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Heart failure 2013 Therapy

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Heart failure 2013 Therapy

  1. 1. Medical Science Tanzania Cardiology Lectures Congestive Heart Failure 3. Treatment Prof. Hennersdorf SES March 2013 ghennersdorf DGK ESC SES 1
  2. 2. General signs and symptoms March 2013 ghennersdorf DGK ESC SES 2
  3. 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. 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. 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. 6. Therapeutic options Acute Heart Failure March 2013 ghennersdorf DGK ESC SES 6
  7. 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. 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. 9. Therapeutic options Chronic Heart Failure March 2013 ghennersdorf DGK ESC SES 9
  10. 10. Evidence March 2013 ghennersdorf DGK ESC SES 10
  11. 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. 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. 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
  14. 14. ß-Blockade in CHF March 2013 ghennersdorf DGK ESC SES 14
  15. 15. ß-Blockade in CHF March 2013 ghennersdorf DGK ESC SES 15
  16. 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. 17. ß-Blockade in CHF Recommended: ß1-selective drugs like metoprolol, bisoprolol + vasodilatation: carvedilol, nevibolol March 2013 ghennersdorf DGK ESC SES 17
  18. 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
  19. 19. Dosage recommendations March 2013 ghennersdorf DGK ESC SES 19
  20. 20. Dosage recommendations March 2013 ghennersdorf DGK ESC SES 20
  21. 21. Improvement of HF in cardiac CXR before treatment after treatment March 2013 ghennersdorf DGK ESC SES 21
  22. 22. Therapeutic options • Surgical – Heart transplantation, bridging – Cardiomyoplasty • Resynchronizing pacemaker therapy (CRT) • Stem cell replacement March 2013 ghennersdorf DGK ESC SES 22
  23. 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
  24. 24. Heart transplantation HTX March 2013 ghennersdorf DGK ESC SES 24
  25. 25. Heart transplantation March 2013 ghennersdorf DGK ESC SES 25
  26. 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. 27. Artificial heart Heartmate® for bridging procedures March 2013 ghennersdorf DGK ESC SES 27
  28. 28. Survival after HTX March 2013 ghennersdorf DGK ESC SES 28
  29. 29. Therapeutic options: cardiac resynchronization therapy CRT March 2013 ghennersdorf DGK ESC SES 29
  30. 30. Therapeutic options March 2013 ghennersdorf DGK ESC SES 30
  31. 31. Therapeutic options: resynchronization therapy March 2013 ghennersdorf DGK ESC SES 31
  32. 32. Therapeutic options: stem cells March 2013 ghennersdorf DGK ESC SES 32
  33. 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. 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. 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. 36. Heart Network Patient Hospital OPD District Hospital Dispensary Home Care March 2013 ghennersdorf DGK ESC SES 36
  37. 37. Heart Network: nurse Hospital Nurse + home care March 2013 ghennersdorf DGK ESC SES 37
  38. 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. 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. 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
  41. 41. The End March 2013 ghennersdorf DGK ESC SES 41

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