heart failure

1. CHRONIC HEART FAILURE
Department of Cardiology
Yangon General Hospital

2. Definition of Heart Failure (ESC )
 Heart failure is a clinical syndrome characterized by
 typical symptoms (e.g., breathlessness, ankle swelling
and fatigue)
 accompanied by signs (e.g., elevated jugular venous
pressure, pulmonary crackles and peripheral oedema)
 caused by structural and/or functional cardiac
abnormality
 resulting in a reduced cardiac output and/or elevated
intra-cardiac pressure at rest or during stress.

3. Causes of Heart Failure
Coronary Artery
Disease
Ischaemic heart disease
Hypertension
Cardiomyopathy Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Arrhythmogenic right ventricular
cardiomyopathy
Valvular heart disease Valvular stenosis & regurgitation
Drugs Cytotoxic agents
Toxin alcohol, medication, cocaine

4. Causes of Heart Failure
Endocrine Diabetes Mellitus
Hypo/Hyperthyroidism,
Cushing syndrome, Adrenal insufficiency
Phaeochromocytoma
Nutritional Deficiency of thiamine, selenium
Obesity, Cachexia
Infiltrative Sarcoidosis, amyloidosis, haemochromatosis
connective tissue disease
Others Chagas disease
HIV infection
Peripartum cardiomyopathy
End stage renal disease

5. Symptoms and Signs of Heart Failure
Symptoms
 Typical
 Breathlessness
 Orthopnoea
 Paroxysmal nocturnal
dyspnoea
 Reduced exercise
tolerance
 Fatigue, tiredness,
increased time to
recover after exercise
 Ankle swelling
Signs
 More specific
 Elevated jugular venous
pressure
 Hepatojugular reflux
 Third heart sound
(gallop rhythm)
 Laterally displaced
apical impulse

6. New York classification of Heart Failure
(NYHA)
 I - Heart disease present, but no undue dyspnoea
from ordinary activity
 II - Comfortable at rest; dyspnoea during ordinary
activities
 III - Less than ordinary activity causes dyspnoea,
which is limiting
 IV - Dyspnoea present at rest; all activities causes
discomfort

7. Definition of Heart Failure with
reduced, mid-range and preserved ejection fraction
( can be performed at tertiary center )
Type
of HF
HFrEF HFmrEF HFpEF
CRITERIA
1 Symptoms
±Signs
Symptoms ±Signs Symptoms ±Signs
2 LVEF <40
%
LVEF 40-49 % LVEF ≥ 50 %
3 1. Elevated levels of
natriuretic peptides
2. At least one additional
criterion:
a. relevant structural
heart disease (LVH
and/or LAE)
b. diastolic dysfunction
1. Elevated levels of
natriuretic peptides
2. At least one additional
criterion:
a. relevant structural heart
disease (LVH and/or LAE)
b. diastolic dysfunction

8. Diagnostic tests in initial assessment of patients
with newly diagnosed heart failure
 Haemoglobin and WBC
 Urea & electrolytes, creatinine (with estimated GFR)
 Liver function tests (Bilirubin, AST, ALT, GGT)
 Glucose, Haemoglobin A1C
 Lipid profile
 TSH
 Ferritin, Transferrin saturation, Total iron binding capacity
(optional )
 12-lead ECG
 Chest X-ray
 Echocardiogram ( if available )

9. CXR in left ventricular failure
 A - Alveolar oedema
(perihilar bat’s wing
appearance)
 B - Kerley B lines
 C - Cardiomegaly
 D - Dilated prominent
upper lobe veins (upper
lobe diversion)
 E - Pleural Effusion

10. Diagnostic algorithm for a
diagnosis of heart failure of
non-acute onset

11. Patient with Suspected
HF (non-acute onset)
ASSESSMENT OF HF PROBABILITY
1. Clinical history:
 History of CAD (MI, revascularization)
 History of arterial hypertension
 Exposition to cardiotoxic drug/radiation
 Use of diuretics
 Orthopnoea/paroxysmal nocternal dyspnoea
2. Physical examination:
 Rales
 Bilateral ankle oedema
 Heart murmur
 Jugular venous dilatation
 Laterally displaced/broadened apical beat
3. ECG
 Any abnormality

12. ASSESSMENT OF HF PROBABILITY
NATRIURETIC PEPTIDES
• NT-proBNP ≥ 125 pg/mL
• BNP ≥ 35 pg/mL
Assessment of
natriuretic
peptides not
routinely done
in clinical
practice
ECHOCARDIOGRAPHY
≥ 1 present
Yes
If HF confirmed (based on all available data):
Determine aetiology and start appropriate treatment
HF unlikely:
Consider other
diagnosis
All absent
No
Normal

13. Management of chronic heart failure
1. General measures
 Stop smoking
 Stop drinking alcohol
 Eat less salt
 Optimize weight and nutrition
2. Treat the cause
 Dysrhythmias
 Valve disease
3. Treat exacerbating factors
 Anaemia
 Thyroid disease
 Infection
 High blood pressure

14. Management of chronic heart failure
4. Avoid exacerbating factors
 NSAIDs ( fluid retention)
 Verapamil ( Negative inotrope)
5. Vaccination (Annual flu vaccination)
6. Pharmacological therapy
Angiotensin converting enzyme inhibitors (ACEI) /
Angiotensin receptor blockers (ARB)
 Beta blockers
 Mineralocorticoid receptor antagonists
 Diuretics

15. Therapeutic algorithm for a patient
with symptomatic heart failure with
reduced LVEF

17. Drugs : Diuretics
 Loop diuretics
 To relieve symptoms
 PO Furosemide 40 mg/ 24 hour (increase dose
as necessary)
 Side effects: hypokalaemia, renal impairment
 Monitor: Urea and electrolytes

18. Drugs : Diuretics
 Potassium sparing diuretics
 PO Spironolactone 25 mg/24 hour
 Risk of hyperkalaemia in patients with CKD,
patients taking ACEI
 Monitor : Urea and electrolytes
 Thiazide diuretics
 If refractory oedema
 PO Metolazone 5-20 mg/ 24 hour

19. Drugs:
Angiotensin converting enzyme inhibitor (ACEI)
 ACEI
 Improves symptoms and prolong life in patients with left
ventricular systolic dysfunction.
 E.g., Enalapril, Lisinopril, Ramipril
 Start at low dose and increase gradually to maximum target
dose
 Regular monitoring of renal function (serum potassium
and Creatinine)

20. Drugs:
Angiotensin converting enzyme inhibitor (ACEI)
Side Effects
 First dose hypotension
 Renal impairment
 Hyperkalemia
 ACEI-induced Cough
 Angioedema
Contraindications
 bilateral renal artery stenosis
 angioedema with previous
therapy
 Creatinine > 220 umol/l
 K > 5 mmol/L
 severe Aortic stenosis &
Mitral stenosis

21. Drugs: Angiotensin receptor blocker (ARB)
 ARB
 If patient has intolerable ACEI induced cough
 E.g., Candesartan, Valsartan
 Side effects: Hyperkalaemia
 Monitor : Serum potassium, creatinine

22. Drugs : Beta Blockers
 Reduce mortality in heart failure
 Use with caution: Start low, go slow in the absence
of fluid retention
 Wait ≥ 2 weeks between each dose increment
 E.g., Carvedilol, Bisoprolol, Nebivolol, Metoprolol
succinate (CR, XL)

23. Drugs: Mineralocorticoid receptor Antagonists
 Spironolactone
 PO 25 mg / 24 hour
 In patients still symptomatic despite optimal therapy
 Post MI patients with LV systolic dysfunction
 Side effect : hyperkalaemia
 Monitor : Electrolytes
 Eplerenone
 If spironolactone is not tolerated

24. Drugs : Digoxin
 In patients with
 Sinus rhythm, left ventricular systolic dysfunction, signs
and symptoms of heart failure while receiving standard
therapy with ACEI and beta blocker
 AF : to slow the rapid ventricular rate
 Dose : 125 mcg/24 hour (if sinus rhythm)
 Monitor: Urea and electrolytes ( maintain serum potassium
at 4-5 mmol/l)

25. Other drugs
 Combination of hydralazine and isosorbide dinitrate
 If intolerant of ACEI and ARB
 ARNI (Angiotensin Receptor-Neprilysin Inhibitor)
 Sacubitril / Valsartan
 If channel blocker
 Ivabradine ( need to monitor heart rate / benefit in AF
???? )

26. Drugs : Starting dose and target dose

27. Intractable heart failure
 Reassess the cause & precipitating factors like NSAID
 Drug compliance? At maximum dose ?
 In patient management :
 Minimal exertion
 Sodium and fluid restriction (1.5 L/ 24 hour PO)
 IV Furosemide 40-80 mg slowly
 Opiates and IV nitrates (may relieve symptoms)
 Weigh daily (aim reduction of 0.5 kg/day)
 Monitoring of renal function ( beware of hypokalaemia)
 DVT prophylaxis : Heparin + TED stockings

28. Device therapy for heart failure
 Considered for intractable heart failure
 Aim : resynchronization therapy
 Prevent worsening heart failure and prevent sudden cardiac
death
 Available devices :
 Implantable cardioverter defibrillator (ICD)
 Cardiac resynchronization therapy (CRTP and CRTD)
 Assessment at tertiary centre (refer to tertiary centre)
 For recommendation of device therapy
 For implantation of device
 For follow-up after device implantation

29. CRT implantation

30. Summary of heart failure management
 Life style modification
 Optimize medical treatment (Guideline directed
medical therapy – GDMT)
 Treatment of precipitating factors
 Vaccination

31. The End