure.
ANA
To evaluate for possible lupus
Viral studies
If viral mycocarditis suspected

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Lab Analysis in Heart Failure (Cont)
BNP
With chronic heart failure, atrial mycotes secrete increase
amounts of atrial natriuretic peptide (ANP) and brain
natriuretic pepetide (BNP) in response to high atrial and
ventricular filling pressures
Usually is > 400 pg/mL in patients with dyspnea due to heart
failure.

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Chest X-ray in Heart Failure
Cardiomegaly
Cephalization of the pulmonary
vessels
Kerley B-lines
Pleural effusions

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Cardiac Testing in Heart Failure
Electrocardiogram:
May show specific cause of heart failure:
Ischemic heart disease
Dilated cardiomyopathy: first degree AV block, LBBB,
Left anterior fascicular block
Amyloidosis: pseudo-infarction pattern
Idiopathic dilated cardiomyopathy: LVH

Echocardiogram:
Left ventricular ejection fraction
Structural/valvular abnormalities

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis
Further Cardiac Testing in Heart Failure
Exercise Testing
Should be part of initial evaluation of all patients with CHF.

Coronary arteriography
Should be performed in patients presenting with heart
failure who have angina or significant ischemia

Endomyocardial biopsy
Not frequently used

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Diagnosis

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Differential Diagnosis
Other common causes for dyspnea include
asthma
chronic obstructive pulmonary disease (COPD)
arrhythmia
infection
interstitial lung disease
anemia
pulmonary embolism (PE)

Other causes for peripheral edema

renal disease immobility
acute renal failure pregnancy
chronic kidney disease endocrine disease
hepatic disease venous and/or lymphatic obstruction
hypoproteinemia drugs
venous insufficiency
Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Treatment
Acute Decompensated Heart Failure
Cardiogenic pulmonary edema is a common and
sometimes fatal cause of acute respiratory distress.

Characterized by the transudation of excess fluid into the

lungs secondary to an increase in left atrial and
subsequently pulmonary venous and pulmonary capillary
pressures.

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Treatment
Acute Decompensated Heart Failure
Treatment
Strict Is and Os, daily weights
Oxygen, mechanical ventilation if needed
Loop diuretics (Lasix!)
Morphine
Vasodilator therapy (nitroglycerin)
Nesiritide (BNP) can help in acute setting, for
short term therapy

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Treatment
Chronic Treatment of Systolic Heart Failure
Correction of systemic factors
Thyroid dysfunction
Infections
Uncontrolled diabetes
Hypertension

Lifestyle modification
Lower salt intake
Alcohol cessation
Medication compliance

Maximize medications
Discontinue drugs that may contribute to heart failure (NSAIDS,
antiarrhythmics, calcium channel blockers)

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Treatment
Order of Therapy
1. Loop diuretics
2. ACE inhibitor (or ARB if not tolerated)
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
Diuretics
Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve symptoms

Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Shown to improve survival in CHF

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
ACE Inhibitor
Improve survival in patients with all severities of
heart failure.

Begin therapy low and titrate up as possible:

Enalapril 2.5 mg po BID
Captopril 6.25 mg po TID
Lisinopril 5 mg po Qdaily

If cannot tolerate, may try ARB

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
Beta Blocker therapy
Certain Beta blockers (carvedilol, metoprolol,
bisoprolol) can improve overall and event free
survival in NYHA class II to III HF, probably in
class IV.

Contraindicated:
Heart rate <60 bpm
Symptomatic bradycardia
Signs of peripheral hypoperfusion
COPD, asthma
PR interval > 0.24 sec, 2 or 3 degree block
nd rd

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
Hydralazine plus Nitrates
Dosing:
Hydralazine
Started at 25 mg po TID, titrated up to 100 mg
po TID
Isosorbide dinitrate
Started at 40 mg po TID/QID

Decreased mortality, lower rates of hospitalization,

and improvement in quality of life.

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
Digoxin
Given to patients with HF to control symptoms such
as fatigue, dyspnea, exercise intolerance

Shown to significantly reduce hospitalization for

heart failure, but no benefit in terms of overall
mortality.

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Medications
Other important medication in Heart
Failure - Statins
Statin therapy is recommended in CHF for the
secondary prevention of cardiovascular disease.

Some studies have shown a possible benefit

specifically in HF with statin therapy

Improved LVEF
Reversal of ventricular remodeling
Reduction in inflammatory markers (CRP, IL-6, TNF-II)

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Complications
Pleural effusion
Atrial fibrillation (most common dysrhythmia)
Loss of atrial contraction (kick) -reduce CO by 10% to 20%
Promotes thrombus/embolus formation inc. risk for stroke
Treatment may include cardioversion, antidysrhythmics,
and/or anticoagulants

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
 Complications
**High risk of fatal dysrhythmias (e.g., sudden cardiac
death, ventricular tachycardia) with HF and an EF
<35%
HF lead to severe hepatomegaly, especially with RV failure
Fibrosis and cirrhosis - develop over time
Renal insufficiency or failure

Yancy CW et al. Circulation. 2013 Oct 15;128(16):e240-319; McMurray JJ. N Engl J Med. 2010 Jan 21;362(3):228-38.
Thank You