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Heart Failure (Chronic (Management (CRT (Screenshot 2018-10-11 at 21.04.41…
Heart Failure
Chronic
CHF is a syndrome, so always look for an underlying cause!
common causes:
• Ischemic heart disease 65-75%
• Dilated cardiomyopathy~30%
• valvular heart disease ~ 10 %
• Hypertension ~ 10 %
• Other~5% ( diabetes, Alcohol and drugs (chemotherapy), Arrhythmias, Pericardial disease, Infections (Chagas’ disease)).
Pathophysiological mechanisms
As HF evolves, changes in vascular function, blood volume, and neurohumoral status occur throughout the body.
These changes serve as compensatory mechanisms to help maintain cardiac output (primarily by the Frank-Starling mechanism) and arterial blood pressure (by systemic vasoconstriction).
Cardiac changes during HF include increased end-diastolic volume; ventricular dilatation or hypertrophy; decreased stroke volume and cardiac output; reduced ejection fraction (systolic dysfunction) or impaired filling (diastolic dysfunction).
Compensatory mechanisms during HF
Cardiac: Frank-Starling mechanism, tachycardia, ventricular dilatation, hypertrophy, Ventricular remodeling,
Neuronal: increased sympathetic adrenergic activity, reduced cardiac vagal activity
Hormonal: activation of angiotensin-aldosterone system, vasopressin, catecholamines, and natriuretic peptides
Clinical Manifestations
SYMPTOMS
Typical: Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, Reduced exercise tolerance, Fatigue, Ankle swelling
Less typical: Nocturnal cough, Wheezing, Depression, Loss of appetite, Palpitation, Dizziness, Syncope, Bloated feeling
PHYSICAL SIGNS
More specific: HIGH jugular venous pressure, Hepatojugular reflux, S3 (ventricular gallop), Displaced PMI
Less specific: Weight gain / Weigh loss, Cachexia, Cardiac murmur, pleural effusion, Tachycardia, irregular pulse, tachypnoe, Hepatic enlargement, Ascites, Cold extremities, Oliguria, Cheyne-Stokes respiration
LV Dysfunction
Systolic: Impaired contractility / ejection (EF<40) 2/3 of the patients
diastolic Impaired filling / relaxation (EF>40)
Diagnosis
BNP, NT-pro-BNP
• Plasma natriuretic peptides should be measured to identify those who need echocardiography.
• BNP levels correlate with the severity of HF
Echocardiography
Common echocardiographic abnormalities
Measurement:
LV ejection fraction
Left ventricular function global and focal
End diastolic/systolic diameter
Fractional shortening, Left atrial size
Left ventricular thickness, Valvular structure/function
Mitral diastolic flow profile, Tricuspid regurgitation
Pericardium, Inferior Vena cava
Doppler indices:
E/A waves ratio - restrictive, slowed relaxation, normal
E/Ea -increased, reduced, intermediate
A mitral-A pulm duration
Pulmonary S wave
Vp
E/Vp
Valsalva manoeuver
• ECHO is the method of choice in pts with suspected HF.
• We perform ECHO to establish:
a diagnosis of either HFrEF, HFmrHF or HFpEF
a cause of HF (MI,valvular diseaseetc.)
a severity of HF
pts who would be suitable for pharmacological and device (ICD, CRT), treatment
Laboratory tests (include BNP/NT-pro-BNP)
ECG: ischaemia, arrhythmia
Chest X-ray: Kerley B lines, pulmonary oedema, cardiomegaly
Echocardiography: show ↓ EF and ventricular dilation.
Sometimes: exercise tests, spirometry, CMR, CT, Holter-ECG, invasive coronary angiography, right heart catheterisation, endomiocardial biopsy
New classification
preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF)
poor prognosis in HF
New York Heart Association classification of heart failure.
Focuses on symptoms
Class I: No limitation of physical activity. no symptoms
Class II: Slight limitation, comfortable at rest or with mild exertion.
Class III: Marked limitation, comfortable only at rest.
Class IV: Symptoms are present at rest.
ACC/AHA Classification: Emphasizes evolution and progression of heart failure.
Class A: risk of HF, no structural changes
Class B: structural changes, no symptoms
Class C: structural changes, symptoms
Class D: End-stage symptoms
Management
Nonpharmacologic
• Exercise training for stable HF patients
• Weight loss in obese patients
• Dietary Na restriction (≤ 2 g/day)
• Fluid and free water restriction (≤ 1.5 L/day)
• Minimize medications like (negative inotrops, NSAIDs)
• Smoking cessation and alcohol intake reduction
Pharmacological
ACE inhibitors: (lisinopril, Captopril, ramipril, trandolapril, perindopril, enalapril)
Beta-blockers: (carvedilol, bisoprolol, metoprolol CR, nebivolol)
Aldosterone antagonists: (spironolacton, eplerenon)
Angiotensin II rec. inhibitors: (candesartan, valsartan, losartan)
Ivabradine (HR>70/min., BB intolerance-Iia class indications) Vasodilators
Digoxin Cardiac glycosides
Diuretics: (Furosemide, Metolazone, Bumetanide)
Drugs to avoid in HF patients
NSAIDs: Induce systemic vasoconstriction, counteract ACE inhibitors.
Thiazolidinediones: Contribute to fluid retention. Should be avoided in severe (class III-IV) failure.
Class I antiarrhythmic drugs: Can be proarrhythmic and have inotropic negative effect.
Calcium channel blockers: (avoid Verapamil and Diltiazem).
Other management considerations
• Cardiac resynchronization therapy (CRT)
• Implantable cardioverter-defibrillator (ICD). Significant benefit in NYHA class II -III HF and EF ≤ 35%
• Revascularisation, valvular disease operation, aneurysmectomy
• Mechanical circulatory support.
• Cardiac transplantation.
for HTN pats.
CRT
ACUTE
Precipitants and Causes:
de novo,arrhythmia , Acute coronary syndrome (ACS)
pulmonary embolism, Hypertensive crisis, Cardiac tamponade
Aortis dissection, Surgery, Peripartum cardiomyopathy, Infection (include endocarditis)
COPD/asthma, Anaemia, Kidney dysfunction, Hypo/Hyperthyroidism
Alcohol and drug abuse
Initial assessment:
History/examination
Blood chemistry, Oxygen saturation
Chest X-ray, ECHO (within 48 hours)
ECG, BNP
Monitoring of the patient's vital functions:
Systolic blood pressure, Heart rhythm and rate
Saturation of oxygen, Respiratory rate
Urine output
Monitoring of the patients with AHF:
Intra-arterial line should be considered in pts with hypotension
Pulmonary artery catheter may be considered in pts who, present refractory symptoms (hypotension, hypoperfusion)
Initial management of a patient with AHF
Management of patient with AHF
Oxygen
to treat hypoxaemia (SpO2 <90%, PaO2<60 mmHg)
should not be used routinely in non-hypoxaemic patients
Diuretics
Loop diuretics i.v.
for all pts with signs/symptoms of fluid overload
regularly monitor symptoms, urine output, renal function and electrolytes
the initial dose should be 20-40mg iv furosemide
Opiates (morphine)
useful in patients with pulmonary oedema, ischaemic chest pain
venodilators
reduce sympathetic drive
but depress respiratory drive and nausea may occur
Vasodilators (nitroglycerine)
reduce preload and afterload
increase stroke volume
should be considered for symptomatic relief in AHF pts with SBP > 90mmHg
should be used with caution in pts with significant mitral or aortic stenosis
Inotropes (dobutamine, dopamine, levosimendan, PDE III inhibitors)
to increase cardiac output, blood pressure, improve peripheral perfussion and maintain end-organ function
cause sinus tachycardia, may induce myocardial ischaemia and arrhythmias (monitor ECG, SBP)
Vasopressors (norepinephrine)
to raise blood pressure and redistribute cardiac output from extremities to the vital organs
have adverse effect similar to those of inotropes
Thrombo-embolism prophylaxis
LMWH
Other drugs
In pts with atrial fibrillation:
Digoxin and/or beta-blocker should be considered as first line therapy
Amiodarone may be considered
After stabilization:
In pts with reduced EF <40%:
Diuretic
ACEi / ARB
Beta-blocker
Aldosterone rerceptor antagonist
Digoxin – to control ventricular rate in atrial fibrillation
rapid onset or worsening of symptoms and/or signs of HF
Features of Heart Failure on CXR
Heart enlargement, Pleural Effusion, Re-distribution (alveolar edema), Kerley B lines (short lines near periphery of the lung near the costophrenic angles, and indicate pulmonary congestion secondary to dilation of pulmonary lymphatic vessels), Bronchiolar-alveolar cuffing
Left ventricular systolic dysfunction (LVSD) is commonly caused by IHD but can also occur with valvular heart disease and hypertension.
SyMptoMS: Left-sided S3/S4 gallop, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, Pleural effusions, Pulmonary edema and crackles
Right ventricular systolic dysfunction (RVSD) may be secondary to chronic LVSD but can occur with primary and secondary pulmonary hypertension, right ventricular infarction, arrhythmogenic right ventricular cardiomyopathy and adult congenital heart disease.
symptoms: Jugular venous distension, Hepatojugular reflex, hepatosplenomegaly with characteristic 'nutmeg' liver, pitting edema, Ascites
Systolic HF (systolic dysfunction) is due to a loss of con- tractile strength of the myocardium accompanied by ventricular dilatation. This type of HF is also accompanied by a decrease in normal ventricular emptying
Heart failure with preserved ejection fraction (diastolic dysfunction) occurs when the filling of one or both ventricles is impaired while the emptying capacity is normal.
A clinical syndrome caused by inability of the heart to pump enough blood to maintain fluid and metabolic homeostasis.
clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional abnormality, resulting in a reduced cardiac output and/ or elevated intracardiac pressures.
