HEART FAILURE SHAHKUR SHABIR SUNNY BANK MEDICAL CENTRE 4 Nov 2011

1. HEART FAILURE SHAHKUR SHABIR SUNNY BANK MEDICAL CENTRE 4 Nov 2011

2. Definition of Heart Failure Cardiac output and BP are inadequate for the body’s requirement. Inability of the heart to pump sufficient oxygenated blood to the metabolising tissue.

3. PROGNOSIS What percentage of Heart failure patients die within 5 years. Male 62% Female 42% What percentage of patient do not survive 18 months from the time of diagnosis 40% It affect 2% of population and upto 7% of the elderly

4. CAUSES OF HEART FAILURE Myocardial infarction Ischeamia Hypertension Cardiomyopathy Diabetes Valvular disease: Mitral valve, Aortic valve, Atrial septal defect. Alcohol Pericardial Effusion/Constrictive Pericarditis Anaemia Thyrotoxicosis Tachycardia Bradycardia: complete heart block, beta blocker Atrial Fibrillation-loss of atrial contraction

5. CAUSES SEPARATED Heart failure causes can be subdivided into groups . PUMP FAILURE Disease of the heart muscle Ischeamic heart disease, cardiomyopathy - e.g HOCM-LV outflow tract obstruction Restricted filling Constrictive pericarditis, tamponade, restrictive cardiomyopathy Inadequate heart rate Beta blocker, heart block, post MI

6. EXCESSIVE PRELOAD Main causes Mitral regurgitation Fluid overload. Fluid overload can cause heart failure EVEN WITH A NORMAL HEART. Usually Renal excretion is impaired or ivi running too fast. Commonly occurs in the elderly.

7. CHRONIC EXCESSIVE AFTERLOAD Aortic stenosis: restriction of blood flow to the body. Hypertension

8. Which heart failure classification is commonly used by doctors to help determine the best course of therapy? New York Heart Classification (NYHC) • Class I (Mild)No limitation of physical activity. • Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath) • Class II (Mild)Slight limitation of physical activity. • Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea • Class III (Moderate)Marked limitation of physical activity. • Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea • Class IV (Severe)Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

9. SYMPTOMS OF HEART FAILURE QUESTION: What symptoms can you have with heart failure other than SOB?

10. HEART FAILURE SYMPTOMS • Dyspnoea • Poor exercise tolerance • Orthopnoea • Paroxysmal nocturnal dyspnoea • Fatigue • Nocturnal cough (pink frothy sputum) • wheeze • Cold peripheries • Weight loss Peripheral Oedema :can occur up to thighs, sacrum Ascites

11. SIGNS OF HEART FAILURE • Looks ill and exhausted • Peripheral cyanosis • Peripheral oedema • Cool peripheries • Pulse tachycardia • Narrow blood pressure difference • RAISED JVP

12. Chest: • Bibasal crackles • Pleural effusion • Wheeze Abdomen: • Hepatomegaly • Ascites

13. In Precordium: • Displaced apex beat (LV dilatation) Heart Sounds: • Gallop rhythm • Murmurs of mitral valve • Murmurs of Aortic valve

14. INVESTIGATIONS REMEMBER HEART FAILURE IS A CLINICAL DIAGNOSES Key investigation is to help diagnosis: ECHOCARDIOGRAM: can pick up valvular disease and confirm LV dysfunction. ECG: look for Ischeamia, LVH, AF, Heart block

15. CXR SIGNS • Cardiomegaly (>50% cardiothoracic ratio, heart size is larger than hemi-thorax) • Prominant upper lobe veins • Pleural effusion • Alveolar shadowing/bats wings • Fluid in Horizontal fissure • Kerley B lines

16. MANAGEMENT CHRONIC • Life style changes: • stop smoking • reduce salt intake • reduce weight. • Treat any obvious causes e.g Valvular disease. • Treat any exacerbating factors anaemia, thyroid disease( bradycardia, heart block or AF), infection

17. HEART FAILURE WITH PRESERVED EJECTION FRACTION Manage the conditions such as: • High BP • Ischeamic Heart Disease • Diabetes • Treat any Congestive symptoms with Diuretics

18. DRUG TREATMENT WITH LEFT VENTRICULAR DYSFUNCTION FIRST LINE TREATMENT ACE INHIBITORS e.g. ramipril start low and titrate upward every 2 weeks Keep close eye on U&E Also to add on Beta Blocker e.g Bisoprolol Still consider even for patients with- PVD, COPD- start low and increase slowly.

19. CONTRAINDICATIONS TO ACE-INHIBITOR • COUGH • Renal failure: creatinine >200 • Hyperkaleamia • Hyponatreamia • Hypotension • Aortic stenosis or LV outflow obstruction • Pregnancy • Severe COPD

20. ALTERNATIVE FIRST LINE TREATMENT Consider as an alternative for patient who have contraindications to ACE- INHIBITORS Angiotensin II Receptor Antogonist e.g. Candesartan SE: Hypotension, dizziness, renal impairment Contraindicated in pregnancy

21. If patient remains symptomatic with Ace inhibitor and B blocker consider adding: SECOND LINE TREATMENT Aldosterone Antogonist - e.g. Spironolactone Must monitor Potassium regular and creatinine.This is a Potassium sparing diuretic.

22. DIURETICS You can titrate up and down as needed. Used for symptomatic releif Furosemide are routinely used to relieve symptoms. Dose e.g. is 40mg/24h, can be increased to 80mg SE: Renal impairment and can reduce K.  Can also use in more severe cases Metolazone 5-20mg/24hours or BUMETANIDE

23. WHAT IF CAN’T TOLERATE ACE INHIBITORS AND ANGIOTENSIN II RECEPTOR ANTOGONIST REFER TO CARDIOLOGIST. Specialised treatment: Hydralazine with nitrate +- Digoxin( even if in sinus rhythm) HYPERTENTION WITH HEART FAILURE Use Calcium channel blocker e.g amlodipine

24. ACUTE MANAGEMENT OF HEART FAILURE Sit the patient upright Oxygen maximum flow (if no lung disease) If in severe distress, call on-call aneasthetist IV access ECG Treat any arrhythmias eg: AF Diamorphine 2.5-5mg iv slowly (caution in COPD) Metachlorpramide 10mg iv Furosemide 40-80mg iv slowly

25. GTN spray or 3mcg S/L tablet Don’t give if BP <90 systolic Start GTN infusion if systolic BP >100 Isosorbide dinitrate 2-10mg /hour Increase the infusion rate every 15 mins if BP remains over 100 If patient worsening Repeat Furosemide 40-80mg Consider CPAP If still not improving or if BP DROPS below Systolic 100 consider ICU For inotropic treatment e.g. dobutamine

26. CASE • Background • 75 Years old • Heart Bypass 1990 • Later stented x2 • Angina • AF • Hypothyroidism • Chronic Renal Failure (Cr 150) • Social Background • Lives alone in a house • No home help • Stairs • EX Smoker (28 years ago) • No alcohol

27. PRESENTED TO HOSPITAL Gradual increase SOB over 2-3 weeks. Normal Exercise Tolerance: could manage stairs. Recently unable to do this. Cough with mildly yellow sputum for 2 months. GP treated with antibiotics. No help. Not able to lie flat. Uses 3 pillows. Over last 5-6 weeks Bilateral leg swelling worsening. Swollen scrotum and penis with oedema making it difficult to pass urine. No chest pain.

28. Medication Lisinopril 2.5mg ON Bisoprolol 2.5mMg ON Nicorandil 10mg BD ISMN 40mg BD Levothyroxine 150mcg OD Atorvastatin 10mg ON Esomeprazole 20mg OD GTN Spray Warfarin

29. ON EXAMINATIONS P 80 RR16 SATS 99% RA BP 98/66 CVS/ HS I + II + 0 Murmur Heart Rate Irregular JVP raised RS/ Crackles bilateral bases GI/ SNT ?Ascites Lower limbs B/L Pitting oedema to groin level.

30. INVESTIGATIONS CXR- Cardiomagaly ECG- Irregular, nil acute ECHO MAY 2010 Severe Left Ventricle impairment Moderate right ventricle impairment

31. TREATMENT Fluid restriction 1 litre/day IV Furosemide 120mg BD for 14 days Then Furosemide 120mg po BD & Metalazone 2.5mg po As days went by on high dose treatments patients U&E showed: DAY CREATININE UREA Baseline 198 Day 14 264 23 Day 16 296 25.2 Day 19 348 30 Poor Urine output Increase in oedema Patient deteriorated and made no improvement.

33. THANK YOU Question?

34. B TYPE NATRIURETIC PEPTIDE OR BNP This is a blood test where the reading correlates to degree of heart failure. In patient with suspected heart failure who have not had an Myocardial Infarction. Measure BNP levels: If level >400= Refer Echocardiogram urgently if level 100-400= Refer Echocardiogram within 2 weeks. if levels less than 100= Heart failure is unlikely.