Definition , Classification , Patho physiology , Stages of Heart Failure , Clinical Features , Investigations , Treatment

1. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com
CRT 2014
Washington
DC, USA

2.  Definition
 Classification
 Patho physiology
 Stages of Heart Failure
 Clinical Features
 Investigations
 Treatment

3. Definition
•Heart failure is a condition when heart fails to meet the metabolic needs
of the body provided the venous return is adequate.
“Heart failure is a complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the ability of the
ventricle to fill with or eject blood”.
•It has become an epidemic all over the world including our country. As
the life is prolonged with modern management of different
cardiovascular diseases, so is the chance of having more of heart failure
patients.
Source: AHA/ACC Guideline, 2005
Source: ACC/AHA 2005 Guideline Update

4. Classification:
Heart Failure may be classified as follows:
Depending on the time of onset:
Acute Heart Failure: Accelerated hypertension, AMI
Chronic Heart Failure: Cardiomyopathy
Depending on the ventricle involved:
Left Heart Failure: Systemic HTN, MS
Right Heart Failure: Cor-pulmonale, Pulmonary Embolism
Source: ACC/AHA 2005 Guideline Update

5. Classification
Depending on the cardiac output:
Low output failure: Classic heart failure
 High output failure: Thyrotoxicosis, Anemia
Depending on the consequence of the heart failure:
Forward Failure-tissue hypoperfusion
 Backward failure-Congestive heart failure
Source: ACC/AHA 2005 Guideline Update

6. Pathophysiology
Increased workload on Heart
Activation of Compensatory Mechanisms
Compensated Heart Failure
Self-defeating Effects of Compensatory Mechanisms
Decompensated Heart Failure

7. Compensatory Mechanisms
Activation of neurohormonal system
Sympathetic Activation:
 Myocardial Contractility
  Herat Rate
 Vasoconstriction
Activation of RAS system :
 Vasoconstriction
 Intravascular Volume (due to Na+ & fluid retention)
Remodeling of the ventricle:
 Hypertrophy
 Dilatation

8. How compensatory mechanisms are self-defeating?
Sympathetic activity -Energy expenditure
Vasoconstriction- After load
Activation of RAS – Preload-venous congestion
( backward failure)
Hypertrophy – Death of cardiac cells
Dilatation – Wall stress

9. Etiology & Precipitating Factors
Etiological factors:
Different causes of myocardial dysfunction
Systolic dysfunction-IHD, Cardiomyopathy
Diastolic dysfunction-HTN, AS, HCM
 Combined-IHD, Valvular diseases
Sudden load on preserved ventricular function
Ruptured sinus of Valsalva-Acute LV failure
Acute pulmonary embolism - Acute RV failure

10. Precipitating Factors
Precipitating factors:
 Anemia
 Infection-RTI, UTI
 Arrhythmias
 Drugs- β-blockers, Anti-arrhythmic, Anti-cancer

11. How MS leads to Left & Right HF
Mitral Steno sis
Increased LA pressure
Increased pulmonary venous pressure
Atrial fibrillation
Left heart failure
Increased pulmonary arteriolar pressure
Pulmonary arterial HTN
RV hypertrophy
RV failure
Anemia/Infection

12. Stages of Heart Failure
Source: ACC/AHA 2005 Guideline Update
Stage Criteria Example
Stage-A At high risk for heart failure but
without structural heart disease or
symptoms of HF.
Hypertension
Coronary Artery Disease
Diabetes Mellitus
Cardiotoxins
Family history of cardiomyopathy
Stage-B Structural heart disease but without
signs or symptoms of HF.
Previous MI
LV systolic dysfunction
Asymptomatic valvular disease
Stage-C Structural heart disease with prior
or current symptoms of heart
failure.
Known structural heart disease,
Shortness of breath & fatigue,
Reduced exercise tolerance
Stage-D Refractory HF requiring specialized
interventions.
Patients who have marked
symptoms at rest despite maximal
medical therapy

13. Cardinal Symptoms of Heart Failure
1. Undue tiredness
2. Fatigability
3. Reduced exercise tolerance
4. Shortness of breath
5. Awakening from sleep at night
6. Swelling of the leg
1, 2 & 3 represent the features of Forward failure
4, 5, & 6 represents the features of Backward failure

14. Diagnosis of Heart Failure
History:
Physical examination:
Investigations:
Routine:
1.CXR; 2. ECG; 3. Echocardiography; 4. CBC
Selective:
1. Cardiac cath; 2. Coronary angiogram;3. Renal function test;
4. Thyroid function test; 5. Radionucliede study
6. Brain Natriuretic Peptide (BNP): useful marker to identify the patient
with heart failure.

15. Management of Heart Failure:
Principles:
 Treatment of heart failure per se:
 Medical (pharmacological/interventional) treatment
 Surgical treatment
 Electrical- ICD; Resynchronization
 Treatment of the underlying causes:
 Correction of precipitating causes:
Objectives:
 To alleviate the symptoms
 To correct the underlying cause
 To improve prognosis

16. Correction of Precipitating Causes:
Control of the infection
Correction of the anemia
Correction & prevention of arrhythmias
Withdrawal / substitution of offending drugs
Treatment of Underlying Causes:
Revascularization for IHD
Treatment of HTN
Treatment of valvular disease

17. Treatment of HF
Treatment depends on the stage of heart failure.
-Treat HTN -Quit smoking
-Treat lipid disorder -Encourage exercise
-Control of metabolic syndrome
-Discourage alcohol intake
Drugs:
-ACE inhibitors or ARB in appropriate patients
Stage-A:
Stage-B:
- Treat HTN -Quit smoking
- Treat lipid disorder -Encourage exercise
- Discourage alcohol intake
Drugs:
- ACE inhibitors or ARB in appropriate patients
-Beta-blockers in appropriate patients
-Device-ICD

18. Treatment of HF
Stage-C:
-Treat HTN -Quit smoking
-Treat lipid disorder -Encourage exercise
-Discourage alcohol intake -Dietary sodium restriction
Drugs for routine use:
-Diuretics
-ACE inhibitors
-Beta-blockers
Drugs in selected patients:
-Aldosterone antagonists
-ARB
-Digitalis
-Hydralazine/Nitrates
Devices in selected patients:
-Biventricular pacing
-ICD

19. Treatment of HF
Stage-D:
-Treat HTN -Quit smoking
-Treat lipid disorder -Encourage exercise
-Discourage alcohol intake -Dietary sodium restriction
Options:
Mechanical assist devices
Heart transplantation
Continuous I.V inotropic infusion
Compassionate end of life care

20. Drugs Used in HF Management:
Conventional Drugs:
♣ Diuretic-
Loop diuretics- Frusemide, Torsemide
Thiazides- Hydrochlorothiazide, Chlorthalidone,METOLAZONE
Potassium sparing- SPIRANOLACTONE, Triamterene,amioloride
♣ ACE Inhibitors- Captopril,Lisinopril
♣ ARBS- Losartan, Valsartan
♣ Vasodilators -Nitrates, Hydralizine
♣ Beta-blockers-Carvidolol,Metoprolol Succinate
♣ Inotrops (Digoxin, Dobutamine, Noradrenaline)

21. Newer Drugs:
 Recombinant human type B natriuretic peptide –
NESIRITIDE
 Neutral endopeptidase inhibitors: Omapatrilet,
Sampatrilet, Candoxatrilat
 Calcium sensitizers- Levosimendan
Nesiritide:
 Recombinant human B type natriuretic peptide
 Nesiritide vs. Nitroglycerine: Nesiritide reduces right
atrial pressure, PCWP, cardiac index greater than
Nitroglycerine. Offers greater relief of dyspnoea than
Nitroglycerine.
Drugs Used in HF Management

22.  Stem cell therapy
 Stem cell regeneration
 Replace or repair myocardial cells using gene therapy
Further Therapy

23. Drugs Symptomatic Relief Prognostic improvement
Frusemide + -
Thiazide + -
Spironolactone + +
ACE inhibitors + +
ARBs + +
Beta-blockers + +
Digoxin + -
Drugs for Heart Failure

24. MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Heart Failure)
 To see the effect of Metoprolol Succinate on mortality,
hospitalization & other clinical events in chronic heart
failure.
 3991 patients; follow up I year.
 Dose 12.5- 25 mg/d 200mg/d
 Significantly fewer cardiovascular death compared with
placebo group.
JAMA 2001

25. COMET (Carvedilol or Metoprolol European Trial):
Purpose:
To compare the effects of Carvediol and Metoprolol on clinical outcome in patients
with heart failure.
No. of patients:
3029
Treatment regimen:
Carvedilol, titrated from 6.25mg to 25 mg b.i.d, or Metoprolol Tertarate IR, titrated
from 12.5 mg to 50mg b.i.d.
Result:
In the Carvedilol group, 34% of patients died compared to 40% in the Metoprolol IR
group.
Lancet 2003

26. COPERNICUS (Carvedilol Prospective Randomized Cumulative Survival Trial):
 To see the effects of Carvedilol on mortality in patients
with severe heart failure.
 No of patients:
2289
 Treatment regimen:
Carvedilol 3.125 mg b. d 25mg b. d or placebo
 Result:
35% decrease in the risk of death in the Carvedilol group
NEJM 2001

27. CONSENSUS (Cooperative North Scandinavian Enalapril Survival Study) :
Purpose:
To investigate the effect of Enalapril, in addition to conventional therapy, on mortality
in severe congestive heart failure.
No. of patients:
253
Treatment regimen:
Enalapril, 2.5mg/day up to 20 mg bid, or placebo.
Result:
Crude mortality was reduced by 40% in the Enalapril group compared to placebo
group.
AJC 1992

28. Purpose:
To compare the effects of 2 Lisinopril dosages on mortality and Morbidity in
patients with chronic heart failure.
No. of patients:
3164
Treatment regime:
Lisinopril, 2.5 or 5mg once daily, plus Lisinopril, upto 30mg, or placebo once
daily.
Result:
Mortality was 8% lower in high-dose group than in low-dose group.
EHJ 1999
ATLAS (Assessment of Treatment with Lisinopril And Survival):

29. ELITE II (Evaluation of Losartan In The Elderly):
Purpose:
To compare the effects of Losartan or Captopril on all-cause mortality &,
secondary, on sudden cardiac death and/or resuscitated cardiac arrest in
patients with symptomatic Heart failure.
No. of patients:
3152
Treatment regimen:
Losartan, 12.5mg titrated as tolerated to 50mg once daily, or Captopril, 12.5 mg
titrated as tolerated to 50mg t. i. d.
Result:
No significant differences in all-cause mortality, sudden death or resuscitated
cardiac arrest with slight favour for Losartan.
Lancet 2000.

30. Val-HeFT(Valsartan Heart failure Trial)
 Purpose: To investigate the effects of valsartan on
mortality, morbidity and quality of life in patients treated
with ACEI
 Patients: 5010; >18yrs, NYHA II- IV
 Dose: valsartan 40mg bd- 160mg bd
 Placebo controlled
 Result: Significantly decreased mortality and morbidity;
improved NYHA class,EF,signs & symptoms of HF and
quality of life
NEJM 2001

31. DIG (Digitalis Investigation Group)
Purpose:
To investigate the effects of digoxin on mortality as well as on hospitalization in heart
failure patients
No. of patients:
5548
Result:
Digoxin in low doses reduces hospitalization & mortality.
EHJ 2006

32. Management of End-stage/ Refractory HF:
When symptoms of heart failure persist or experience rapid recurrence of symptoms
despite optimal medical therapy, these group of patients are considered to have end-
stage HF or refractory HF.
Management:
Step-1: Hospitalization.
Step-2: Low doses of a loop diuretic combined with moderate dietary sodium
restriction.
Step-3: Progressive increments in the doses of a loop diuretic & frequently the addition
of a second diuretic that has a complementary mode of action.
Step-4: Intravenous dopamine or dobutamine.

33. Re-synchronization Therapy:
•In approximately 30% of patients with heart failure, the disease process not only
depresses cardiac contractility but also affects the conduction pathway. Such
dyssyncrony has been associated with clinical instability and an increased risk of death
in patients with HF.
•Cardiac re-synchronization reduces the degree of ventricular dyssyncrony, increase in
LVEF, decrease LV end-diastolic dimension and also decrease in the magnitude of
mitral regurgitation. As a result, there occur significant improvement in functional
capacity, clinical status, and quality of life.

34. Indication of Cardiac Resynchronization Therapy
 Severe heart failure (NYHA-III&IV)
 LBBB
 QRS width >120 msec.
 Echocardiography :evidence of in coordinate LV
contraction

35. Resynchronization

36. Cardiac Transplantation
 Severe symptomatic despite maximal medical
treatment.
 Freedom from other major diseases e.g., DM,
renal failure, malignancy, pulmonary disease.
 One year survival 90%
Five year survival 60%.

37.  Heart failure is a disease of wide spectrum
 Pathophysiologically heart failure is considered
under a single umbrella.
 Etiology and causes are so varied that heart
failure touches almost every chapter of
cardiology.

38.  Diagnostically, it is not a formidable
problem,though assessment of the course of the
disease demands meticulous observation and
judgment from the physicians

39.  Management of heart failure now progressed a long
way and still is evolving.
 There are so many options available that one must
be vigilant to keep pace with the evolving concepts
of management.

40. Recommendations for Biomarkers in HF

41. Recommendations for Noninvasive Cardiac Imaging

42. Recommendations for Invasive Evaluation

43. Recommendations for Treatment of Stage B HF

44. Stage C HFrEF: evidence-based, guideline-directed medical therapy

45. Recommendations for Pharmacological Therapy for Management of Stage C
HFrEF.

46. Recommendations for Treatment of HFpEF

47. Recommendations for Device Therapy for Management of Stage C HF.

48. Indications for CRT therapy algorithm

49. Recommendations for Inotropic Support, MCS, and Cardiac Transplantation.

50. Stages in the development of HF and recommended therapy by stage.

51. Classification of patients presenting with acutely decompensated
heart failure.

52. Recommendations for Therapies in the Hospitalized HF Patient

53. Recommendations for Hospital Discharge

54. Pharmacological management of patients with newly discovered AF.
AF indicates atrial fibrillation; and HF, heart failure.

55. Pharmacological management of patients with recurrent paroxysmal AF. AF indicates atrial
fibrillation.

56. Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF.

57. Thank Youdrtoufiq19711@yahoo.com
Asia Pacific Congress of
Hypertension, 2014, February
Cebu city,
Phillipines
Seminar on Management
of Hypertension,
Gulshan, Dhaka