HEART FAILURE“pump failure”

DEFINITION

Heart failure is the inability of the heart to supply adequate blood flow and therefore oxygen delivery to the peripheral tissues and organs

Cardiac output is about 5 l /min at rest

Increases to upto 25 l/ min

Heart failure occurs when the heart is unable to meet the demand

EPIDEMIOLOGY Only cardiovascular disease with

increasing incidence and prevalance

due to Aging population Increased survival after MI--thrombolysis Improvement of medical and surgical

treatment

Important cause of morbidity and mortality 1 yr mortality –10 – 20 % NYHA class 1V -- > 50 % 4 yr mortality –50 %Debilitating disease Significant decrease in quality of life• Due to symptoms• Decrease functional capabilities• Frequent hospitalizations

CLASSIFICATION OF HEART FAILUREThis is based on: How rapid symptoms develop---acute HF ---chronic HF Which ventricle is involved---right side HF ---left side HF Over all cardiac output---systolic HF ---diastolic HF

CLASSIFICATION ACCORDING TO ONSET OF SYMPTOMS:

Acute heart failure--characterized by a rapid onset of heart failure that may

occur following 1- MI 2-myocarditis 3-arrythmias 4- infection 5- PEIf it is not fatal may progress to chronic heart failure

Chronic heart failureThis results from the heart undergoing

adaptive responses to precipitating cause and this cardiac response leads to impaired function.

1- anemia2-thyrotoxicosis3-non compliance to medications4- diet—high salt

ETIOLOGY Myocardial infarction Coronary artery disease Valvular heart disease Idiopathic cardiomyopathy Viral or bacterial cardiomyopathy myocarditis

ETIOLOGY cont. Pericarditis Arryhthmias Hypertension Thyroid disease Pregnancy Septic shock

ETIOLOGY cont. Toxins—anthracyclines

amphetamine

cocaine Metabolic---haemachromatosis

wilson,s disease

pheochromocytoma

SYMPTOMS cont.{ FACES} Fatigue Activity decrease Cough { specially supine,frothy red sputum Edema Shortness of breath { NYHA }

SYMPTOMS

NYHA classification of dyspnoe Class 1—no shortness of breath {SOB} Class 11—SOB on severe exertion Class 111—SOB on mild exertion Class 1v---SOB at rest

Heart failure management issues High mortality High readmission rates Poor Rx adherance On going symptoms Reduced quality of life Dose adjustment in the elderly

Heart failure therapeutic goals 1ry goal = reduce symptoms Improve quality of life Reduce hospitalization Prevent sudden death

DIET approach to the pt. with heart failureD—diagnose---eteiology ---severity of LV dysfunctionI –initiate---diuretics { thiazide , frusemide } ---beta blockers ---ACEI ---digoxin ---spironolactone

E—educate----diet

---exercise

---life style

T---titrate---optimize ACEI

---optimize beta blockers

General measuresCorrect precipitating causes Treat ischemia Control hypertension D/C smoking Treat lipid abnormality Treat and control hypertension

Low salt dietFluid restrictionRegular exerciseUpright position to reduce pulmonary

congestionProphylactic anticoaggulationAvoid –ve inatropic drugs

Identify triggers

Acute sudden onset Chronic gradual onset

ischemia anemia

arrythmia thyrotoxicosis

infection Non compliance

P.E diet

Acute valvular pathology

Drugs like NSAID

INVESTIGATION CBC U+E LFT Cardiac enzymes CXR ECG Echocardiogram

TREATMENT Diuretics Digoxin ACE inhibitors Vasodilators Beta blockers

DRUGSDiuretics ---thiazide diuretic

---frusemide {loop diuretic}

----spironolactone { K sparing} Titrate to euvolumic state Maintain ideal body wt ={ dry wt= normal

JVP / trace or no pedal edema}

ACEI Cornerstone in the Rx of heart failure Continue indefinitely if EF < 40 % Rx for all asymptomatic pts with EF < 35% Rx for all symptomatic pts with EF =35% Use max. tolerated dose

ACEI cont.. Captopril---capoten Enalapril----renetic Lisinopril----zestril Fosinopril---staril

Angiotensin receptor blockers Same action and benefits as ACEI Used in pts who cannot tolerate ACEI due to

side effects Candesartan Irbesartan Losartan Valsartan Telemisartan

Beta blockers Titrate to max. tolerated dose Continue indefinitely Bisoprolol Carvidelol metaprolol

patient selection for successful beta blocker initiation

Stable symptoms Stable background heart failure medication No hypotension No bradycardia Euvolumic status Start low and titrate slowly

Patients with heart failure who should NOT be started on beta blockers

Bronchospastic pulmonary disease Severe bradycardia High degree A / V block Sick sinus syndrome NYHA class 1V Pts. Who require IV therapy for HF Hospitalized pts specially for worsening HF Unstable symptoms

Digoxin For persisting symptoms in systolic

dysfunction For symptomatic and rate control of AF To decrease the dose in elderly and pts

with renal failure

Aldosterone antagonistSpironolactone Add to ACEI , diuretics , beta blockers ,+/-

digoxin Used in NYHA class 111 and 1V CHF EF < 35% It leads to 30 % ↓ in death from

progressive HF

Cardiac resynchronization therapy {CRT}

ACC / AHA guidline summary– management of pts with current or prior symptoms of heart failure and a reduced left ventricular EF

Diuretics and salt restrictions for fluid retention

ACE I in all pts unless CI Beta blockers in all stable pts , unless CI

Three beta blockers proven to reduce mortality should be used…

Metaprolol Bisoprolol CarvidelolDrugs that adversely affect the pts should be

avoided or withdrawn if possible…• NSAID• Most antiarrythmic drugs• Most calcium channel blockers

Angiotensin 11 receptor blockers are used in pts who cannot tolerate ACEI. Two drugs which are approved are

• Candesartan

• larsartanAn implantable cardioverter-defibrillator

ICD for 2ry prevention to prolong survival in pts with h/o cardiac arrest , vent. Fib.

Drugs that should be avoided or used with caution

NSAID Thiozolidindione group PDE-5 inhibitors—sildenafil Antiarryhtmics