Management of Heart failure

1. Diagnosis and treatment of acute
and chronic heart failure
Dr. M A Hasnat
MBBS,FCPS (Medicine),MD (Cardiology)
Fellow European Society of Cardiology (FESC),
Member Indian Academy Echocardiography (FIAE)
Consultant (Cardiology)
KGH, Dhaka

4. Definition
HF is a clinical syndrome characterized by typical
symptoms (e.g. breathlessness, ankle swelling and
fatigue) that may be accompanied by signs (e.g.
elevated jugular venous pressure, pulmonary
crackles and peripheral oedema) caused by a
structural and/or functional cardiac abnormality,
resulting in a reduced cardiac output and/or
elevated intra-cardiac pressures at rest or during
stress.
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

5. Classification By Definition
• Systolic Heart Failure: Characterized by reduced
ejection fraction and clinically present with left
ventricular failure.
• Diastolic Heart Failure: Characterized by increased
resistance to filling due to increased filling pressures.

6. Classification Based on CO
• High Output Failure: The normal heart fails to
maintain normal or increased output in conditions
like anemia, hyperthyroidism, pregnancy. Usually
right sided failure occurs followed by left sided
failure with presence of shortened circulatory time.
• Low Output Failure: Heart fails to generate adequate
output in conditions like cardiomyopathy, valvular
heart disease, tamponade and bradycardia.

7. Classification by location
• Left Heart Failure: This is characterized by a
reduction in left ventricular output and an increase
in left atrial and pulmonary venous pressure.
• Right Heart Failure: This is characterised by a
reduction in right ventricular output and an increase
in right atrial and systemic venous pressure.
The term ‘cor pulmonale’ is used to describe right
heart failure that is secondary to chronic lung
disease.

8. • Biventricular Heart Failure: In biventricular
failure, both sides of the heart are affected.
• Congestive cardiac failure: Characterized by
congestion in lung and tussue.

9. Forward and Backward HF
• Forward Heart Failure: This results from
inadequate discharge of blood into arterial
system leading to poor tissue perfusion.
• Backward Heart Failure: This results from
failure of one or both ventricles to fill normally
and discharge its contents, causing back
pressure on the atria and venous system.

10. According to onset and severity
• Chronic HF
• Acute Heart Failure (AHF)
– AHF refers to rapid onset or worsening of symptoms
and/or signs of HF.
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

11. Classification Based on EF
• HF with reduced EF (HFrEF)– Ejection fraction <40%.
• Heart failure with mid-range ejection fraction
(HFmrEF) – Ejection Fraction 40-49%
• Heart Failure with Preserved Ejection Fraction
(HFpEF) – Ejection Fraction ≥ 50%.
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

13. ACC/AHA stages of HF
(based on structure and damage to heart)
• Stage A: Patients at risk for heart failure who have not yet
developed structural heart changes (i.e. those with diabetes,
those with coronary disease without prior infarct).
• Stage B: Patients with structural heart disease (i.e. reduced
ejection fraction, left ventricular hypertrophy, chamber
enlargement) who have not yet developed symptoms of heart
failure.
• Stage C: Patients who have developed clinical heart failure.
• Stage D: Patients with refractory heart failure requiring
advanced intervention (i.e. biventricular pacemakers, left
ventricular assist device, transplantation)

14. NYHA functional classification
(based on symptoms or physical activity)
• Class I: No limitation of physical activity. Ordinary
physical activity does not cause undue fatigue,
palpitation or dyspnoea
• Class II: Slight limitation of physical activity. Comfortable
at rest, but ordinary physical activity results in HF
symptoms
• Class III: Marked limitation of physical activity.
Comfortable at rest, but less than ordinary activity results
in HF symptoms
• Class IV: Symptoms of HF present at rest. If any physical
activity is undertaken, discomfort is increased

15. Aetiologies of HF
• Diseased myocardium
• Abnormal loading conditions
• Arrhythmias
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

19. European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

20. European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

21. Essential Initial Investigations:
• Natriuretic peptides
• ECG
• Echocardiography
• CXR
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

22. Recommended other Inv in Patients with HF
• CBC
• Electrolytes, urea, creatinine (with estimated GFR)
• Liver function tests (bilirubin, AST, ALT)
• Glucose, HbA1c
• TSH
• Ferritin, TSAT
• ETT
European Heart Journal (2016) 37, 2129–2200 doi:10.1093/eurheartj/ehw128

24. Management of Patient with HF
• Patient education.
• Treatment of underlying cause.
• Pharmacological treatment.
• Device therapy.
• Prevention of developing overt HF.

27. Other Pharmacological Treatment
• ARB is recommended in symptomatic patients
unable to tolerate an ACE-I.
(patients should also receive a beta-blocker and an MRA).
• Hydralazine and isosorbide dinitrate should be
considered identified black with EF ≤35% or with an LVEF
<45% combined with a dilated LV in NYHA Class III–IV despite
treatment with an ACE-I a beta-blocker and an MRA to reduce
the risk of HF hospitalization and death.

28. • Digoxin may be considered in symptomatic
patients in sinus rhythm despite treatment
with an ACE-I (or ARB), a beta-blocker and an
MRA, to reduce the risk of hospitalization.
• N-3 PUFA preparation may be considered in
symptomatic HF patients.

32. Device Therapy in HF
• Cardiac resynchronization therapy (CRT).
• Implantable cardioverter-defibrillator (ICD).
• Pacemaker.
• Left ventriculas assist device (LVAD).

33. CRT

34. CRT is recommended for symptomatic patients
with HF in sinus rhythm with a QRS duration
≥150 msec and LBBB QRS morphology and with
LVEF ≤35% despite OMT.

35. ICD

36. An ICD is recommended patients who have recovered from a
ventricular arrhythmia causing haemodynamic instability, and
who are expected to survive for >1 year with good functional
status.

37. LVAD

41. Delaying or preventing the development of overt HF or
preventing death before the onset of symptoms
• Treatment of hypertension.
• Treatment with statins.
• Counseling and treatment for smoking cessation and
alcohol intake reduction.
• Treating other risk factors of HF (e.g. obesity,
dysglycaemia).
• ACE-I
• Beta-blocker
• ICD

42. Treatment of co-morbidities

46. Empagliflozin, in patients with diabetes at high cardiovascular risk, reduce
hospitalization for HF and mortality (but not myocardial infarction or stroke).

48. Management of acute heart failure

55. Thank You