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CONGESTIVE CARDIAC FAILURE – AN UPDATE ON MANAGEMENT Dr SYED  RAZA Consultant Cardiologist MD,MRCP(UK),Dip. Card(UK),CCT(UK),FCCP(USA)
OBJECTIVE ,[object Object],[object Object],[object Object],[object Object]
CASE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic Dilemma ,[object Object],[object Object],[object Object],[object Object],[object Object]
FAILING HEART
FURTHER CAREFUL EVALUATION ,[object Object],[object Object],[object Object],[object Object],[object Object]
Epidemiology of Heart Failure  ,[object Object],[object Object],[object Object],[object Object],*Rich M.  J Am Geriatric Soc . 1997;45:968–974. American Heart Association. 2001  Heart and Stroke Statistical Update . 2000.  3.5 4.7 10 0 2 4 6 8 10 12 1991 2000 2037* Heart Failure Patients in US (Millions)
Facts on Heart Failure ,[object Object],[object Object],[object Object],03/21/11
Heart Failure Admissions British Heart Foundation, 2002 Average duration of hospital admission (days)
Heart Failure Mortality
Causes of Mortality in Heart Failure ,[object Object],[object Object],[object Object],[object Object]
Prognostic Value of Haemoglobin Levels at Discharge in Older Patients Admitted With Heart Failure. 2 Syed Raza ,  1 Nicolas Wisniacki,  2 Pam Aimson,  2 Chris Manning,  1 Alejandra Abramovsky,  1 Vinod Gowda,  1 Michael Lee,  2 Jason Pyatt. 1 Department of Medicine, University of Liverpool &  2 Department of Cardiology, Royal Liverpool and Broadgreen University Hospitals. United Kingdom.
How Heart Failure Is Diagnosed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Symptoms
The Donkey Analogy  ,[object Object]
I  GIVE UP .  I CAN’T  TAKE  IT ANY MORE  !!
Acute Decompensated Heart Failure /Pulmonary Edema >Medical Emergency !
But
CHF- Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Left Ventricular Dysfunction ,[object Object],[object Object],[object Object],30% 70% Diastolic Dysfunction Systolic Dysfunction (EF < 40%) (EF > 40 %) 1  Lilly, L.  Pathophysiology of Heart Disease .  Second Edition p 200
Systolic vs. Diastolic ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Right Heart Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
What is present in this extremity, common to right sided HF?
EMERGENCY MANAGEMENT  (Pneumonic) U Upright Position N Nitrates L Lasix O Oxygen A  Amiodorone >  ACEI / ARB D Digoxin, Dobutamine M Morphine Sulfate E Extremities Down
Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations . –  Initial diagnosis of heart failure. –  Management of severe heart failure (NYHA  class IV), heart failure that does not respond to treatment, heart failure due to valve disease, or heart failure that can no longer be managed  at home –  Advice and care of women who are planning a pregnancy or are pregnant. Care of pregnant women should be shared between the cardiologist and obstetrician. Patients with previous MI Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks
Rational for Medications (Why does my doctor have me on so many pills??) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Compensatory Mechanisms:  Renin-Angiotensin-Aldosterone (RAAS)   Vasoconstriction Oxidative Stress Cell Growth Proteinuria LV remodeling Angiotensinogen Angiotensin I Angiotensin II 3 .AT  II receptor 1 .Renin 2 .Angiotensin Converting Enzyme 1.Direct Renin Inhibitor (Aliskiren) 2.ACEI 3.A2RB
ACE-I ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Angiotensin-Receptor Blockers ,[object Object],[object Object],[object Object]
ACE + ARB ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Beta-Blockers ,[object Object],[object Object],[object Object],[object Object],[object Object]
Beta- Blocker therapy-which to pick? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Initial and Target Doses of beta-blockers for HF Medication Starting Dose Target Dosage Bisoprolol 1.25mg daily 10mg daily Carvedilol 3.125mg bid 25mg bid Metoprolol CR/XL 12.5-25mg daily 200mg daily
Aldosterone Antagonists ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Digoxin ,[object Object],[object Object],[object Object],[object Object]
Treatment of Special Populations ,[object Object],[object Object],[object Object],[object Object],[object Object],Jessup M  et al.  J Am Coll Cardiol . 2009;53;1343-82.
Nesiritide (Natrecor)  ,[object Object],[object Object],[object Object],[object Object]
Some Practical Tips ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ENHANCED  EXTERNAL  COUNTERPULSATION (EECP)
Ultrafiltration
DEVICE  THERAPY ,[object Object],[object Object],[object Object],[object Object]
Biventricular Pacing (CARDIAC  RESYNCHRONISATION THEARPY) ,[object Object],Overview of Device Therapy
 
Cardiac Resynchronization Therapy Key Points ,[object Object],[object Object],[object Object],[object Object]
Heart Failure and Sudden Cardiac Death   ,[object Object],[object Object],[object Object],[object Object]
IMPLANTABLE CARDIAC DEFIBRILLATOR Device Shown: Combination Pacemaker & Defibrillator
Who should receive  an ICD? ,[object Object],[object Object],[object Object],[object Object]
Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β -Blockers 35% 12% Aldosterone  Antagonists 30% 19% ICD 31% 8.5%
Other Therapies? ,[object Object],[object Object],[object Object]
Left ventricular assist device
 
Newer Generation Artificial Hearts
ARTIFICIAL  HEART
 
 
Heart Transplantation ,[object Object],[object Object],[object Object]
Worldwide Heart Transplants
Trends in Hospitalization for Heart Failure by Age Group 1979-2004 (CDC, 2006) 03/21/11
MULTI  DISCIPLINARY APPROACH  (INTEGRATED CARE) ,[object Object],03/21/11
Outcomes of the  Heart Failure Team ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],03/21/11
Telehealth Program ,[object Object],[object Object],[object Object],03/21/11
 
 
One of the Best Devices for Monitoring Heart Failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
                                                                                                                                                                                                                                                      Recent Developments and Future Challenges of Integrated Care in Heart Failure  in Europe and Northern America   The International Network of Integrated Care, The Julius Center of the University Medical Center Utrecht and the University of Southern Denmark 11th International Conference on Integrated Care: 4.7. Paper session: IC for heart failure patients Pilot Study of Integrated home Care for Patients of Congestive Cardiac Failure: British District Hospital Experience –  Dr Syed  S.M. Raza et al.,  Dept. of Cardiology & Acute Medicine, Huddersfield and Calderdale Royal Hospitals NHS Trust, UK   March 30 - April 1, 2011 in Odense, Denmark  
REHABLITATION PROGRAMME
In Summary…. ,[object Object],[object Object],[object Object],[object Object]

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Heart failure – an update

  • 1. CONGESTIVE CARDIAC FAILURE – AN UPDATE ON MANAGEMENT Dr SYED RAZA Consultant Cardiologist MD,MRCP(UK),Dip. Card(UK),CCT(UK),FCCP(USA)
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  • 9. Heart Failure Admissions British Heart Foundation, 2002 Average duration of hospital admission (days)
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  • 12. Prognostic Value of Haemoglobin Levels at Discharge in Older Patients Admitted With Heart Failure. 2 Syed Raza , 1 Nicolas Wisniacki, 2 Pam Aimson, 2 Chris Manning, 1 Alejandra Abramovsky, 1 Vinod Gowda, 1 Michael Lee, 2 Jason Pyatt. 1 Department of Medicine, University of Liverpool & 2 Department of Cardiology, Royal Liverpool and Broadgreen University Hospitals. United Kingdom.
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  • 16. I GIVE UP . I CAN’T TAKE IT ANY MORE !!
  • 17. Acute Decompensated Heart Failure /Pulmonary Edema >Medical Emergency !
  • 18. But
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  • 24. What is present in this extremity, common to right sided HF?
  • 25. EMERGENCY MANAGEMENT (Pneumonic) U Upright Position N Nitrates L Lasix O Oxygen A Amiodorone > ACEI / ARB D Digoxin, Dobutamine M Morphine Sulfate E Extremities Down
  • 26. Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations . – Initial diagnosis of heart failure. – Management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment, heart failure due to valve disease, or heart failure that can no longer be managed at home – Advice and care of women who are planning a pregnancy or are pregnant. Care of pregnant women should be shared between the cardiologist and obstetrician. Patients with previous MI Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks
  • 27.
  • 28. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS) Vasoconstriction Oxidative Stress Cell Growth Proteinuria LV remodeling Angiotensinogen Angiotensin I Angiotensin II 3 .AT II receptor 1 .Renin 2 .Angiotensin Converting Enzyme 1.Direct Renin Inhibitor (Aliskiren) 2.ACEI 3.A2RB
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  • 35. Initial and Target Doses of beta-blockers for HF Medication Starting Dose Target Dosage Bisoprolol 1.25mg daily 10mg daily Carvedilol 3.125mg bid 25mg bid Metoprolol CR/XL 12.5-25mg daily 200mg daily
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  • 41. ENHANCED EXTERNAL COUNTERPULSATION (EECP)
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  • 48. IMPLANTABLE CARDIAC DEFIBRILLATOR Device Shown: Combination Pacemaker & Defibrillator
  • 49.
  • 50. Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β -Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8.5%
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  • 60. Trends in Hospitalization for Heart Failure by Age Group 1979-2004 (CDC, 2006) 03/21/11
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  • 68.                                                                                                                                                                                                                                                     Recent Developments and Future Challenges of Integrated Care in Heart Failure in Europe and Northern America   The International Network of Integrated Care, The Julius Center of the University Medical Center Utrecht and the University of Southern Denmark 11th International Conference on Integrated Care: 4.7. Paper session: IC for heart failure patients Pilot Study of Integrated home Care for Patients of Congestive Cardiac Failure: British District Hospital Experience – Dr Syed S.M. Raza et al., Dept. of Cardiology & Acute Medicine, Huddersfield and Calderdale Royal Hospitals NHS Trust, UK   March 30 - April 1, 2011 in Odense, Denmark  
  • 70.