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- 2. Heart Failure Dr. Uma Narayanamurthy, MD, Assistant Professor, Department of Pharmacology, MGMC&RI, Puducherry.
- 5. Congestive Heart Failure Common Causes Chronic Acute CAD Hypertensive HD Rheumatic Heart Dis Congenital Heart Dis Cor pulmonale Cardiomyopathy Anemia Bacterial endocarditis Valvular disorders Acute MI Dysrhythmias Pulmonary emboli Thyrotixicosis Hypertensive crisis Rupture of papillary muscle VSD Myocarditis
- 7. Compensatory Mechanisms: Renin-Angiotensin-AldosteroneSystem Renin + Angiotensinogen Angiotensin I Angiotensin II Peripheral Vasoconstriction Afterload Cardiac Output Heart Failure Cardiac Workload Preload Plasma Volume Salt & Water Retention Edema Aldosterone Secretion ACE Kaliuresis Beta Stimulation • CO • Na+ Fibrosis
- 8. Adapted from Cohn JN. N Engl J Med. 1996;335:490–498. Pathologic remodeling Low ejection fraction Death Symptoms: Dyspnea Fatigue Edema Chronic heart failure •Neurohormonal stimulation •Myocardial toxicity Sudden Death Pump failure Coronary artery disease Hypertension Cardiomyopathy Valvular disease Myocardial injury Pathologic Progression of CV Disease Diabetes
- 9. Congestive Heart Failure Pathophysiology • Left Venticular Failure – Most Common • Left ventricular function • Blood backup – left atrium & pulmonary veins • Increased pulmonary pressure • Fluid extravasation from pulmonary capillary bed to interstitium & alveoli • Results: Pulmonary Congestion Pulmonary Edema
- 11. Congestive Heart Failure Pathophysiology • Right Ventricular Failure • Backward flow of blood to right atrium and venous circulation • Systemic venous congestion in systemic circulation • Results: peripheral edema, hepatomegaly, splenomegaly, vascular congestion of the GI tract, jugular vein distention • Primary Cause: left ventricular failure • Chronic pulmonary congestion & hypertension result in right ventricular failure • Cor pulmonale – ventricular dilation & hypertrophy
- 13. Pathophysiology- Structural Changes with HF • Dec. contractility • Inc. preload (volume) • Inc. afterload (resistance) • **Ventricular remodeling (ACE inhibitors can prevent this) • Ventricular hypertrophy • Ventricular dilation
- 18. Drugs in Heart Failure • Ionotropic Drugs Digoxin, Dobutamine, Dopamine, Amrinone, Milrinone • Diuretics – Furosemide, Thiazides • RAS inhibitors – ACE inhibitors, ARBs • Vasodilators Venodilators – GTN, ISDN Arteriolar dilators – Pot.Channel blockers,CCBs Mixed – ACE inhibitors, ARBs, Alpha blockers, PDE3 inhibitors, Nitroprusside Beta blockers • Arrest or reverse progression
- 19. Congestive Heart Failure Medical Treatment Goals • Decreasing Intravascular Volume • Decreasing Venous Return • Decreases preload – decreases the volume to the left ventricle during diastole • Med: Diuretics – Lasix (furosemide) • Decreasing Afterload • Decrease systemic vascular resistance • CO increases • Pulmonary congestion decreases • Meds: Nitroglycerine (NTG); Morphine; Calcium Channel Blockers
- 20. Congestive Heart Failure Medical Treatment Goals • Improving Gas Exchange & Oxygenation • Supplemental oxygen • Morphine • Severe cases – intubation / ventilation • Improving Cardiac Function • Increase cardiac contractility without increasing cardiac oxygen consumption • Hemodynamic Monitoring: • pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG) • Inotropic Meds: Digoxin • Inotropic meds used with hemodynamic monitoring: • Dobutamine • Inodilators: (inotropic & vasodilator): Milrinone
- 21. Congestive Heart Failure Medical Treatment Goals • Reducing Anxiety • Sedative action of IV Morphine • Complication: respiratory depression • Determine & Treat Underlying Cause • Systolic or Diastolic failure • Aggressive drug therapy
- 22. Heart Failure Treatments: Medication Types •ACE inhibitor (angiotensin-converting enzyme) •ARB (angiotensin receptor blockers) •Beta-blocker •Digoxin •Diuretic •Aldosterone blockade Type What it does •Expands blood vessels which lowers blood pressure, neurohormonal blockade •Similar to ACE inhibitor—lowers blood pressure •Reduces the action of stress hormones and slows the heart rate •Slows the heart rate and improves the heart’s pumping function (EF) •Filters sodium and excess fluid from the blood to reduce the heart’s workload •Blocks neurohormal activation and controls volume
- 23. Rational for Medications(Why does my doctor have me on so many pills??) • Improve Symptoms • Diuretics (water pills) • digoxin • Improve Survival • Betablockers • ACE-inhibitors • Aldosterone blockers • Angiotensin receptor blockers (ARB’s)
- 24. Lifestyle Changes •Eat a low-sodium, low-fat diet •Lose weight •Stay physically active •Reduce or eliminate alcohol and caffeine •Quit Smoking What Why •Sodium is bad for high blood pressure, causes fluid retention •Extra weight can put a strain on the heart •Exercise can help reduce stress and blood pressure •Alcohol and caffeine can weaken an already damaged heart •Smoking can damage blood vessels and make the heart beat faster
- 25. Chronic HF-End Stage Collaborative Management • Nonpharmacologic therapies (cont’d) • Biventricular Pacing • Implantable cardiac defibrillators (ICD) • Intraaortic balloon pump (IABP) therapy • Used for cardiogenic shock • Allows heart to rest • Ventricular assist devices (VADs) • Takes over pumping for the ventricles • Used as a bridge to transplant • Destination therapy-permanent, implantable VAD • Cardiomyoplasty- wrap latissimus dorsi around heart • Ventricular reduction -ventricular wall resected • Transplant/Artificial Heart • New gadgets to help doctors manage heart failure
- 26. Overview of Device Therapy Biventricular Pacing VentricularDysynchrony • Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction
- 28. Implantable Cardioverter-Defibrillators for HF • Sustained ventricular tachycardia is associated with sudden cardiac death in HF. • About one-third of mortality in HF is due to sudden cardiac death. • Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter- defibrillator (ICD) for the primary prevention of SCD.
- 29. Intraaortic balloon pump IABP Machine
- 31. Cardiomyoplasty technique: left latissimus dorsi muscle (LDM) transposed into chest through a window created by resecting the anterior segment of 2nd rib (5 cm). LDM is then wrapped around both ventricles. Sensing and pacing electrodes are connected to an implantable cardiomyostimulator
- 32. Left Ventricular reduction Surgery-Bautista procedure…indicated in some cases…
- 33. Click here for UTube Artificial Heart animination!
- 34. Newer Generation Artificial Hearts
- 35. Stage A At high risk for developing heart failure. Includes people with: Hypertension Diabetes mellitus CAD (including heart attack) History of cardiotoxic drug therapy History of alcohol abuse History of rheumatic fever Family history of CMP Exercise regularly Quit smoking Treat hypertension Treat lipid disorders Discourage alcohol or illicit drug use If previous heart attack/ current diabetes mellitus or HTN, use ACE- I Stage B Those diagnosed with “systolic” heart failure- have never had symptoms of heart failure (usually by finding an ejection fraction of less than 40% on echocardiogram Care measures in Stage A + Should be on ACE-I Add beta -blockers Surgical consultation for coronary artery revascularization and valve repair/replacement (as appropriate Stage C Patients with known heart failure with current or prior symptoms. Symptoms include: SOB, fatigue Reduced exercise intolerance All care measures from Stage A apply, ACE-I and beta-blockers should be used + Diuretics, Digoxin, Dietary sodium restriction Weight monitoring, Fluid restriction Withdrawal drugs that worsen condition Maybe Spironolactone therapy Stage D Presence of advanced symptoms, after assuring optimized medical care All therapies -Stages A, B and C + evaluation for:Cardiac transplantation, VADs, surgical options, research therapies, Continuous intravenous inotropic infusions/ End-of-life care Therapies
- 36. Thank U