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HEART FAILURE AND BREATHLESSNESS IN END STAGE CARE

HEART FAILURE AND BREATHLESSNESS IN END STAGE CARE. Dr K Ranjadayalan , Consultant Cardiologist BMI The London Independent Hospital Newham University Hospital. A Breathless patient. 57 yr old Male P/C Effort Dyspnoea for 6 weeks Bilateral leg swelling P/H H/T for 4 years

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HEART FAILURE AND BREATHLESSNESS IN END STAGE CARE

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  1. HEART FAILURE AND BREATHLESSNESS IN END STAGE CARE Dr K Ranjadayalan, Consultant Cardiologist BMI The London Independent Hospital Newham University Hospital

  2. A Breathless patient • 57 yr old Male • P/C Effort Dyspnoea for 6 weeks • Bilateral leg swelling • P/H H/T for 4 years • S/H - Non smoker, moderate alcohol intake

  3. A Breathless Patient • O/E No “JACC”, bilateral pitting oedema • CVS • Pulse-110/min, BP I 145/96, Raised JVP • Normal heart sounds • Increased respiratory rate • Scattered wheeze • RHC tenderness with hepatomegaly • Investigations ? In the community • Cause of breathlessness – • ? Cardiac (Heart Failure) • ? Respiratory

  4. Most likely Cause of his breathlessness is: • Left Heart failure • Late onset bronchial asthma • Chest infection • Right Heart failure • Congestive Heart failure **Please vote on the tablets provided

  5. Heart Failure • Definition • Different types of HF • Pathophysiology of HF • Causes of HF • When to suspect HF • Investigations & management of HF

  6. Natural History of Heart Failure Mechanism of Death Sudden Death 40% Worsened HF 40% Other 20% 100% Progression Survival Annual Mortality 30 - 80% < 5% 10% 20 - 30 % 0% Asymptomatic Mild Moderate Severe Left Ventricular Dysfunction and Symptoms

  7. Definition of HF • A clinical syndrome due to failure of the heart to maintain adequate cardiac output (blood flow) due to a structural or functional defect of the heart. • Structural defect - Common • Ventricular Dysfunction orValve malfunction • Structural defect - Uncommon • Abnormal shunts or Pericardial disease

  8. What happens when the Cardiac output drops? Body • Activation of Neurohormonalsystem • Diversion of blood flow to brain Heart • Increase in intracardiacpressures • Dilatation or hypertrophy of ventricles • Dilatation of atria • Fibrosis, Hypertrophy & apoptosis

  9. Neurohormonal activation in HF 1. Sympathetic activation • Vasoconstriction (Afterload) • Sinus tachycardia (Preload) 2. Renin Angiotensin Aldosterone system • Vasoconstriction (Afterload) • salt & water retention (Preload) Preload - volume of blood in the LV immediately before systole Afterload - resistance to blood flow in arteries

  10. Why ? • Cardiac Output = Stroke Volume (SV) X Heart Rate (HR) • Blood Pressure = Cardiac Output X Peripheral Resistance (PR) • SV - Increase in fluid retention, Sympathetic activation • HR - Sympathetic activation • PR – Vasoconstriction - Angiotensin 11 & sympathetic activation

  11. Neurohormonal activation in HF • Natriuretic peptides Atrial natriuretic peptides ( ANP) • Secreted from atria Brain natriuretic peptides ( BNP) • Secreted from ventricles (cardiac) Diuresis, vasodilatation (by reducing angiotensin, aldosterone, & endothelin)

  12. Types of Heart failure • *Left heart failure – Acute or Chronic • Right heart failure – Acute or Chronic • Congestive heart failure – Chronic * Functionally - Systolic or Diastolic

  13. Causes of Left Heart Failure (Acute or Chronic) 1.. Coronary artery disease 2.Hypertension • Valvular disease (congenital or acquired) • Cardiomyopathy – HCM, DCM, RCM, AF induced CM

  14. Hypertension to HF Obesity DiabetesIGT LVH Diastolic Dysfunction CHF HTN CAD Systolic Dysfunction Smoking Lipids Diabetes MI Overt HF LV Remodeling Normal LV Structureand Function Subclinical LV Dysfunction Adapted with permission from: Vasan RS, Levy D. Arch Intern Med. 1996;156:1790.

  15. Causes of Dilated Cardiomyopathy • Alcohol, cocaine • Connective tissue diseases • Drugs - Herceptin, Antidepressant • Endocrine causes – Thyroid, acromegaly, diabetes • Familial – 10 to 20% • Infiltration – Sarcoid, Fe deposits • Infection – viral • Pregnancy

  16. Causes of Right Heart Failure (Chronic) • Left Heart Failure - CCF • Chronic Lung disease – Cor Pulmonale • Recurrent Pulmonary embolism • Congenital Heart Disease • Idiopathic Pulmonary H/T

  17. When to suspect HF ?

  18. Left heart failure • Breathlessness on exertion • Fatigue • Paroxysmal nocturnal dyspnoea -2am • Orthopnoea (indicative of fluid overload) • Cough & wheezing (Cardiac)

  19. Signs of Left heart failure (1) • Increased respiratory rate • Increased heart rate (Sinus or atrial fib or flutter) • Sweating • Cyanosis • Cold extremities • BP- High, low, normal

  20. Signs of Left heart failure (2) • Cardiomegaly – Displaced apex • Third heart sound • Mitral or Aortic murmur • Crackles • Wheeze • Pleural effusion – bilateral or unilateral

  21. Symptoms of Right heart failure • Dyspnoea • Peripheral oedema • Abdominal distension • GI symptoms- Nausea, vomiting, loss of appetite

  22. Signs of Right heart failure • Raised JVP • Parasternal heave – RV enlargement • Murmur, third heart sound • Hepatomegaly with signs of liver dysfunction • Leg or sacral oedema • Ascites

  23. Basal crackles – specific for fluid overload-High PCWP • Clear lung fields tell you very little about the fluid status in heart failure • Examination of the neck veins is the best physical exam technique for determining the fluid status in heart failure

  24. Investigations of Heart Failure (Chronic) • ECG • Brain Natriuretic Peptides –BNP or NTpro BNP • CXR • Echocardiography • Blood tests • Angiography – Non invasive or invasive • Cardiac MRI – Ischaemic or Nonischaemic • Myocardial biopsy

  25. ESC Guidelines for Heart Failure Diagnosis Suspected Heart Failure because of symptoms & signs Assess presence of cardiac disease by ECG, X-ray or BNP(where available) Normal Heart Failure unlikely Test abnormal Normal Heart Failure unlikely Imaging by echocardiography Test abnormal Assess aetiology, degree, precipitating factors & type of cardiac dysfunction Additional diagnostic tests Where appropriate (e.g. coronary angiography) Choose therapy Eur Heart Journal (2001)22, 1527-1560

  26. Breathless patient 1

  27. Breathless patient 2

  28. Role of Echocardiography in HF • Gold standard investigation • Differentiates Systolic and diastolic dysfunction • Quantifies Systolic dysfunction - LVEF • Quantifies Diastolic dysfunction – Grade 1 to 4 • Identifies the cause of heart failure

  29. Treatment of Heart failure (Chronic) • Non pharmacological • Pharmacological • Surgical • Device therapy • Transplant

  30. Non pharmacological • Avoid alcohol, smoking & stress • Bed rest during acute exacerbations • Counseling • Diet low in salt • Exercise • Fluid restriction

  31. How Do We Make Heart Failure Patients (LVSD) Live Longer?  Angiotensin II (Renin-Angiotensin Aldosterone System [RAAS] Norepinephrine (Sympathetic Nervous System [SNS]) RAAS Inhibition -Blockade Disease Progression Devices

  32. How do we make Heart Failure patients Feel Better & Live longer? • Diuretics– Furosemide, metolazone • RASSInhibition– ACEI or ARBs, Anti Aldosterone • Beta blockers– Bisoprolol, Carvedilol, Metoprolol, Nebivolol

  33. Beta blocker in HF • Indicated for symptomatic & asymptomatic LVSD • Start low and go slow • Aim for heart rate 55 to 60/min • Benefit more in sinus rhythm than in AF patients

  34. Benefits of Beta blocker in HF • Reduce SCD and total death • Improve LV size and Function • Reduce onset of AF and VT • Meta analysis of 19,000 patients

  35. Spironolactone in HF • Aldosterone antagonist spironolactone at low dose (12.5 mg to 25 mg once daily) should be considered for NYHA Class 11 or IV Heart failure • Serum potassium concentration should be monitored after the first week and at regular intervals thereafter and after any change in dose of spironolactone • For spironolactone intolerant patients or young males consider Eplerenone • Avoid in significant renal dysfunction

  36. Digoxin in HF • No prognostic benefit • Cardiac tonic – reduce symptoms and admissions • Can be used for rate control of AF if rhythm control not possible

  37. Device therapy in HF • ICD 2. Biventricular pacing- CRT

  38. Why ICD ? • Sudden cardiac arrest is 6 to 9 times more likely in HF than in the general population • Sudden death is caused most commonly by VT or VF in patients with LV dysfunction • 90% of patients do not survive their first cardiac arrest

  39. Indications for ICD • Impaired LV with sustained or non sustained VT • Resuscitated VF/VT arrests not due to reversible cause • Patients with Previous MI , LVEF<35%,QRS >120

  40. 3. LVAD 4.Heart transplant

  41. Summary • Heart failure is common and the prevalence is increasing • The main cause of systolic HF is CAD & Diastolic HF- H/T • The burden of HF is the disabling symptoms, activity limitation, arrhythmias, frequent hospitalisations and high mortality • Pharmacological treatment and device therapy have been shown to improve the outcome in systolic but not diastolic HF • Patients with advanced Heart failure and their families should be offered supportive care

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