Congestive Heart Failure

Michele Ritter, M.D.Argy – February, 2007

Heart Failure

Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).

The Vicious Cycle of Congestive Heart Failure

Decreased Blood Pressure andDecreased Renal perfusion

Stimulates the Release of renin, Which allows

conversion of Angiotensin

to Angiotensin II. Angiotensin II stimulates

Aldosterone secretion which causes retention of

Na+ and Water, increasing filling pressure

LV Dysfunction causesDecreased cardiac output

Types of Heart Failure

Low-Output Heart Failure Systolic Heart Failure:

decreased cardiac output Decreased Left ventricular ejection fraction

Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic

pressures May have normal LVEF

High-Output Heart Failure Seen with peripheral shunting, low-systemic vascular

resistance, hyperthryoidism, beri-beri, carcinoid, anemia Often have normal cardiac output

Right-Ventricular Failure Seen with pulmonary hypertension, large RV infarctions.

Causes of Low-Output Heart Failure

Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM)

50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) Ischemic heart disease, perpartum, hypertension,

HIV, connective tissue disease, substance abuse, doxorubicin

Hypertension Valvular Heart Disease

Diastolic Dysfunction Hypertension Coronary artery disease Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy

Clinical Presentation of Heart Failure

Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea

(PND) Due to reduction in cardiac ouput:

Fatigue (especially with exertion( Weakness

Physical Examination in Heart Failure

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>

Measuring Jugular Venous Pressure

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

Laboratory Analysis (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.

Chest X-ray in Heart Failure

Cardiomegaly Cephalization of the pulmonary

vessels Kerley B-lines Pleural effusions

Cardiomegaly

Pulmonary vessel congestion

Pulmonary Edema due to Heart Failure

Kerley B lines

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

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

Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.

Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.

Further testing in Heart Failure

Endomyocardial biopsy Not frequently used Really only useful in cases such as viral-

induced cardiomyopathy

Classification of Heart Failure

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

Classification of Heart Failure (cont.)

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

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)

Order of Therapy

1. Loop diuretics2. ACE inhibitor (or ARB if not

tolerated)3. Beta blockers4. Digoxin5. Hydralazine, Nitrate6. Potassium sparing diuretcs

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

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

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, 2nd or 3rd degree block

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.

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.

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-alphaII)

Meds to AVOID in heart failure

NSAIDS Can cause worsening of preexisting HF

Thiazolidinediones Include rosiglitazone (Avandia), and

pioglitazone (Actos) Cause fluid retention that can exacerbate HF

Metformin People with HF who take it are at increased

risk of potentially lethic lactic acidosis

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.

Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.

Management of Refractory Heart Failure

Inotropic drugs: Dobutamine, dopamine, milrinone,

nitroprusside, nitroglycerin Mechanical circulatory support:

Intraaortic balloon pump Left ventricular assist device (LVAD)

Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with

maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.

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.

Acute Decompensaated Heart Failure (cont.)

Causes: Acute MI

Rupture of chordae tendinae/acute mitral valve insufficiency

Volume Overload Transfusions, IV fluids Non-compliance with diuretics, diet (high

salt intake) Worsening valvular defect

Aortic stenosis

Decompensated Heart Failure

Symptoms Severe dyspnea Cough

Clinical Findings Tachypnea Tachycardia Hypertension/Hypotension Crackles on lung exam Increased JVD S3, S4 or new murmur

Labs/Studies in Acute Decompensated Heart Failure

Chemistry, CBC EKG Chest X-ray May consider cardiac enzymes 2D-Echo

Decompensated Heart Failure

Treatment Strict I’s and O’s, 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

Case # 1

A 65-year old male with a history of hypertension, DM, CAD s/p MI and three-vessel CABG in 2002, presents with worsening dyspnea on exertion. He states that he occassionally has a dry cough, but denies any recent chest pain, fevers, N/V. Patient states that he usually can get up a flight of stairs if he stops half-way, but over the last several days, has not been able to climb them at all.

Case # 1 (cont.)

PMH: CAD – MI and CABG in 2002 Hypertension Diabetes Mellitus Hypothyroidism

Allergies: NKDA

Outpatient Meds: Synthroid Metformin Norvasc

Case # 1 (cont.)

Physical Exam: 97.6, 168/72, 99, 28, 93% on RA Gen: Alert and oriented x 3, breathing

rapidly CV: RRR, no murmurs; mod. JVD Resp: Crackles throughout lungs Abd.: soft, nontender, NABS Ext: 2 + pitting edema bilaterally

Case # 1 (cont.)

Labs: Hgb: 13.5 WBC: 8 Platelets: 240 Sodium: 139 Potassium: 3.8 BUN: 18 Cr: 0.8

Trop. I – 0.01 CPK: 120

Case # 1

Case # 1

What studies would you like to check in this patient?

What medications would you like to start/change?

What vital signs do you want to monitor?

Case # 2

A 45-year old obese woman with diabetes mellitus is evaluated for a 1-month history of progressive shortness of breath. Two months ago, she had a flu-like illness with nausea, vomiting, and sweating. She has not followed up with a physician regularly. One of her siblings has “heart problems” and her mother died suddenly and unexpectedly at age 55 years.

Case # 2

On examination her heart rate is 75/min and her blood pressure is 185/93 mm Hg. BMI is 32.9. Jugular venous pressure is mildly elevated. Lung examination reveals a few bibasilar crackles. Cardiac examination reveals regular rhythm, normal S1 and S2 and the presence of an S3. There is mild peripheral edema. An echocardiogram is significant for left ventricular hypertrophy and severely decreased systolic function (left ventricular ejection fraction, 20%) An electrocardiogram shows a previous anteroseptal MI.

Case # 2

Which of the following is the most appropriate next diagnostic test?

(A) Measurement of plasma BNP(B) Serum Protein Electrophoresis(C) Cardiac Stress Test(D) Cardiac catheterization(E) Endomyocardial biopsy