Management of Heart failure

HEART FAILURE
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2
Introduction
Causes & Types
Pathophysiology &
risk fators
Diagnosis
Treatment
CONTENTS

4
Introduction
 Definiton:
 A clinical syndrome resulting from any structural or
functional cardiac defect
 The heart is unable to pump sufficiently to maintain blood
flow to meet the body's needs

5
Introduction
 The most common causes of heart failure are
coronary artery disease, high blood pressure, and
diabetes.
 HF is diagnosed on the presence of characteristic
signs and symptoms and not on the basis of any
diagnostic tests

6
Introduction
 Heart failure is a common, costly, and potentially fatal
condition.
 In 2015 it affected about 40 million people globally.
 Overall around 2% of adults have heart failure and in those
over the age of 65, this increases to 6–10%.
 In the year after diagnosis the risk of death is about 35%
after which it decreases to below 10% each year.

8
Common causes of HF
 Ischemic heart disease ~ 40 percent
 Dilated cardiomyopathy ~ 30 percent
 Primary valvular heart disease ~ 15
percent
 Hypertensive heart disease ~ 10 percent
 Other ~ 5 percent

9
Types of HF
 According to cardiac output:
a. Low-Output Heart Failure
b. High-Output Heart Failure
 According to anatomical side
a. Left side heart failure
b. Right side heart failure
 According to onset
a. Acute heart failure
b. Chronic heart failure

10
Low-Output HF
 Causes:
I. Systolic Dysfunction
 Coronary Artery Disease
 Idiopathic dilated cardiomyopathy (DCM)
 Hypertension
 Valvular Heart Disease

11
Low-Output HF
II. Diastolic Dysfunction
 Hypertension
 Coronary artery disease
 Hypertrophic obstructive cardiomyopathy (HCM)
 Restrictive cardiomyopathy

12
High-Output HF
 Seen with hyperthyroidism, beri-beri, carcinoid,
anemia
 Often with normal cardiac output

14
Pathophysiology of HF
 Pump fails → decreased stroke volume /CO.
 Compensatory mechanisms kick in to increase CO
 SNS stimulation → release of epinephrine/nor-
epinephrine
o Increase HR
o Increase contractility
o Peripheral vasoconstriction (increases afterload)
 Myocardial hypertrophy: walls of heart thicken to
provide more muscle mass → stronger contractions

15
 Hormonal response:
 ↓ renal perfusion interpreted by juxtaglomerular
apparatus as hypovolemia. Thus: Kidneys release
renin, which stimulates conversion of antiotensin I →
angiotensin II, which causes:
o Aldosterone release → Na retention and water
retention (via ADH secretion)
o Peripheral vasoconstriction

16
 Compensatory mechanisms may restore CO to near-
normal.
 But, if excessive the compensatory mechanisms can
worsen heart failure because:
 Vasoconstriction:
o ↑ the resistance against which heart has to pump (i.e.,
↑ afterload), and may therefore ↓ CO

17
 Na and water retention:
o ↑ fluid volume, which ↑ preload. If too much
“stretch” (d/t too much fluid) → ↓ strength of
contraction and ↓ CO
 Excessive tachycardia → ↓ diastolic filling time →
↓ventricular filling → ↓ SV and CO

20
Risk factors of HF
 CAD
 Age
 HTN
 Obesity
 Cigarette smoking
 Diabetes mellitus
 High cholesterol
 African descent

22
C/P of HF
 Symptoms
 Left Heart Failure:
o Dyspnea on exertion
o Dyspnea at rest
o Orthpnea
o Paroxysmal nocturnal dyspnea (PND)
o Fatigue, inability to exercise

23
C/P of HF
 Symptoms
 Right Heart Failure:
o Swelling of feet, hands
o Abdominal distention/fullness
o Right upper quadrant pain
o Early satiety
o Weight loss (cardiac cachexia)

24
C/P of HF
 Signs
 Left Heart Failure:
o Rales
o Pleural effusions
o Displaced apical impulse
o Tachycardia, LVS3, murmur of MR(mitral regurge)
o Narrow pulse pressure

25
C/P of HF
 Signs
 Right Heart Failure:
o Edema of lower extremities
o Elevated JVP(jugular vein pressure)/+
HJR(hepatojugular reflux)
o RVS3, murmur of TR(tricuspid regurge)
o Hepatomegaly, RUQ(right upper quadrant) tenderness
o Ascites - Pleural effusions

27
Classification of HF
 New York Heart Association (NYHA)
 Class I : symptoms of HF only at levels that would
limit normal individuals.
 Class II : symptoms of HF with ordinary exertion
 Class III : symptoms of HF on less than ordinary
exertion
 Class IV : symptoms of HF at rest

28
Classification of HF
 American College of Cardiology and the American
Heart Association(ACC/AHA) Guidelines
 Stage A : High risk of HF, without structural heart
disease or symptoms
 Stage B : Heart disease with asymptomatic left
ventricular dysfunction
 Stage C : Prior or current symptoms of HF
 Stage D : Advanced heart disease and severely
symptomatic or refractory HF

29
Clinical Presentation of HF

30
Investigation
I. LAB
A) Non specific
 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
 Viral studies (If viral myocarditis suspected)
 Others

31
Investigation
I. LAB
B) Specific
 BNP:
o With chronic heart failure, atrial myocytes secrete
increase amounts of atrial natriuretic peptide (ANP) and
brain natriuretic peptide (BNP) in response to high atrial
and ventricular filling pressures
o Promotes vasodilation, diuresis and natriuresis
o Usually is > 400 pg/mL in patients with dyspnea due to
heart failure.

32
Investigation
II. Radiological
 Chest X-ray:
o Cardiomegaly
o Cephalization of the
pulmonary vessels
o Kerley B-lines
o Pleural effusions

33
Investigation
Cardiomegaly
Pulmonary
vessel
congestion
Kerley B lines

34
Investigation
III. Cardiac testing
 ECG:
o May show specific cause of heart failure e.g Ischemic
heart disease
 ECHO:
o Left ventricular ejection fraction
o Structural/valvular abnormalities

35
Investigation
III. Cardiac testing
 Exercise Testing
o Should be part of initial evaluation of all patients with
CHF.
 Coronary arteriography
o Should be performed in patients presenting with heart
failure who have angina or significant ischemia
o Measure cardiac output, degree of left ventricular
dysfunction, and left ventricular end-diastolic pressure.

36
Diagnosis of HF
 HF should be suspected on the basis of clinical
presentation and radiographic findings.
 It’s a clinical diagnosis. There is no diagnostic test!
 Depressed ventricular EF should be confirmed with
echocardiography, or cardiac catheterization with left
ventriculography.

38
Treatment
Management of Chronic heart failure:
 General measures
 Correct underlying cause
 Remove precipitating cause
 Prevention of deterioration of cardiac function
 Control of congestive HF state

39
Treatment
Correction of systemic factors
 Thyroid dysfunction
 Infections
 Uncontrolled diabetes
 Hypertension

40
Treatment
Nonpharmacologic therapy:
 Exercise training:
o for stable HF patients increased exercise capacity,
decreased hospitalization rate, increased quality
of life, decreased symptoms.
 Weight loss in obese patients
 Dietary Na restriction

41
Treatment
Nonpharmacologic therapy:
 Fluid and free water restriction especially if
hyponatremic
 Minimize medications known to have deleterious
effects on heart failure (negative inotrops, NSAIDs,
over-the-counter stimulants)
 Oxygen
 Fluid removal (dialysis, thoracentesis, paracentesis)

42
Medical Treatment
Order of drug therapy
o Loop diuretics
o ACE inhibitor (or ARB if not tolerated)
o Beta blockers
o Digoxin
o Hydralazine, Nitrate
o Potassium sparing diuretics

43
Medical Treatment
Diuretics
A. Loop diuretics
 Furosemide, buteminide
 For Fluid control, and to help relieve symptoms
B. Potassium-sparing diuretics
 Spironolactone, eplerenone
 Help enhance diuresis
 Maintain potassium
 Shown to improve survival in CHF

44
Medical Treatment
ACE Inhibitor
 Improve survival in patients with all severities of heart
failure.
 Begin therapy low and titrate up as possible:
o Enalapril
o Captopril
o Lisinopril
 If cannot tolerate, may try ARB

45
Medical Treatment
Beta Blocker therapy
 Certain Beta blockers (carvedilol, metoprolol,
bisoprolol) can improve overall survival in NYHA
class II to III HF, probably in class IV.
 Contraindicated:
o Heart rate <60 bpm
o Symptomatic bradycardia
o Signs of peripheral hypoperfusion
o COPD, asthma
o Prolonged PR interval, 2nd or 3rd degree heart block

46
Medical Treatment
Hydralazine plus Nitrates
 Hydralazine + Isosorbide dinitrate
 can be useful to reduce morbidity or mortality in
patients with current or prior symptomatic HF who
cannot be given an ACE inhibitor or ARB
 Recommended for African Americans with NYHA
class III–IV
 Decreased mortality, lower rates of hospitalization, and
improvement in quality of life.

47
Medical Treatment
Digoxin
 Given to patients with HF to control symptoms such as
fatigue, dyspnea, exercise intolerance
 Digoxin can be used in HF patients with atrial
fibrillation to help rate control
 Shown to significantly reduce hospitalization for heart
failure, but no benefit in terms of overall mortality.

48
Medical Treatment
Other important medication
 Statin therapy:
 recommended in CHF for the secondary prevention of
cardiovascular disease.
 Benefits:
o Improved LVEF(left ventricular ejection fraction)
o Reversal of ventricular remodeling
o Reduction in inflammatory markers e.g CRP

49
Medical Treatment
Meds to AVOID in heart failure
 NSAIDS
o Can cause worsening of pre-existing HF
 Thiazolidinediones
o Cause fluid retention that can exacerbate HF
 Metformin
o increased risk of potentially lactic acidosis

50
Implantable Cardioverter-
Defibrillators for HF
 Sustained ventricular
tachycardia is
associated with sudden
cardiac death in HF.
 About one-third of
mortality in HF is due
to sudden cardiac
death.

52
Acute Decompensated HF
 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.

53
 Causes:
 Acute MI
o Rupture of chordae tendinae/acute mitral valve
insufficiency
 Volume Overload
o Transfusions, IV fluids
o Non-compliance with diuretics, diet (high salt intake)
 Worsening valvular defect
o Aortic stenosis

54
 Clinical manifestations:
 Symptoms
o Severe dyspnea
o Cough

55
 Clinical manifestations:
 Signs
o Tachypnea
o Tachycardia
o Hypertension/Hypotension
o Crackles on lung exam
o Increased JVD(jagular venous distension)
o S3, S4 or new murmur

56
 Investigations:
 Chemistry, CBC
 ECG
 Chest X-ray
 May consider cardiac enzymes
 2D-Echo

57
 Treatment
 Oxygen, mechanical ventilation if needed
 Loop diuretics (Lasix)
 Morphine
 Vasodilator therapy (nitroglycerin)
 Positive inotropes e.g Dobutmaine
 Nesiritide (BNP) : can help in acute setting, for
short term therapy

59
thanksF o r W a t c h i n g

Management of Heart failure

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