This document summarizes a lecture on the treatment of congestive heart failure. It defines heart failure classifications according to the New York Heart Association. For acute heart failure, the main treatment goals are treating life-threatening conditions and improving quality of life through vasodilation, organ protection, and volume control. Chronic heart failure treatment aims to improve quality of life, reduce disability, and increase longevity. Evidence-based drug therapies recommended for chronic heart failure include ACE inhibitors, beta-blockers, and aldosterone antagonists. Other options discussed include surgical treatments like heart transplantation and resynchronization therapy, as well as developing treatments like stem cell therapy. The document emphasizes the importance of home care programs for long-term heart failure

1. Medical Science Tanzania Cardiology Lectures
Congestive Heart Failure
3. Treatment
Prof. Hennersdorf SES
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2. General signs and symptoms
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3. Definition of Heart Failure CHF
• New York Heart Association (NYHA)
– I  no visible signs and symptoms
– II  signs and symptoms at high level exercise
– III  signs and symptoms at low level exercise
– IV  no physical exercise possible, bed rest
necessary
Worldwide used as functional definition of CHF!
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4. Treatment Goals
IV
II Main treatment goal
for chronic disease
??
??
III ?? I
Main treatment goal
for acute disease HTX option
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5. Therapeutic objectives
• Acute CHF
Main approach
– Treatment of life threat Vasodilation
Organ protection
– Improvement of life quality Volume control
• Chronic CHF
– Improvement of life quality
– Reduction of Disability
– Increase of longevity
Adding life to years rather than years to life
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6. Therapeutic options
Acute Heart Failure
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7. Therapeutic options (ER, ICU)
• Physical approach in cardiogenic pulmonary edema
– Oxygen delivery
– Bed rest / upright position
– Secure (central) venous line
– Urinary catheter
– Blood letting
• Drugs (iv administration)
– Diuretics (short term, furosemide)
– Digitalis (?; fast AF ?)
– Thrombembolic prophylaxis (heparin; PTT necessary)
• Drugs orally (cave hypotension)
– Nitroglycerine sublingually
– Consider ACEI sublingually
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8. Therapeutic options
(cardiogenic shock)
• Volume expansion under hemodynamic control
– Pulmonary artery cath
– Arterial pressure line
• Mechanical assistance: IABP
• Cathlab: PCI
• Surgery: revascularization
• Drugs
– Catecholamines: Dopamin, Dobutamin
– Phosphodiesterase (PDE)-Inhibitors: Amrinone, Milrinone (not
evidence based)
– Thrombembolic prophylaxis: heparine (PTT)
– Fast acting diuretics
• Acid base control
• Electrolyte contol (potassium)
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9. Therapeutic options
Chronic Heart Failure
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10. Evidence
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11. Therapeutic challenge
Systolic heart failure: mostly common in CHD and RHD
Drugs and recommendations according to guidelines
Diastolic heart failure: mostly common in hypertension
Long term follow up dependent on
treatment of underlying disease
Drugs recommendations not yet established
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12. Therapeutic options
• First line recommendation: Prevention
– Prevention of CHD, Hypertension, valvular
disease, infections
– Information, home care, transmission of simple
behavior rules:
• Hygiene and clean water supply
• Motion: physical activity, limited sport action
• Nutrition: salt restriction
• Refrain smoking
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13. Therapeutic options
• Conservative
– RAS modification
• ACE-I
• AT1-receptor antagonists
• Aldosterone antagonists (Eplerenone ®)
– beta-AR competition
• Betablockers
– classical 3D options
• Diuretics (fast acting, medium acting; cave potassium)
• Diet
• Digitalis (?) not first choice!
– Others: (Pulmonary artery Hypertension)
Avoid
• Bosentan
use of
• Sildenafil
NSAIDs
like
COXIBs
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14. ß-Blockade in CHF
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15. ß-Blockade in CHF
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16. ß-Blockade in CHF
Reduction of adrenergic receptors AR
Betablockade:
NE receptor recovery,
NE Muscle cell; contractility function improves
NE
E
NE
NE
NE Muscle cell; contractility
NE
E
NE
E
NE
E
NE Muscle cell; contractility
E
E
AR Recovery
E
AR Reduction
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17. ß-Blockade in CHF
Recommended:
ß1-selective drugs like metoprolol, bisoprolol
+ vasodilatation: carvedilol, nevibolol
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18. Therapeutic options. ACE-I
• Trials
– CONSENSUS 1987 Captopril
– SOLVD 1999 Enalapril
– SAVE 1992 Captopril
– VHEFT 1991 Enalapril/Hydralazin
– CIBIS III 2005 Enalapril/Bisoprolol
Demonstrate highly significant improvement of survival in different stages
of heart failure (II –IV): Evidence Class A - IA
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19. Dosage recommendations
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20. Dosage recommendations
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21. Improvement of HF in cardiac CXR
before treatment after treatment
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22. Therapeutic options
• Surgical
– Heart transplantation, bridging
– Cardiomyoplasty
• Resynchronizing pacemaker therapy (CRT)
• Stem cell replacement
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23. Therapeutic options
• HTX
– Surgically solved
– Concomitant therapy problems (rejection) solved
– Donor problems unsolved and will persist
But: therapeutic choice for subsets of younger patients
with severe symptoms mostly on
iv therapy and/or ICU care
without chance to recover appropriately.
Bridging procedure desirable
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24. Heart transplantation HTX
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25. Heart transplantation
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26. Heart transplantation
Christian Neethling Barnard
3rd september 1967
original OR theatre
Groote Schuur Hospital
Cape Town SAR
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27. Artificial heart
Heartmate® for bridging procedures
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28. Survival after HTX
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29. Therapeutic options: cardiac
resynchronization therapy CRT
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30. Therapeutic options
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31. Therapeutic options: resynchronization
therapy
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32. Therapeutic options: stem cells
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33. Therapeutic challenge: home care
• Medication starts in the hospital
• Medication continues in household enviroment, rural areas
• Doctor‘s contacts rare
• Patient‘s survey difficult.
• Therefore: narrow control schedules concerning
– Nurse directed home care
– Continuous medical education of both patient and personal
(nurses/doctors)
– Outpatient visits
– Establishing telemedical processes
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34. Therapeutic home care options
• Home care (nurse driven)
– Scheduled visits on regular basis (nurse, AMO)
– Visits following questionnaire
– Data acquisition and transmission
(telemedicine?)
• Severity of symptoms
• Daily activities ability
• Controls
– Medication
– Weight (listing by patient)
– Blood pressure
– other
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35. CHF Questionnaire; example
How do you feel since last visit? Scale of 10 pts
In your opinion, are there main changes:
breathing
weight gain
Urinary output
palpitation?
How do you think developed your personal daily
activities (DAs)?
worse
same
better
which kind of DAs is mostly impaired?
home
leisure
employment
What about your medication:
intake OK?
complaints?
self made changes?
incompatibilty?
wishes?
Suggestions?
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36. Heart Network
Patient
Hospital
OPD
District Hospital
Dispensary Home Care
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37. Heart Network: nurse
Hospital
Nurse
+
home care
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38. Heart Network: Internet
Patient data file, database: EPF*
Access by authorized personal
throughout the country
*electronic patient file
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39. Heart Network
• Telecardiology (telemedicine)
– Electronic provision of data transmission
– Generation of medical data in remote areas (rural)
– Overcoming of doctors shortages
– Secure transmission line
– Targets:
• Hospital Centers
• Home care physician
• Home care nurse
• Specialized medical call centers
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40. Heart Network
• Telemedical patient kit
– Smartphone with Apps (Skype)
– Balance
– ECG device
– Blood pressure device
– Glukose test kit
– Finger tip pulse oxymeter
– Questionnaire
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41. The End
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