Heart failure basics

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Basics of heart failure for rehab students internal medicine course

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Heart failure basics

  1. 1. Congestive Heart Failure Hanna Al-Makhamreh, MD FACC Interventional cardiology
  2. 2. Heart Failure  Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).
  3. 3. The Vicious Cycle of Congestive Heart Failure Decreased Blood Pressure and Decreased Renal perfusion Stimulates the Release of renin, Which allows conversion of Angiotensin to Angiotensin II. Angiotensin II stimulates Aldosterone secretion which causes retention of Na+ and Water, increasing filling pressure LV Dysfunction causes Decreased cardiac output
  4. 4. Types of Heart Failure  Systolic Heart Failure:  decreased cardiac output  Decreased Left ventricular ejection fraction  Diastolic Heart Failure:  Elevated Left and Right ventricular end-diastolic pressures  May have normal LVEF  .
  5. 5. Causes of Low-Output Heart Failure  Systolic Dysfunction  Coronary Artery Disease  Idiopathic dilated cardiomyopathy (DCM)  50% idiopathic (at least 25% familial)  9 % mycoarditis (viral)  peripartum, HIV, connective tissue disease, substance abuse, doxorubicin  Hypertension  Valvular Heart Disease(MR,AR)  Diastolic Dysfunction  Hypertension  Hypertrophic obstructive cardiomyopathy (HCM)  Restrictive cardiomyopathy  AS
  6. 6. Clinical Presentation of Heart Failure  Due to excess fluid accumulation:  Dyspnea (most sensitive symptom)  Edema  Hepatic congestion  Ascites  Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)  Due to reduction in cardiac ouput:  Fatigue  Weakness
  7. 7. Physical Examination in Heart Failure  S3 gallop  Low sensitivity, but highly specific  Cool, pale, cyanotic extremities  Have sinus tachycardia, diaphoresis and peripheral vasoconstriction  Crackles or decreased breath sounds at bases (effusions) on lung exam  Elevated jugular venous pressure  Lower extremity edema  Ascites  Hepatomegaly  Splenomegaly  Displaced PMI  Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>
  8. 8. Lab Analysis in Heart Failure  CBC  Since anemia can exacerbate heart failure  Serum electrolytes and creatinine  before starting high dose diuretics  Fasting Blood glucose  To evaluate for possible diabetes mellitus  Thyroid function tests  Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF.  Iron studies  To screen for hereditary hemochromatosis as cause of heart failure.  ANA  To evaluate for possible lupus  Viral studies  If viral mycocarditis suspected
  9. 9. Laboratory Analysis (cont.)  BNP  With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures  Usually is > 400 pg/mL in patients with dyspnea due to heart failure.
  10. 10. Chest X-ray in Heart Failure  Cardiomegaly  Cephalization of the pulmonary vessels  Kerley B-lines  Pleural effusions
  11. 11. Cardiomegaly
  12. 12. Pulmonary vessel congestion
  13. 13. Pulmonary Edema due to Heart Failure
  14. 14. Cardiac Testing in Heart Failure  Electrocardiogram:  May show specific cause of heart failure:  Ischemic heart disease  Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular block  Amyloidosis: pseudo-infarction pattern  Idiopathic dilated cardiomyopathy: LVH  Echocardiogram:  Left ventricular ejection fraction  Structural/valvular abnormalities
  15. 15. Further Cardiac Testing in Heart Failure  Coronary arteriography  Should be performed in patients presenting with heart failure who have angina or significant ischemia  Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.  Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.
  16. 16. Classification of Heart Failure  New York Heart Association (NYHA)  Class I – symptoms of HF only at levels that would limit normal individuals.  Class II – symptoms of HF with ordinary exertion  Class III – symptoms of HF on less than ordinary exertion  Class IV – symptoms of HF at rest
  17. 17. Classification of Heart Failure (cont.)  ACC/AHA Guidelines  Stage A – High risk of HF, without structural heart disease or symptoms  Stage B – Heart disease with asymptomatic left ventricular dysfunction  Stage C – Prior or current symptoms of HF  Stage D – Advanced heart disease and severely symptomatic or refractory HF
  18. 18. Chronic Treatment of Systolic Heart Failure  Correction of systemic factors  Thyroid dysfunction  Infections  Uncontrolled diabetes  Hypertension  Lifestyle modification  Lower salt intake  Alcohol cessation  Medication compliance  Maximize medications  Discontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers)
  19. 19. Order of Therapy 1. Loop diuretics 2. ACE inhibitor (or ARB if not tolerated) 3. Beta blockers 4. Digoxin 5. Hydralazine, Nitrate 6. Potassium sparing diuretcs
  20. 20. Diuretics  Loop diuretics  Furosemide, buteminide  For Fluid control, and to help relieve symptoms  Potassium-sparing diuretics  Spironolactone, eplerenone  Help enhance diuresis  Maintain potassium  Shown to improve survival in CHF
  21. 21. ACE Inhibitor  Improve survival in patients with all severities of heart failure.  Begin therapy low and titrate up as possible:  Enalapril – 2.5 mg po BID  Captopril – 6.25 mg po TID  Lisinopril – 5 mg po QDaily  If cannot tolerate, may try ARB
  22. 22. Beta Blocker therapy  Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV.  Contraindicated:  Heart rate <60 bpm  Symptomatic bradycardia  Signs of peripheral hypoperfusion  COPD, asthma  Heart block
  23. 23. Management of Refractory Heart Failure  Inotropic drugs:  Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin  Mechanical circulatory support:  Intraaortic balloon pump  Left ventricular assist device (LVAD)  Cardiac Transplantation  A history of multiple hospitalizations for HF  Escalation in the intensity of medical therapy  A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.

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