A direct and focused approach to a heart failure patient

1. HEART FAILURE
Dr A. Maphane

2. OUTLINE
• DEFINITION
• CLASSIFICATIONS OF HF
• EPIDEMIOLOGY
• RISK FACTORS
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• DIAGNOSIS
• MANAGEMENT
• REFERENCES

3. DEFINITION
UPTODATE DEFINITION-
• Heart failure (HF) 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.

4. CLASSIFICATIONS OF HF
Classification by Definition
• Systolic HF- Characterized by reduced ejection fraction and enlarged
ventricle size.
• Diastolic HF- Characterized by increased resistance to filling due to
increased filling pressures.
Classification by Location
• Left ventricular Failure
• Right ventricular Failure
• Biventricular Failure

5. Classification clinically
• Heart Failure with preserved Ejection Fraction (HFpEF)- EF ≥50%
• Heart Failure with mid-range Ejection Fraction (HFmrEF)- EF 40-50%
• Heart Failure with reduced Ejection Fraction (HFrEF)- EF ≤ 40%
Classification based on cardiac output
• High output Failure- The normal heart fails to maintain normal or
increased output in conditions like anaemia, hyperthyroidism,
pregnancy
• Low output failure- Heart fails to generate adequate output in
conditions like cardiomyopathy, valvular heart disease, tamponade
and bradycardia.

6. New York Heart Association (NYHA) Classification
• Class I: HF does not cause limitations to physical activity; ordinary
physical activity does not cause symptoms.
• Class II: HF causes slight limitations to physical activity; the patients
are comfortable at rest, but ordinary physical activity results in HF
symptoms.
• Class III: HF causes marked limitations of physical activity; the
patients are comfortable at rest, but less than ordinary activity causes
symptoms of HF.
• Class IV: HF patients are unable to carry on any physical activity
without HF symptoms or have symptoms when at rest

7. AMERICAN HEART ASSOCIATION (AHA)
CLASSIFICATION
• Stage A: High risk of heart failure, but no structural heart disease or
symptoms of heart failure;
• Stage B: Structural heart disease, but no symptoms of heart failure;
• Stage C: Structural heart disease and symptoms of heart failure;
• Stage D: Refractory heart failure requiring specialized interventions.

8. EPIDEMIOLOGY
• According to AHA approx. 23 million people have HF worldwide.
• Prevalence increase w/ age, according to the Framingham Heart study
currently- men: 8/1000 @ 50-59yrs rising 66/1000 @ 80-89yrs
- women: 8 and 79/1000 respectively
• Elements contributing to the rise: life expectancy, improved rx of
HTN, Valvular and Coronary disease, BMI and cigarette smoking.
• Lifetime risk: @ 40yrs risk of HF is 1/5 in both genders
• Five (5) yr mortality is approx. 50%

9. RISK FACTORS & PRECIPITANTS
Patient-Specific (Modifiable) Medical Non-modifiable
-Tobacco use (1.6) -Diabetes (1.9) -Age
-Sedentary life style -Hypertension (1.4) -Genetics
-Poor diet -Obesity (1.3)
-Coronary heart disease (8.1)
-Valvular heart disease (1.5)
Precipitants Of Heart Failure
Hypertension Failure to take meds
Endocarditis Arrhythmias
Anaemia Infarction/ischemia/Infection
Rheumatic Heart disease Lung problems (PNA, PE,COPD)
Thyrotoxicosis Endocrine (Pheochromocytoma, hyperaldosteronism)
Dietary indiscretion

10. PATHOPHYSIOLOGY

11. CLINICAL FEATURES

13. DIAGNOSIS
Framingham diagnostic criteria for Heart Failure
*Heart failure is diagnosed when patient has 2 Major OR 1 Major plus 2
Minor
Major Criteria Minor Criteria
-Acute pulmonary oedema -Ankle oedema
-Cardiomegaly -Dyspnoea on exertion
-Hepatojugular reflex -Hepatomegaly
-Neck vein distension -Nocturnal cough
-Orthopnoea or PND -Pleural effusion
-Rales -Tachycardia (>120bpm)
-S3 gallop

14. CONT’D
INVESTIGATIONS
Blood tests
• FBC-r/o anaemia and infection
• RFT- baseline electrolytes & r/o renal impairment
• LFT
• Fasting glucose- r/o DM
• BNP and NT-proBNP
• Others: Cardiac enzymes, TFT, lipid profile, Urinalysis
• ECG
• CXR
• ECHOCARDIOGRAM

16. MANAGEMENT
Major goals of treatment
1. To improve prognosis and reduce mortality
2. To alleviate symptoms and reduce mortality by reversing or slowing
the cardiac and peripheral dysfunction
For In-patients
1. to reduce the length of stay and subsequent readmission
2. to prevent organ system damage and
3. to appropriately manage the co-morbidities that may contribute to
poor prognosis

17. PREDICTORS OF POOR OUTCOME AND HIGH
MORTALITY
• Serum urea >15 mmol/L
• Systolic blood pressure <115mmHg
• Serum creatinine >2.72 mg/dL (or 240 µmol/L)
• N-terminal pro-brain natriuretic peptide (NT-pro-BNP) >986 pg/mL ‚
• Left ventricular ejection fraction <45%
• Hyponatremia

18. CRITERIA FOR ADMISSION TO ICU
• Patient is intubated or likely to require respiratory support/intubation
based on the following:
-SpO2 ≤ 90% despite supplemental O2
- Pt using accessory muscles and RR ≥25/min
• Signs and symptoms of hypoperfusion and/or sBP <90mmHg
• Heart rate <40 or >130bpm

19. APPROACH TO TREATMENT

20. TX OF ACUTE DECOMPENSATED HF
INITIAL THERAPY
• Airway assessment and continuous pulse oximetry to assure
adequate oxygenation and ventilation
• Supplemental oxygen and ventilatory support as indicated
• Vital signs assessment with attention to hypotension or
hypertension
• Continuous cardiac monitoring
• Intravenous access
• Seated posture

21. • Prompt diuretic therapy
-Furosemide: doses ≥ maintenance total daily oral dose. With daily
electrolyte monitoring.
• Early vasodilator therapy (for severe hypertension, acute mitral
regurgitation, or acute aortic regurgitation)
-Nitroglycerin: 5-10 mcg/min IV (max 200mcg/min). Given as adjunct
therapy
-Nitroprusside: 5-10mcg/min IV. Used in cases of urgent lowering of
afterload
• VTE prophylaxis- LMWH or unfractioned heparin

22. • OPIATES
-Morphine: causes arteriolar and venous dilatation
• Urine output monitoring
• Sodium restriction: <2g/day
• Fluid restriction: <1.5-2L/day

23. TX OF CHRONIC HEART FAILURE (HFrEF)
Non-pharmacological
• Sodium restriction (<2g/day)
• Fluid restriction (1.5-2L/day)
• Exercise training
Pharmacological
• ACEI- Enalapril(2.5-10mg BD) or Captopril (6.25-50mg TDS).
-side effects: Cr, K, cough and angioedema OR
• ARBs- Candesartan (4-32mg QD). Alternative for ACEI
-side effects: K, Cr

24. CONT’D
• Hydralazine + nitrates: used if patient cannot tolerate ACEI/ARBS
• Beta-blockers: Carvedilol (3.125-25mg BD), Metoprolol (12.5-
200mg/d), Bisoprolol (1.25-10mg/d)
-side effects: Bradycardia
- contraindicated in ADHF
• Aldosterone antagonists: Spironolactone (12.5-25mg QD)
-side effect: K
• Diuretics: Furosemide for sx relief
• Digoxin (optimal levels 0.5-0.8 ng/mL) add on if persistent sx despite
use of ACEI, B-blockers, Diuretics
• Others: omega-3, anticoagulation, Vaccination (Pneumococcal & Influ)

26. DISCHARGE CRITERIA
1. Exacerbating factors have been addressed and are under control
2. Volume status has been optimized
3. Diuretic therapy has been successfully transitioned to oral
medication, with discontinuation of IV vasodilator and inotropic
therapy if required for at least 24 h
4. Oral therapy for chronic heart failure (HF), including angiotensin
convertase enzyme inhibitors (ACEIs) and beta blockers (for patients
with reduced LVEF), has been established with stable clinical status
5. Patient and family education completed, including clear discharge
instructions

27. CONT’D
6. Left ventricular ejection fraction (LVEF) documented:
echocardiography is the gold standard
7. Smoking cessation (if applicable) counselling initiated

28. FOLLOW-UP

29. REFERENCES
• Uptodate
• Pocket Medicine
• Heart Failure: Diagnosis, Management and Utilization by Arati A.
Inamdar
• NEJM
• European society of cardiology: Heart Failure 2016

30. QUESTIONS…….COMMENTS……SUGGESTIONS
THANK YOU!!!