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CHRONIC HEART FAILURE

CHRONIC HEART FAILURE. Faculty of Medicine University of Brawijaya. Introduction. Definition : Heart Failure. “ The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. “ E. Braunwald

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CHRONIC HEART FAILURE

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  1. CHRONIC HEART FAILURE Faculty of Medicine University of Brawijaya

  2. Introduction

  3. Definition : Heart Failure “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.“ E. Braunwald “Pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues.”Euro Heart J; 2001. 22: 1527-1560

  4. DEFINITION OF HEART FAILURE. Criteria 1 and 2 should be fulfilled in all cases 1. Symptoms of heart failure (at rest or during exercise) And 2. Objective evidence of cardiac dysfunction (at rest) And (in cases where the diagnosis is in doubt) 3. Response to treatment directed towards heart failure Task Force Report. Guidelines for the diagnosis and treatment of chronic heart failure. European Society of Cardiology.2001

  5. EPIDEMIOLOGY Europe • The prevalence of symptomatic HF range from 0.4-2%. • 10 million HF pts in 900 million total population USA • nearly 5 million HF pts. • ± 500,000 pts are D/ HF for the 1sttime each year. • Last 10 years  number of hospitalizations has increased. • Nearly 300,000 patients die of HF each year. Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560 ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

  6. DESCRIPTIVE TERMS in HEART FAILURE • Acute vs Chronic Heart Failure • Systolic vs Diastolic Heart Failure • Right vs Left Heart Failure • Mild , Moderate, Severe Heart Failure Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1528

  7. New York Heart Association (NYHA) Classification of Heart Failure Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1531 (Adapted from Williams JF et al., Circulation. 1995; 92 : 2764-2784)

  8. ACC/AHA – A New Approach To The Classification of HF ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

  9. Stages in the evolution of HF and recommended therapy by stage Stage A Stage B Stage C Stage D Pts with : • Struct. HD • Shortness of breath and fatigue, reduce exercise tolerance Pts with : • Hypertension • CAD • DM • Cardiotoxins • FHx CM Pts with : • Previous MI • LV systolic dysfunction • Asymptomatic Valvular disease Pts who have marked symptoms at rest despite maximal medical therapy. Refract. Symp.of HF at rest Struct. Heart Disease Develop Symp.of HF THERAPY • All measures under stage A,B and C • Mechanical assist device • Heart transplantation • Continuous IV inotrphic infusions for palliation THERAPY • All measures under stage A • Drugs for routine use: • diuretic • ACE inhibitor • Beta-blockers • digitalis THERAPY • Treat Hypertension • Stop smoking • Treat lipid disorders • Encourage regular exercise • Stop alcohol & drug use • ACE inhibition THERAPY • All measures under stage A • ACE inhibitor • Beta-blockers ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

  10. EVOLUTION OF CLINICAL STAGES NORMAL No symptoms Normal exercise Normal LV fxn Asymptomatic LV Dysfunction Compensated CHF No symptoms Normal exercise Abnormal LV fxn Decompensated CHF No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Refractory CHF Symptoms not controlled with treatment

  11. Evolution of the Concept of Heart Failure 1950 to 2000 19502000 Aetiology Hypertension CHD Valvular heart dis Hypertension Dilated CMP Natural Course Slowly progressive Slowly progressive (remodelling) or unpredictable and rapid ( coronary event ) Understanding Hemodynamic model Neurohormonal model Common cause Pulmonary infection Sudden death of death Pump failure Arrhythmia Atrial Ventricular Treatment goal Control edema Improve quality of life Slowing Heart Rate + reduce mortality + reduce hospitalization

  12. Patophysiology of C H F

  13. g g a a b c d e f AO Aortic closure Aortic pressure Ventricular pressure Cross- over MO Atrial pressure A2 M1 P2 T1 Heart sounds S4 S3 Cardiologic systole a c v JVP T P P ECG Opie (2001) Q S 0 800 msec The Wiggers cycle g f iso e a b c d iso

  14. PULMONARY VENOUS PRESSURE Input Filling Emptying Stroke volume EFeffective ED volume = x x LV Distensibility Relaxation Left atrium Mitral valve Pericardium Contractility Afterload Preload Structure Heart rate Diastolic function Systolic function Output CARDIAC OUTPUT Block diagram of left ventricular pump performance (Little, 2001)

  15. PRESSURE – VOLUME CURVE OF SYSTOLIC AND DIASTOLIC FAILURE DIASTOLIC FAILURE SYSTOLIC FAILURE Decreased diastolic chamber distensibility Normal diastolic chamber distensibility Normal Left Ventricular Pressure Left Ventricular Pressure Left Ventricular Volume Left Ventricular Volume (Zile & Brutsaert 2002)

  16. Abnormal relaxation Pericardial restraint B A Left ventricular pressure Chamber dilation Increased chamber stiffness D C Left ventricular volume Mechanisms that cause diastolic dysfunction. (Zile, 1990)

  17. - Synergistic LV contraction - LV wall integrity - Valvular competence DETERMINANTS OF VENTRICULAR FUNCTION CONTRACTILITY PRELOAD AFTERLOAD STROKE VOLUME HEART RATE CARDIAC OUTPUT

  18. Frank-Starling Law

  19. Ventricular Function Curve:Frank-Starlings Normal SV Congestion LVEDV

  20. The Pathophysiology of Heart Failure Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688

  21. Pathophysiological Sequence of CHF Heart Failure Inadequate Cardiac Output ( ) O2 Delivery (rest and/or exercise) Systemic Vasoconstriction SAS (NE)) RAAS (A-II) () Flow to Skin, Gut, and Renal Circulations

  22. Neurohormonal Activation Activation of RAS and ANS Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688

  23. SNS: sympathetic nervous system

  24. Sympathetic nervous system up-regulation Increased Norepinephrine levels Direct Myocardial toxicity Activation of the RAA system Decreased Renal blood flow Myocyte dysfunction Increased Angiotensin II & Aldosteron Myocyte necrosis Increased HR, PVR & arteriolar vasoconstriction Increased myocardial oxygen demand Intracellular Ca2+ overload/ Energy depletion Na+ & water retention Vasoconstriction Cardiac remodeling Apoptosis Cesario et.al; Reviews in cardiovascular medicine, vol 3, no.1, 2002

  25. Causes of Heart Failure • Myocardial Damage or Disease • Infarction (Acute) / Ischemia • Myocarditis • Hypertrophic Cardiomyopathy • Excess Load on Ventricle • Volume/ Pressure Overload • Resistance to Flow into Ventricle • Cardiac Arrhythmias

  26. Primary Changes in CHF

  27. MI-INDUCED HEART FAILURE Myocardial Damage Contractility Pump Performance () Systolic Work Load () SAS Drive Vasoconstriction RAAS SYSTEM FLUID RETENTION

  28. Diagnosis of C H F

  29. IDENTIFICATIONS OF HF PATIENTS • With a Syndrome of Decrease Exercise Tolerance • With a Syndrome of Fluid Retention • With No Symptoms or Symptoms of Another Cardiac or Non Cardiac Disorder (MI, Arrythmias, Pulmonary or Systemic Thromboembolic Events)

  30. SYMPTOMS AND SIGN • Breathlessness, Ankle Swelling, Fatique → Characteristic Symptoms • Peripheral Oedema, JVP ↑, Hepatomegaly → Signs of Congestion of Systemic Veins • S3 , Pulmonary Rales , Cardiac Murmur 

  31. E C G • A low Predictive Value • LAH and LVH May Be Associated wit LV Dysfunction • Anterior Q-wave and LBBB a good predictors of EF ↓↓ • Detecting Arrhytmias as Causative of HF CHEST X-RAY • A Part of Initial Diagnosis of HF → Cardiomegaly, Pulmonary Congestion • Relationship Between Radiological Signs and Haemodynamic Findings may Depend on the Duration and Severity HF

  32. HAEMATOLOGY & BIOCHEMISTRY • A Part of Routine Diagnostic • Hb, Leucocyte, Platelets • Electrolytes, Creatinine, Glucose, Hepatic Enzyme, Urinalysis • TSH, C-RP, Uric Acid ECHOCARDIOGRAPHY • The Preferred Methods • Helpful in Determining the Aetiology • Follow Up of Patients Heart Failure

  33. PULMONARY FUNCTIONS • A Little Value in Diagnosis Heart Failure • Usefull in Excluding Respiratory Diseases EXERCISE TESTING • Focused on Functional, Treatment Assessment and Prognostic

  34. STRESS ECHOCARDIOGRAPHY • For Detecting Ischaemia • Viability Study NUCLEAR CARDIOLOGY • Not Recommended as a Routine Use CMR ( CARDIAC MAGNETIC RESONANCE IMAGING) • Recommended if Other Imaging Techniques not Provided Diagnostic Answer

  35. INVASIVE INVESTIGATION • Elucidating the Cause and Prognostic Informations • Coronary Angiography : in CAD’s Patients • Haemodynamic Monitoring : To Assess Diagnostic and Treatment of HF • Endomyocardial Biopsy : in Patients with Unexplained HF

  36. NATRIURETIC PEPTIDES • Cardiac Function ↓↓ (LV Function ↓↓) → ↑↑ Plasma Natriuretic Peptide Concentration (Diagnostic Blood Use for HF) • Natriuretic Peptide ↑↑ : Greatest Risk of CV Events Natriuretic Peptide ↓↓ : Improve Outcome in Patients with Treatment • Identify Pts. With Asymptomatic LV Dysfunction (MI, CAD)

  37. ALGORITHM FOR THE DIAGNOSIS OF THE HF (ESC, 2001) Suspected Heart Failure Because of symptoms and signs If NormalHeart FailureUnlikely Assess Presence of Cardiac Disease by ECG, X-Ray or NatriureticPeptides (Where Available) Tests Abnormal If NormalHeart Failure Unlikely Imaging by Echocardiography (Nuclear Angiography or MRI Where Available) Tests Abnormal Assess Etiology, Degree, Precipitating Factors and Type of Cardiac Dysfunction Additional Diagnosis Tests Where Appropriate (e.g. Coronary Angiography) Choose Therapy

  38. Treatment of C H F

  39. Aims of Treatment • Prevention • Prevention and/or controlling of diseases leading to cardiac dysfunction and heart failure • Prevention of progression to heart failure once cardiac dysfunction is established • Morbidity Maintenance or improvement in quality of life • Mortality Increased duration of life Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

  40. ACC/AHA & EUROPE (ESC) 2001GUIDELINES FOR THE MANAGEMENTOF HEART FAILURE • ACE-inhibitor • Use as first line therapy • Should be up titrated to the dosages shown in the large clinical trial, and not titrated based on symptomatic improvement • DIURETIC→ to control fluid overload • Β-BLOCKER • For all patients with stable mild-severe HF on standard treatment

  41. ACC/AHA & EUROPE (ESC) 2001GUIDELINES FOR THE MANAGEMENTOF HEART FAILURE • Aldosteron Receptor Antagonis • in advance HF ( NYHA III-IV ) • DIGOXIN • in AF (atrial fibrillation) • May be added for symptom relief • ARB • Considered in patients not tolerate ACE- inhibitors and not on β - blocker

  42. Management Outline • Establish that the patient has HF. • Ascertain presenting features: pulmonary oedema, exertionalbreathlessness, fatigue, peripheral oedema • Assess severity of symptoms • Determine aetiology of heart failure • Identify precipitating and exacerbating factors • Identify concomitant diseases • Estimate prognosis • Anticipate complications • Counsel patient and relatives • Choose appropriate management • Monitor progress and manage accordingly Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

  43. Pregnancy Arrhythmias (AF) Infections Hyperthyroidism Thromboembolism Endocarditis Obesity Hypertension Physical activity Dietary excess TREATMENT Correction of aggravating factors MEDICATIONS

  44. Treatment options • Non-pharmacological management • General advice and measures • Exercise and exercise training • Pharmacological therapy • Angiotensin-converting enzyme (ACE) inhibitors • Diuretics • Beta-adrenoceptor antagonists • Aldosterone receptor antagonists • Angiotensin receptor antagonists • Cardiac glycosides • Vasodilator agents (nitrates/hydralazine) • Positive inotropic agents • Anticoagulation • Antiarrhythmic agents • Oxygen • Devices and surgery • Revascularization (catheter interventions and surgery), other forms of surgery • Pacemakers • Implantable cardioverter defibrillators (ICD) • Heart transplantation, ventricular assist devices, artificial heart • Ultrafiltration, haemodialysis Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

  45. PHARMACOLOGIC THERAPY Neurohumoral Control Improved symptoms Decreasedmortality Prevention of CHF yes ? DIURETICS NO ? yes = yes DIGOXIN minimal yes mort. no INOTROPES ? yes yes no Vasodil.(Nitrates) ? yes ACEI YES yes YES Other neurohormonal control drugs + / - yes YES ?

  46. TREATMENT Normal AsymptomaticLV dysfunction EF <40% Symptomatic CHF NYHA II ACEI Symptomatic CHF NYHA - III Diuretics mild Neurohormonal inhibitors Digoxin? Symptomatic CHF NYHA - IV Loop Diuretics Inotropes Specialized therapy Transplant Secondary prevention Modification of physical activity

  47. Pharmacological therapy

  48. Stages in the evolution of HF and recommended therapy by stage Stage A Stage B Stage C Stage D Pts with : • Struct. HD • Shortness of breath and fatigue, reduce exercise tolerance Pts with : • Hypertension • CAD • DM • Cardiotoxins • FHx CM Pts with : • Previous MI • LV systolic dysfunction • Asymptomatic Valvular disease Pts who have marked symptoms at rest despite maximal medical therapy. Refract. Symp.of HF at rest Struct. Heart Disease Develop Symp.of HF THERAPY • All measures under stage A,B and C • Mechanical assist device • Heart transplantation • Continuous IV inotrphic infusions for palliation THERAPY • All measures under stage A • Drugs for routine use: • diuretic • ACE inhibitor • Beta-blockers • digitalis THERAPY • Treat Hypertension • Stop smoking • Treat lipid disorders • Encourage regular exercise • Stop alcohol & drug use • ACE inhibition THERAPY • All measures under stage A • ACE inhibitor • Beta-blockers ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

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