3. Definition of Heart Failure CHF
• New York Heart Association (NYHA)
– I no visible signs and symptoms
– II signs and symptoms at high level exercise
– III signs and symptoms at low level exercise
– IV no physical exercise possible, bed rest
necessary
Worldwide used as functional definition of CHF!
March 2013 ghennersdorf DGK ESC SES 3
4. Treatment Goals
IV
II Main treatment goal
for chronic disease
??
??
III ?? I
Main treatment goal
for acute disease HTX option
March 2013 ghennersdorf DGK ESC SES 4
5. Therapeutic objectives
• Acute CHF
Main approach
– Treatment of life threat Vasodilation
Organ protection
– Improvement of life quality Volume control
• Chronic CHF
– Improvement of life quality
– Reduction of Disability
– Increase of longevity
Adding life to years rather than years to life
March 2013 ghennersdorf DGK ESC SES 5
6. Therapeutic options
Acute Heart Failure
March 2013 ghennersdorf DGK ESC SES 6
7. Therapeutic options (ER, ICU)
• Physical approach in cardiogenic pulmonary edema
– Oxygen delivery
– Bed rest / upright position
– Secure (central) venous line
– Urinary catheter
– Blood letting
• Drugs (iv administration)
– Diuretics (short term, furosemide)
– Digitalis (?; fast AF ?)
– Thrombembolic prophylaxis (heparin; PTT necessary)
• Drugs orally (cave hypotension)
– Nitroglycerine sublingually
– Consider ACEI sublingually
March 2013 ghennersdorf DGK ESC SES 7
8. Therapeutic options
(cardiogenic shock)
• Volume expansion under hemodynamic control
– Pulmonary artery cath
– Arterial pressure line
• Mechanical assistance: IABP
• Cathlab: PCI
• Surgery: revascularization
• Drugs
– Catecholamines: Dopamin, Dobutamin
– Phosphodiesterase (PDE)-Inhibitors: Amrinone, Milrinone (not
evidence based)
– Thrombembolic prophylaxis: heparine (PTT)
– Fast acting diuretics
• Acid base control
• Electrolyte contol (potassium)
March 2013 ghennersdorf DGK ESC SES 8
9. Therapeutic options
Chronic Heart Failure
March 2013 ghennersdorf DGK ESC SES 9
11. Therapeutic challenge
Systolic heart failure: mostly common in CHD and RHD
Drugs and recommendations according to guidelines
Diastolic heart failure: mostly common in hypertension
Long term follow up dependent on
treatment of underlying disease
Drugs recommendations not yet established
March 2013 ghennersdorf DGK ESC SES 11
12. Therapeutic options
• First line recommendation: Prevention
– Prevention of CHD, Hypertension, valvular
disease, infections
– Information, home care, transmission of simple
behavior rules:
• Hygiene and clean water supply
• Motion: physical activity, limited sport action
• Nutrition: salt restriction
• Refrain smoking
March 2013 ghennersdorf DGK ESC SES 12
13. Therapeutic options
• Conservative
– RAS modification
• ACE-I
• AT1-receptor antagonists
• Aldosterone antagonists (Eplerenone ®)
– beta-AR competition
• Betablockers
– classical 3D options
• Diuretics (fast acting, medium acting; cave potassium)
• Diet
• Digitalis (?) not first choice!
– Others: (Pulmonary artery Hypertension)
Avoid
• Bosentan
use of
• Sildenafil
NSAIDs
like
COXIBs
March 2013 ghennersdorf DGK ESC SES 13
16. ß-Blockade in CHF
Reduction of adrenergic receptors AR
Betablockade:
NE receptor recovery,
NE Muscle cell; contractility function improves
NE
E
NE
NE
NE Muscle cell; contractility
NE
E
NE
E
NE
E
NE Muscle cell; contractility
E
E
AR Recovery
E
AR Reduction
March 2013 ghennersdorf DGK ESC SES 16
17. ß-Blockade in CHF
Recommended:
ß1-selective drugs like metoprolol, bisoprolol
+ vasodilatation: carvedilol, nevibolol
March 2013 ghennersdorf DGK ESC SES 17
18. Therapeutic options. ACE-I
• Trials
– CONSENSUS 1987 Captopril
– SOLVD 1999 Enalapril
– SAVE 1992 Captopril
– VHEFT 1991 Enalapril/Hydralazin
– CIBIS III 2005 Enalapril/Bisoprolol
Demonstrate highly significant improvement of survival in different stages
of heart failure (II –IV): Evidence Class A - IA
March 2013 ghennersdorf DGK ESC SES 18
23. Therapeutic options
• HTX
– Surgically solved
– Concomitant therapy problems (rejection) solved
– Donor problems unsolved and will persist
But: therapeutic choice for subsets of younger patients
with severe symptoms mostly on
iv therapy and/or ICU care
without chance to recover appropriately.
Bridging procedure desirable
March 2013 ghennersdorf DGK ESC SES 23
26. Heart transplantation
Christian Neethling Barnard
3rd september 1967
original OR theatre
Groote Schuur Hospital
Cape Town SAR
March 2013 ghennersdorf DGK ESC SES 26
27. Artificial heart
Heartmate® for bridging procedures
March 2013 ghennersdorf DGK ESC SES 27
33. Therapeutic challenge: home care
• Medication starts in the hospital
• Medication continues in household enviroment, rural areas
• Doctor‘s contacts rare
• Patient‘s survey difficult.
• Therefore: narrow control schedules concerning
– Nurse directed home care
– Continuous medical education of both patient and personal
(nurses/doctors)
– Outpatient visits
– Establishing telemedical processes
March 2013 ghennersdorf DGK ESC SES 33
34. Therapeutic home care options
• Home care (nurse driven)
– Scheduled visits on regular basis (nurse, AMO)
– Visits following questionnaire
– Data acquisition and transmission
(telemedicine?)
• Severity of symptoms
• Daily activities ability
• Controls
– Medication
– Weight (listing by patient)
– Blood pressure
– other
March 2013 ghennersdorf DGK ESC SES 34
35. CHF Questionnaire; example
How do you feel since last visit? Scale of 10 pts
In your opinion, are there main changes:
breathing
weight gain
Urinary output
palpitation?
How do you think developed your personal daily
activities (DAs)?
worse
same
better
which kind of DAs is mostly impaired?
home
leisure
employment
What about your medication:
intake OK?
complaints?
self made changes?
incompatibilty?
wishes?
Suggestions?
March 2013 ghennersdorf DGK ESC SES 35
36. Heart Network
Patient
Hospital
OPD
District Hospital
Dispensary Home Care
March 2013 ghennersdorf DGK ESC SES 36
37. Heart Network: nurse
Hospital
Nurse
+
home care
March 2013 ghennersdorf DGK ESC SES 37
38. Heart Network: Internet
Patient data file, database: EPF*
Access by authorized personal
throughout the country
*electronic patient file
March 2013 ghennersdorf DGK ESC SES 38
39. Heart Network
• Telecardiology (telemedicine)
– Electronic provision of data transmission
– Generation of medical data in remote areas (rural)
– Overcoming of doctors shortages
– Secure transmission line
– Targets:
• Hospital Centers
• Home care physician
• Home care nurse
• Specialized medical call centers
March 2013 ghennersdorf DGK ESC SES 39
40. Heart Network
• Telemedical patient kit
– Smartphone with Apps (Skype)
– Balance
– ECG device
– Blood pressure device
– Glukose test kit
– Finger tip pulse oxymeter
– Questionnaire
March 2013 ghennersdorf DGK ESC SES 40
