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Heart Failure approach 2022.pdf
- 1. 10-10-2022 1 Col Bharat Malhotra Senior Advisor (Medicine) REFERENCE Harrison’s Principles of internal medicine Harrison's 21st Ed (2022) Davidson’s Principlesand practice of Medicine (2018) AHA & European Guidelines on management of Acute and Chronic Heart Failure (2021 & 2022) Incidence and Prevalence of HF worldwide PREVALENCE Developed Countries: 2% Asia : 0.1 -7% India : 0.12- 0.44% 40-60 yrs: 1-2% > 80 years: 12% • Complex clinical syndrome • that results from structural or functional impairment • of ventricular filling or ejection of blood • leads to cardinal manifestation of dyspnea and fatigue and fluid retention American Heart Association Cardiology Guidelines (2022) Chronic HF describes those who have had an established long-standing diagnosis of HF or who have a more gradual onset of symptoms. Acute HF is rapid onset of new or worsening of preexisting HF requiring hospitalization. In pathophysiological terms • HF is defined as a syndrome • characterized by elevated cardiac filling pressures and / or • inadequate peripheral O2 delivery • at rest or during stress caused by cardiac dysfunction STAGE A STAGE B STAGE C STAGE D AT RISK HF PRE HF SYMPTOMATIC HF ADVANCED HF Symptom + Sign of HF Structural heart disease Marked Symptom + Sign of HF Structural heart disease Repeated Hospitalizations HFrEF HFmrEF HFpEF Symptoms + Signs Symptoms + Signs Symptoms + Signs LV EF < 40% LV EF 41% - 49% LV EF > 50% Objective evidence of cardiac structural or functional abnormality including increase BNP HF improved EF (Treatment remains same as that of HFrEF)
- 2. 10-10-2022 2 DILATED CARDIOMYOPATHY CORONARYARTERY DISEASE TACHYARRHYTHMIAS Drug Induced Alcohol Metabolic Endocrinal Autoimmune Viral - Myocarditis VALVULAR DISEASE Lt –Rt SHUNTING HYPERTENSION HYPERTROPHIC CARDIOMYOPATHY RESTRICTIVE CARDIOMYOPATHY Amylodosis Sarcoidosis Haemochromatosis STENOTIC VALVULAR DISEASE HYPERTENSION ENDOMYOCARDIAL DISORDERS CONSTRICTIVE PERICARDITIS HIGH OUTPUT STATES AV Fistula Chronic Anemia Thyrotoxicosis Beri Beri OTHER FACTORS Coronary Ischemia Arrhythmias Uncontrolled hypertension Pulmonary embolism Systemic infection/ sepsis Patient related factors Provider related factors Na & Water RETENTION INCREASE PRELOAD VASOCONSTRICTION INCREASE AFTERLOAD DECREASES MYOCARDIAL CONTRACTILITY DECREASES CARDIAC OUTPUT SVC IVC P Artery P Vein Aorta Lungs Lt A Rt A Rt V Lt V Chronic HF describes those who have had an established long-standing diagnosis of HF or who have a more gradual onset of symptoms.
- 3. 10-10-2022 3 The diagnosis of CHF requires the presence of symptoms and/or signs of HF and objective evidence of cardiac dysfunction PRO BNP BNP ECHO Chronic Symptoms & signs of HF Risk factors for HF Abnormal ECG/ CXR Confirm Heart Failure Define EF & Etiology EF Structure > 125 pg/mL > 35 pg/mL Dyspnoea during exercise on less strenuous activity ultimately may occur at rest Paroxysmal nocturnal dyspnoea, Orthopnoea Fatigue, Poor effort tolerance Ankle edema Nocturnal cough Anorexia, nausea, early satiety, Rt upper quadrant abdominal pain & fullness Confusion, Disorientation, Oliguria CONGESTION RAISED JVP Prominent P2 Hepatomegaly Hepatojugular reflux Ascites Pedal edema Cardiomegaly S3, S4 Pulmonary crackles Pleural Effusions LOW CARDIAC OUTPUT Lethargy, fatigue, Alter mental state Cool Extremities Sinus tachycardia Narrow pulse pressure Lower BP • AKI – Due to poor renal perfusion • Impair liver function • Hypokalemia, hyperkalemia • Hyponatremia • Thromboembolism • Atrial or ventricular arrhythmias • Sudden cardiac death 12 lead ECG CXR PA View BNP/ NT Pro BNP test ECHO Test for Comorbidities Test for Etiology CBC Urea Creatinine Electrolytes Fasting Glucose, HBA1c Lipid Profile TSH Iron status – Serum Iron, TIBC, Ferritin High pretest probability of CAD –PCI Intermediate probability of CAD Stress ECHO, Exercise testing Specific disease workup if required Cardiac – MRI [Infiltrative disorders) Endomyocardial biopsy Rt Heart catheterization – done rarely in evaluation for transplant ECG – May by abnormal due to ACS, tachyarrhythmias, LBBB, Chamber enlargement
- 4. 10-10-2022 4 BNP [ >35 pg/mL CHF] [ >100 pg/dLAHF ] NT Pro BNP [ > 125 pg/mL CHF] [ >400 pg/dLAHF ] Released from failing heart (sensitive marker for HF) • Support diagnosis of HF • Prognosis • GDMT • Falsely elevated in acute cardiac illness, critical illness, Sepsis, PE, AKI BIOMARKERS: Troponin T (Ischemia) New diagnosis of HF Clinical change in patient with known diagnosis of HF Assess structure, chambers, Valves, flow dynamics, function, EF ACEI/ARB/ARNI B Blocker MRA Dapagliflozin/Empagliflozin Diuretics for fluid retention LV EF < 35% QRS WNL ICD LV EF > 35% Device not indicated If symptom persist (go to Class II recommendation) LV EF < 35% SR, QRS BROAD CRT AIM of Rx Improve survival Improve clinical status ACEI • Enalapril • Ramipril • Lisinopril ARB • Losartan • Valsartan ARNI • Sacubitril+ Valsartan (Combination) B Blocker MRA SGLT2 Diuretics Bisoprolol Metoprolol Nebivolol Carvedilol Spironolactone Eplerenone Dapagliflozin Empagliflozin Furosemide Torsemide Metolazone ARNI
- 5. 10-10-2022 5 Reduce HR further In Blacks only In AF cases Trials Stage IVABRADINE Hydralazine & Isosorbide Digoxin Vericiguat • Dyslipidemia, Hypertension, diabetes, obesity Treat risk factors • CABG/ PCI CAD • Anticoagulation, Digoxin AF • Assess and treat if required Sleep Disorders • IV Ferric Carboxy maltose Iron deficiency • Limited Exercise and weight reduction • Low salt diet, Low fat diet, smoking cessation Advise • Influenza • Pneumococcal Vaccine Reduce risk of SCD LV EF < 35% QRS WNL Ischemic origin after 40 d if survival is > 40 days Post cardiac arrest VT with hypotension Reduce mortality and morbidity in selected patients and improves cardiac function LV EF < 35% QRS wide with LBBB Sinus rhythm Symptomatic HF patients CABG/ PCI Valve Repair Acute HF is rapid onset of new or worsening of preexisting HF requiring hospitalization.
- 6. 10-10-2022 6 PRO BNP BNP ECHO Acute Symptoms & signs of HF Risk factors for HF Abnormal ECG/ CXR/ SpO2 Confirm Heart Failure Define EF & Etiology EF Structure > 400 pg/mL > 100 pg/mL The diagnosis of AHF requires the presence of Rapid onset of HF or acute decompensation of existing HF HIGH OUTPUT STATES Chronic Anemia Thyrotoxicosis Beri Beri OTHER FACTORS Coronary Ischemia Arrhythmias Uncontrolled hypertension Valvular heart disease Pulmonary embolism Systemic infection/ sepsis Patient related factors Provider related factors • Volume overload Acute Decompensation (Typical) • Volume overload • Hypoperfusion with End organ dysfunction Acute Decompensation (Low Output) • Severe Pulmonary congestion • Hypoxia Acute Pulmonary Edema • Hypotension with low cardiac output • End Organ Failure Cardiogenic Shock CONGESTION Orthopnea Pedal edema Pleural Effusions Ascites Cardiomegaly S3 Tachypnoea Pulmonary crackles Raised JVP LOW PERFUSION Lethargy, fatigue, Alter mental state Cool Extremities Sinus tachycardia Narrow pulse pressure Lower BP End organ dysfunction Low P E R F U S I O N CONGESTION NO YES NO Warm Dry Warm Wet YES Cold Dry Cold Wet Hospitalized 12 lead ECG CXR PA View, SpO2, ABG BNP/ NT Pro BNP test ECHO Test for Comorbidities Test for Etiology CBC Urea Creatinine Electrolytes Fasting Glucose, HBA1c Lipid Profile Evaluate – coexisting infections TSH Iron status – Serum Iron, TIBC, Ferritin High pretest probability of CAD –PCI SpO2 monitor ABG Swan Ganz Catheter (Assess PA pressures) In cardiogenic shock O2, NIV, Ventilatory support Congestion/ Fluid overload • IV Loop Diuretics • Increase dose - IV loop diuretic, • Loop diuretic + metolazone • Renal replacement therapy Hypoperfusion • Inotropes – Dobutamine, Dopamine (Milrinone, Levosimendan) • Vasopressors - Norepinephrine • Mechanical circulatory support, Emergency PCI Vasodilators- IV Nitrates , IV Nitroprusside Other drugs :IV opioids (in acute pulm edema), Anticoagulants (in AF)
- 7. 10-10-2022 7 DIURETICS • Furosemide Continuous vs Bolus Add on • Chlorothiazide or Metolazone Refractory or in Cardiorenal Syndrome • RRT Vasodilator Inotropes Vasopressor Other Rx Nitroglycerine Na Nitroprusside (Reserve drug) Nesiritide (Utilizationwaned) Dobutamine Dopamine Milrinone, Levosimendan (Utilizationwaned) Norepinephrine ACS Arrhythmia Infection Anemia Switch to oral Rx as for HFrEF Mechanical Circulatory support ULTRAFILTERATION EMERGENCY PCI REFRACTORY HF- CARDIAC TRANSPLANT 69 years old Female Dyspnoea on exertion - 3 month Anorexia Vital Stable Pedal edema present Pro BNP 544 pg/mL ECHO – EF 40% , MR + 65 years Male smoker, diabetes Progressive dyspnoea 3 days and now dyspnoeic at rest 1 day. Temp 100 F, Pallor Pulse 104/min RR 28/min, Spo2 90% BP 122/80 mmHg Warm peripheries JVP raised Pedal edema present Tender hepatomegaly. Pro BNP 544 pg/mL ECHO – EF 25% , MR + RWMA + Trop T positive 52 years Male Progressive dyspnoea 1 year associated with wheeze On treatment with bronchodilators from Pvt Nursing home reported to our hospital due to no improvement in symptoms. Don’t mistake cardiac asthma for bronchial asthma EXAMINE PATIENT HAD SIGNIFICANT MURMUR
- 8. 10-10-2022 8