Heart Failure       Overview      Salah Abusin, MD, MRCP          Cardiology Fellow             Chicago, IL          Secre...
Definition• complex clinical syndrome characterized by  impaired myocardial performance and  progressive activation of the...
Stage A• Stage A:  – patients at high risk for developing heart failure with    no structural heart disease• Examples  –  ...
Stage B• Patients with structural heart disease who have  not yet developed symptoms of heart failure• Examples  – previou...
Stage C• Patients with past or current symptoms of  heart failure associated with underlying  structural heart disease• Ex...
Stage D• Patients with end-stage heart failure who  require specialized advanced treatment• who have marked symptoms at re...
NYHA Classification of HF
Causes of HF• Valvular Heart Disease• Ischemic Cardiomyopathy• Non Ischemic Cardiomyopathy  – Dilated CMP  – Hypertensive ...
HF Symptoms• Classic Symptoms• Dyspnea, usually with exertion.• Orthopnea (i.e., dyspnea when lying down,  usually describ...
Symptoms of HF• Fatigue and low exercise tolerance are common  complaints in patients with heart failure.• Dizziness may o...
Signs of HF• Neck  – Elevated Jugular Venous Pressure• Chest Examination  – Lung Crackles  – Dullness at the lung bases co...
Signs of HF• Displaced Cardiac Apex• Loud S2 (Pulmonary Hypertension)• Specific murmurs in patients with valvular  heart d...
ECG•   Signs of prior MI•   Chamber enlargement and hypertrophy•   heart block•   Arrhythmias•   Pericardial Effusion
Chest Xray
Echocardiography• Establishes the diagnosis most of the time• Allows assessment of abnormalities of cardiac  structure and...
Left Ventricular Function•   Ejection Fraction•   Equals Stroke Volume/End Diastolic Volume•   Expressed as a percentage• ...
Case Examples• Normal Echo
Severe LV dysfunction     EF 10-15%
Severe RV dysfunction
Hypertrophic Cardiomyopathy
Severe Mitral Stenosis
LAD MI
Cardiac Catheterization• Coronary Angiography  – To diagnose ischemic cardiomyopathy  – Prior to Valve Surgery in patients...
Management• Definitive Management depends on the  underlying cause• Medical Therapy  – Acute  – Chronic• Non Medical Thera...
Valvular Heart Disease• Mitral Stenosis  – Diuretics to relieve pulmonary congestion  – Beta Blockers     • for rate contr...
• Aortic Stenosis  – Aortic Valve Replacement  – Percutaneous Aortic Valve Replacement in non    surgical candidates• Prim...
Dilated Cardiomyopathy          Systolic Heart Failure• Acute Medical Therapy  – Oxygen  – Diuretics  – Intravenous vasodi...
Chronic Medical Therapy• ACE inhibitors    – ARB (Angiotensin Blockers) if patient cannot      tolerate ACE inhibitors•   ...
ACE Inhibitors• Proven in multiple clinical trials to improve  mortality and morbidity due to Heart Failure• Examples  – L...
Beta blockers• Proven in multiple clinical trials to improve  mortality and morbidity due to Heart Failure  – Metoprolol, ...
Spironolactone• Proven in multiple clinical trials to improve  mortality and morbidity due to Heart Failure• Dosage: 25mg ...
Digoxin• Reduces rates of rehospitalization with heart  failure• Not proven to reduce mortality from HF• Avoid in patients...
Anticoagulation• Indications  – LV thrombus  – Patients with Atrial Fibrillation and Mitral Stenosis  – Consider in all pa...
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Heart failure

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Heart failure

  1. 1. Heart Failure Overview Salah Abusin, MD, MRCP Cardiology Fellow Chicago, IL Secretary GeneralSudanese American Medical Association
  2. 2. Definition• complex clinical syndrome characterized by impaired myocardial performance and progressive activation of the neuroendocrine system leading to circulatory insufficiency and congestion.
  3. 3. Stage A• Stage A: – patients at high risk for developing heart failure with no structural heart disease• Examples – hypertension – atherosclerotic disease – Diabetes – Obesity – metabolic syndrome – Patients using cardiotoxins – with FHx CM
  4. 4. Stage B• Patients with structural heart disease who have not yet developed symptoms of heart failure• Examples – previous MI – LV remodeling including LVH and low EF – asymptomatic valvular disease
  5. 5. Stage C• Patients with past or current symptoms of heart failure associated with underlying structural heart disease• Examples – known structural heart disease and shortness of breath and fatigue, reduced exercise tolerance
  6. 6. Stage D• Patients with end-stage heart failure who require specialized advanced treatment• who have marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)
  7. 7. NYHA Classification of HF
  8. 8. Causes of HF• Valvular Heart Disease• Ischemic Cardiomyopathy• Non Ischemic Cardiomyopathy – Dilated CMP – Hypertensive CMP – Hypertrophic CMP• Other
  9. 9. HF Symptoms• Classic Symptoms• Dyspnea, usually with exertion.• Orthopnea (i.e., dyspnea when lying down, usually described as number of pillows used while sleeping) is typical with more advanced cases of LV dysfunction or in decompensated heart failure.• Paroxysmal nocturnal dyspnea (PND)
  10. 10. Symptoms of HF• Fatigue and low exercise tolerance are common complaints in patients with heart failure.• Dizziness may occur in the setting of impaired perfusion, but is more commonly iatrogenic (i.e., related to the use of heart failure medications).• Palpitations and syncope may occur in patients with underlying arrhythmia and require prompt evaluation.• Anorexia and abdominal pain are common symptoms of• Other cough, insomnia, and depressed mood.
  11. 11. Signs of HF• Neck – Elevated Jugular Venous Pressure• Chest Examination – Lung Crackles – Dullness at the lung bases consistent with pleural effusion• Abdomen – Ascites – Hepatomegaly • Tender in acute HF • pulsatile liver in severe Tricuspid Regurgitation
  12. 12. Signs of HF• Displaced Cardiac Apex• Loud S2 (Pulmonary Hypertension)• Specific murmurs in patients with valvular heart disease• A third heart sound (S3 gallop)
  13. 13. ECG• Signs of prior MI• Chamber enlargement and hypertrophy• heart block• Arrhythmias• Pericardial Effusion
  14. 14. Chest Xray
  15. 15. Echocardiography• Establishes the diagnosis most of the time• Allows assessment of abnormalities of cardiac structure and function• Left Ventricular systolic and diastolic function• Right Ventricular size and function• Left and Right Atrial Size• Severity of valvular lesions• IVC size
  16. 16. Left Ventricular Function• Ejection Fraction• Equals Stroke Volume/End Diastolic Volume• Expressed as a percentage• Normal = 55 -65%• Systolic Heart Failure if EF <50% – Or HF with reduced EF• Heart Failure with preserved EF if EF>50%
  17. 17. Case Examples• Normal Echo
  18. 18. Severe LV dysfunction EF 10-15%
  19. 19. Severe RV dysfunction
  20. 20. Hypertrophic Cardiomyopathy
  21. 21. Severe Mitral Stenosis
  22. 22. LAD MI
  23. 23. Cardiac Catheterization• Coronary Angiography – To diagnose ischemic cardiomyopathy – Prior to Valve Surgery in patients > 40 or those <40 with risk factors• Right/Left Heart Catheterization – Assess Hemodynamics – Measure PVR and reversibility with Vasodilators• Endomyocardial Biopsy – In select patients
  24. 24. Management• Definitive Management depends on the underlying cause• Medical Therapy – Acute – Chronic• Non Medical Therapy – Cardiac Surgery – Device Therapy
  25. 25. Valvular Heart Disease• Mitral Stenosis – Diuretics to relieve pulmonary congestion – Beta Blockers • for rate control in the event of atrial fibrillation – Anticoagulation • For all patients with atrial fibrillation – Percutaneous Balloon Mitral Valvuloplasty for select patients – Mitral Valve Surgery
  26. 26. • Aortic Stenosis – Aortic Valve Replacement – Percutaneous Aortic Valve Replacement in non surgical candidates• Primary Mitral Regurgitation – Afterload reduction with vasodilators – Mitral Valve Surgery• Aortic Valve Regurgitation – Afterload reduction with vasodilators – Mitral Valve Surgery
  27. 27. Dilated Cardiomyopathy Systolic Heart Failure• Acute Medical Therapy – Oxygen – Diuretics – Intravenous vasodilators • Nitroglycerin • Nesiritide • Nitroprusside – Inotropic Therapy • Milrinone • Dobutamine
  28. 28. Chronic Medical Therapy• ACE inhibitors – ARB (Angiotensin Blockers) if patient cannot tolerate ACE inhibitors• Beta blockers• Spironolactone• Digoxin• Anticoagulation
  29. 29. ACE Inhibitors• Proven in multiple clinical trials to improve mortality and morbidity due to Heart Failure• Examples – Lisinopril, Enalapril• Side Effects – Increase Creatinine – Hyperkalemia – Cough – Hypotension – Angioedema
  30. 30. Beta blockers• Proven in multiple clinical trials to improve mortality and morbidity due to Heart Failure – Metoprolol, carvedilol, bisoprolol• Side Effects – bradycardia – hypotension – fatigue – Hypotension – Angioedema
  31. 31. Spironolactone• Proven in multiple clinical trials to improve mortality and morbidity due to Heart Failure• Dosage: 25mg once daily (no uptitration)• Side Effects – hyperkalemia – Painful gynecomastia
  32. 32. Digoxin• Reduces rates of rehospitalization with heart failure• Not proven to reduce mortality from HF• Avoid in patients with renal failure• Dosage 0.125mg once daily• Narrow therapeutic window• Digoxin toxicity
  33. 33. Anticoagulation• Indications – LV thrombus – Patients with Atrial Fibrillation and Mitral Stenosis – Consider in all patients with Non valvular atrial fibrillation and HF• Warfarin• Novel anticoagulants – Rivoraxaban – Dabigatran

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