LVF,Left Ventricular Failure.Heart Failure,ALVF.

1. LEFT VENTRICULAR FAILURE
–AN UPDATE.
Presenter: Dr Hasan Mahmud Iqbal
MD Cardiology.Thesis Part.
NHFH&RI.

2. Defining Heart Failure…
Ref: 1. Braunwald’s Heart Disease: A textbook of cardiovascular medicine, 9th Edition.2012.
2. Hurst’s The Heart, 14th Edition.2017.

3. LeftVentricular Failure…

4. Incidence & Prevalence…

7. Ref: Wang TJ, et al. The epidemiology of ‘‘asymptomatic’’ left ventricular
systolic dysfunction: implications for screening. Ann Intern Med 2003;
138:907–916.
Natural
History of HF
Patient:

8. Etiology

9. Etiology Of LeftVentricular Failure
Loss of muscles: •Volume over
load:
Pressure
overload:
Restricted Filling:
•Post MI,
•Chronic ischemia
•Connective
tissue diseases
•Infection,
•Poisons
(alcohol,cobalt,
doxorubicin)
•Regurgitate valve
•High output
status
•Systemic
hypertension
•Outflow
obstruction
•Pericardial
diseases
•Restrictive
cardiomyopathy
•
•Tachyarrhythmia

11. Pathophysiology…

12. • Neurohormonal activation
Activation of the sympathetic nervous system.

13. • Activation of the Renin-Angiotensin System:
Renal hypoperfusion and sympathetic stimulation of the kidneys result in
increased production of renin by the juxtaglomerular apparatus.
Renin transform angiotensinogen into the angiotensin I, which is
subsequently cleaved by angiotensin-converting enzyme (ACE) to the biologically
active angiotensin II.
Angiotensin II stimulates aldosterone production by the zona glomerulosa of
the adrenal cortex, which in turn promotes reabsorption of sodium in exchange for
potassium in the distal nephron. Chronically, aldosterone results in the promotion of
hypertrophy and fibrosis in the vasculature and myocardium, endothelial dysfunction,
and inhibition of norepinephrine uptake.

14. Other neurohormonal derangements.

15. Pathophysiology…

16. Neurohormoral activation and compensatory mechanisms in heart failure.

17. Functional Classification of HF:
ACC/AHA classification of heart failure:
Stage A:
Stage B:
Stage C
Stage D:

18. The New York Heart Association (NYHA) functional
classification of HF:

19. The Killip classification- Grades the severity of signs of
decompensated heart failure in the post-acute coronary syndrome
setting and is highly predictive of 30-day mortality.

21. Categorization Of Left Ventricular Failure…
Systolic Diastolic Both
Impaired contractility
of the left
ventricle(EF%)
Associated with
chamber dilation
Poor ventricular
filling and high
LVEDP.
left ventricular
hypertrophy-stiff,
noncompliant
ventricle
Often coexist,
particularly in
patients with
coronary artery
disease.

22. Categorization Of Left Ventricular Failure…
Acute Chronic Acute on
chronic LVF
1.Acute MI
2. Acute native valve
failure e.g Chordal
rupture, Endocarditis
3. Acute myocarditis
1.Ischemic cardiomyopathy
2.Dilated cardiomyopathy.
3.Hypertensive and diabetic
cardiomyopathy
4.Valvular disorders
5.Thiamine deficiency
Infection
Viral
Bacterial

23. General approach for LVF Patient…

24. History :
Physical Examination:
Discussed later on.

25. 12lead ECG Chest X-Ray (P/A) Blood:
It may reveal-
-MI
- left ventricular
hypertrophy(LVH)
- Arrhythmia e.g AF
-IHD
- Enlarged hilar vessels
- Ground glass/Reticular
shadowing of alveolar
edema
-Prominence of upper
lobe vessels
-Septal or Kerley’s B
line
-Pulm. oedema
-NT Pro -BNP
-Complete blood count
-Blood Urea
-Serum Electrolytes
-Serum Creatinine
-Blood sugar
-TSH

26. Class I In patients with dyspnea, measurement of BNP or NT-pro
BNP is useful to support a diagnosis or exclusion of HF.
Class I Measurement of BNP or NT-proBNP is useful for
establishing prognosis or disease severity in chronic HF
Class I Measurement of baseline levels of natriuretic peptide
biomarkers and/or cardiac troponin on admission to the
hospital is useful to establish a prognosis in acutely
decompensated HF.
2017 ACC/AHA/HFSA Heart Failure Focused Update

27. Features in CXR…
Normal Acute LVF

28. • Most useful diagnostic test in the evaluation of patients with heart
failure.
• Provide information about etiology and prognosis of heart failure.
• Regional wall motion abnormalities, EF, LV dimensions, LV
mass,the myocardial performance index (Tei index), measures of
diastolic dysfunction all can be done by Echo.

30. Clinical assessment…
Acute left heart failure:
Causes-

32. • Orthopnea,Paroxysmal nocturnal dyspnea, Cheyne-Stokes respiratory
patterns
• Pulmonary rales
• S3 gallop
• Pulsus alternans , narrow pulse pressure
Hypotension

33. Management of ALVF:
> 18 mm Hg
< 2.0 L/min/m2
ESCAPE trial

34. Patients with acute cardiogenic pulmonary edema should be positioned
upright.
Intravenous opiates
Maximizing oxygenation is vital.

35. Medical Management…
Vasodilators: Nitroglycerin:

36. Sodium Nitroprusside :
-It is a potent vasodilator with venous and arteriolar effects.
- Requires hemodynamic monitoring.
-Dosage of 0.1 to 0.2 μg/kg/min is used and titrated every 5
minutes to achieve response while maintaining MAP > 65 mm Hg.
-Nitroprusside is particularly useful where a rapid and large
reduction in afterload is desired (e.g., cardiogenic shock and acute
severe aortic regurgitation or MR).

37. Nesiritide…

38. Diuretics…

39. InotropicTherapy:
Dobutamine:
drug
of choice in the acute setting.

40. Temporary mechanical circulatory
support…
IABP IMPELLA

41. MCS is beneficial in carefully selected
patients with stage D HF in whom
definitive management (e.g., cardiac
transplantation) or cardiac recovery is
anticipated or Planned.
(Level of Evidence: B)
Class I
Temporary mechanical circulatory
support…

42. •Management of Chronic Heart
Failure….

43. General Mx Of Chronic HF:

44. Continued MedicalTherapy…
ACE inhibitors:

45. ACE Inhibitors:
(ARNI)
(valsartan/sacubitril) is approved by FDA

46. 2013 Recommendation+2017 ACC/AHA/HFSA Heart
Failure Focused Update…
Class I
2013
Recommendation
The use of ACE inhibitors is beneficial for
patients with prior or current symptoms of
chronic HFrEF to reduce morbidity and mortality.
2013
Recommendation
The use of ARBs to reduce morbidity and mortality
is recommended in patients with prior or current
symptoms of chronic HFrEF who are intolerant to
ACE inhibitors because of cough or angioedema.
2017 Focused Update
New clinical trial data
In patients with chronic symptomatic HFrEF
NYHA class II or III who tolerate an ACE inhibitor or
ARB, replacement by an ARNI is recommended to
further reduce morbidity and mortality.

47. β-Adrenergic blockers…
• Principle- “start low and go slow.”

48. Ivabradin…
2016 ACC/AHA/HFSA Focused Update on New Pharmacological
Therapy for Heart Failure…
Class II
Ivabradine can be beneficial to reduce HF
hospitalization for patients with symptomatic (NYHA
class II-III) stable chronic HFrEF (LVEF< 35%) who are
receiving a beta blocker at maximum tolerated dose,
and who are in sinus rhythm with a heart rate of 70 bpm
or greater at rest.

49. Aldosterone receptor antagonists…
Indication

50. •DeviceTherapy…

51. 2013 ACCF/AHA Heart Failure Guidelines:
Class I
ICD therapy
For primary prevention of sudden cardiac
death to reduce mortality in nonischemic
dilated cardiomyopathy or ischemic heart
disease at least 40 days post-MI with
LVEF of 35% or less and NYHA class II or III
symptoms who have expectation of survival
for more than 1 year.
CRTTherapy
For patients who have LVEF of 35% or less, sinus
rhythm, LBBB with a QRS duration of 150 ms or
greater, and NYHA class II, III, or ambulatory IV
symptoms on GDMT.

52. 2013 ACCF/AHA Heart Failure Guidelines:
Class I
Coronary artery revascularization via CABG or PCI is
indicated for patients with angina and suitable coronary
anatomy, especially for a left main stenosis (>50%) or
left main equivalent disease.

53. CardiacTransplantation…
2013 ACCF/AHA Heart Failure Guidelines:
Class I
Evaluation for cardiac transplantation is indicated
for carefully selected patients with advanced HF
(Stage D) despite GDMT, device, and surgical
management.

54. THANK YOU ALL…