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Congestive Heart Failure

Congestive Heart Failure. Prof. Gianfranco Piccirillo MD, PhD Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche.

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Congestive Heart Failure

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  1. Congestive Heart Failure Prof. Gianfranco Piccirillo MD, PhD Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche

  2. DefinitionClinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. Congestive Heart Failure

  3. Terminology (European Heart Journal 2016; 37- ESC GUIDELINES) Congestive Heart Failure

  4. Terminology Refractory end-stage HF Symptomatic HF Asymptomatic HF Previous MI;LV systolic disfunction; Asintomatic valvular disease High Risk for Developing HF Hypertension;CAD; Diabetes Mellitus Family history of cardiomiopathy Congestive Heart Failure

  5. Terminology • KillipClassification of CHF • Class I: no clinical signs of heart failure • Class II: crackles, s3 gallop and elevated jugular venous pressure • Class III: frank pulmonary edema • Class IV: cardiogenic shock In-Hospital Mortality by Killip Class Congestive Heart Failure

  6. Prevalence, Incidence and Mortality rates • Prevalence • Worldwide: 23 million • USA: 5.8 million • Europe: 15 million • Incidence • Worldwide: 2 million new cases/year • USA: 550.000 new cases/year • (CirculationResearch 2013) • Mortality at 5 years of follow-up: • 24.4% for age 60 year • 54.4% for age 80 year • (JAMA Internal Medicine 2015; 175) Congestive Heart Failure

  7. Etiology Common causes of chronic heart failure -Coronary artery disease -Hypertensive cardiovascular disease -Diabete mellitus -Valvular heart disease -Dilated cardiomyopathy (20-30% are familial) -Infiltrative cardiomyopathy -Hypertrofic cardiomyopathy Congestive Heart Failure

  8. Etiology Exacerbatingfactors for acute heartfailure -Acute myocardialinfarction -Uncorrected high blood pressure -Atrialfibrillation and otherarrhythmias -Negative inotropicdrugs (e.g. verapamil, nifedipine) -Otherdrugs (e.g. nonsteroidal anti-inflammatorydrugs) -Endocrine abnormalities (e.g. diabete mellitus) -Drugnoncompliance -Concurrentinfection Congestive Heart Failure

  9. Etiology Congestive Heart Failure

  10. Titolo Presentazione

  11. HEART FAILURE “PROGNOSIS”

  12. Pathophysiology Congestive Heart Failure

  13. Pathophysiology Metabolic Syndrome Criteria Congestive Heart Failure

  14. Pathophysiology Congestive Heart Failure

  15. Pathophysiology Congestive Heart Failure

  16. Etiology Congestive Heart Failure

  17. HFpEFAcute (diastolicHeartFailure) pulmonaryedemaAtrialFibrillationMyocardialInfarctionHFrEF(sistolicHeartFailure) Cerebral Infarction/hemorrhage Vasculopaties Disseminated Cerebral Coronary Sudden Arrhithmic Death Coronary Artery Disease Congestive Heart Failure

  18. Congestive Heart Failure

  19. Congestive Heart Failure

  20. Pressure-volume loops Congestive Heart Failure

  21. Progression of left ventricle morphology Diastolic disfunction Sistolic disfunction Congestive Heart Failure

  22. Symptoms and signs Congestive Heart Failure

  23. Symptoms and signs Congestive Heart Failure

  24. Diagnosis Congestive Heart Failure

  25. Echocardiography • Transthoracicechocardiography (TTE) • is the method of choice for assessment • of myocardialsystolic and diastolic • function of bothleft and right ventricles. • Assessment of LV measuringLVEF • Assessment of RV and pulmonary • Arterial pressure measuring • TAPSE (tricuspidannularplane • systolicexcursion) and tissue • Doppler-derivedtricuspidallateralannular • systolicdysfunction Congestive Heart Failure

  26. Echocardiography • DIASTOLIC FUNCTION EVALUATION • By Doppler echocardiography the left • ventricular filling is analyzed both by • transvalvular mitral flow (related to changes in the gradient A-V) and through the flow profile of the pulmonary veins (faithful mirror of the left atrial filling) Congestive Heart Failure

  27. Echocardiography • The components of the transvalvular mitral flow velocity are formed by the wave E (early diastolic rapid filling) and A wave (atrialdiastolic contraction). • Useful indication of diastolic function can be deduced from: • E/A ratio • the deceleration time (DT) • isovolumic relaxation time (IVRT) Congestive Heart Failure

  28. Congestive Heart Failure

  29. Echocardiography • Pulmonary Vein Flow: • There are usually four distinct components in the PVF: •   S1 corresponds to protosistole and is • determined by atrial relaxation • S2 corresponds to the meso and • end-systole and is determined by the increase in pressure in VP • D corresponds to the proto and • mesodiastole and is determined by the decrease of left atrial pressure related to the opening of the mitral • A corresponds to the end-diastole and is determined by atrial systole Congestive Heart Failure

  30. Echocardiography Congestive Heart Failure

  31. Echocardiography Congestive Heart Failure

  32. Echocardiography Normal Pattern: IVRT 70-90 msec DT about 200 msec 1< E/A <2 S/D about 1 Congestive Heart Failure

  33. Echocardiography Congestive Heart Failure

  34. Echocardiography Congestive Heart Failure

  35. Echocardiography Mild diastolic disfunction (grade 1, impaired relax): IVRT >100 msec DT > 220 msec E/A <1 S/D >1.5 Congestive Heart Failure

  36. Echocardiography Modearate diastolic disfunction (grade 2, pseudonormal) : IVRT 60-100 msec DT 150-200 msec 1<E/A <2 S/D about 1 Ar wave>0.3 m/s Congestive Heart Failure

  37. Echocardiography Severe diastolic disfunction (grade 3, restrictive) : IVRT <60 msec DT <150 msec E/A >2 S/D < 1 Ar wave >>0.3 m/s Congestive Heart Failure

  38. HFpEF HFrEF Congestive Heart Failure

  39. Congestive Heart Failure

  40. Diastolic Heart Failure (HFpEF)in heart failure with preserved ejection fraction (which is the most frequent type of failure ever) hypertensive crisis are the most frequent precipitating factor, followed by poor compliance of patients to therapy (often elderly patients with co-morbidities) Congestive Heart Failure

  41. Recommendations to prevent or delay the development of overt heart failure or prevent death before the onset ofsymptoms Congestive Heart Failure

  42. Pharmacological treatments indicated in patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction (HFrEF) ACEi= angiotensin-converting enzyme inhibitor MRA=mineralcorticoid receptor antagonist d)Or Angiotensin Receptor Blocker if ACEi is not tollerated/controindicated HRQOL=heart-related quality of life HTN= hypertension Congestive Heart Failure

  43. ARNI= angiotensin receptor neprilysin inhibitor (new therapeutic class of agents acting on the renin-angiotensin-aldosterone system) CRT= cardiac resynchronization therapy H-ISDN=hydralazine and isosorbide dinitrate LVAD= left ventricular assist device OMT= optimal medical therapy VT/VF= ventricular tachycardia/fibrillation ICD= implntable cardioverter defibrillator Congestive Heart Failure

  44. Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) HFrEF Congestive Heart Failure

  45. Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) HFrEF PUFA= polyunsaturated fatty acid Congestive Heart Failure

  46. Pharmacological targets in Renin-Angiotensin-AldosteroneSystem Congestive Heart Failure

  47. Evidence-based doses of disease-modifyingdrugs in key randomized trials in heart failure withreduced ejection fraction (or after myocardialinfarction) Congestive Heart Failure

  48. Recommendations for implantable cardioverter-defibrillator in patients with heart failure Congestive Heart Failure

  49. Cardiac resynchronization therapy Congestive Heart Failure

  50. Thankyou for yourattention Congestive Heart Failure

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