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Congestive Heart Failure A Real Threat

Congestive Heart Failure A Real Threat. Etiology. Systolic Dysfunction(Decreased contractility): Reduction in muscle mass(due to ishcemia&MI ) Dilated cardiomyopathies ( idiopathic,viral,alcoholic ) Ventricular Hypertrophy: Pressure overload(systemic or pulmonary hypertension,

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Congestive Heart Failure A Real Threat

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  1. Congestive Heart Failure A Real Threat

  2. Etiology Systolic Dysfunction(Decreased contractility): Reduction in muscle mass(due to ishcemia&MI) Dilated cardiomyopathies(idiopathic,viral,alcoholic) Ventricular Hypertrophy: Pressure overload(systemic or pulmonary hypertension, aortic or pulmonic valve stenosis) Volume overload(valvularregurgitation,high output states)

  3. Etiology • Diastolic Dysfunction(restriction in ventricular filling): • Increased ventricular stiffness • Ventricular hypertrophy • Infiltrative Myocardial disease (endomyocardial fibrosis) • Myocardial ischemia and infarction • Mitral or Tricuspid valve stenosis • Pericardial disease(Pericarditis)

  4. Compensatory mechanisms in heart failure

  5. Classification(NYHA)

  6. Classification(AHA)

  7. Treatment

  8. Treatment (Con,t) • Stage A: • Treat Risk factors: • Control Glucose level • Control BP • Dyslipidemia • Thyroid disorder • Valvular disease • Avoid drugs which aggravate heart failure

  9. Class II Wet Sx Diuretics (loop) + ACE Dry Sx ACE  + B  (no diuretics) Sx don’t resolve Sx resolve didn’t improve improved give digoxin digoxin Spironolactone + B Spironolactone improved didn’t improve improved didn’t improved Plan B Spironolactone Plan B Give B Spironolactone

  10. Class III  directly give ACE inh & Loop Sx still exist Px responded Digoxin B & Spironolactone Didn’t respond Didn’t respond Plan B Plan B

  11. Class IV (see if you hospitalize him or not) ACE  + Loop D + digoxin (don’t start B) If Px was already on B Did not respond optimize it Plan B Plan B Stage D worsening Stage C (II, III, IV)

  12. Give aggressive diuretic therapy IV (thiazide and loop) to cause profound diuresis • (give IV due to diuretic resistance • Give iv high dose • give combination Give positive inotropic agents (he is already on ACE inh, digoxin) improve Taper down +inotrop and go back to chronic Tx Plan B Stage D or worsening Stage C Hospitalize your Px. Optimize drug therapy if not improved wet dry not improved • Tissue hypoperfusion • SBP < 80 • Worsening renal function • ↙Na  hypervolemia dilutional hyponatremia cyanosis • Hemodynamic Monitoring (monitor BP, temp., CO, T0).

  13. Treatment (Con,t) • Stage B=Class I • ACE inhibitors Or • Beta blocker if recent or previous MI& reduced ejection fraction due to remodeling • Stage C Є class II,III,&IV • ACE inhibitors & Beta blockers In all Px • If Sx still exist Or EF still low Add Digoxin • When symptoms resolves add aldactone

  14. Role of drugs in CHF

  15. Angiotensin converting enzyme inhibitors • Cardioprotctive effect • Preload & Afterload • RA system less Na/water retention • bradykinin level vasodilation • mortality, hypertrophy, & fibrosis

  16. ACE inhibitor Approved for Use in HF

  17. BETA BLOCKERS • Mortality • Vasoconstriction • Carvidilol alpha+beta blocker &antioxidant effect • Bisoprolol • Metoprolol

  18. DIGOXIN • + inotropic effect • sympathetic output from CNS(NE) • Not mortality but improve Sx • Therapeutic level: 0.5-1ng/ml for CHF • Max: 1-1.5ng/ml for A fib

  19. Clinical Pharmacokinetics of Digoxin

  20. Diuretics • Sx relief of edema & pulmonary congestion • Direct vasodilation , Preload • DOC: Furosamide: Na excretion 20-25% Thiazide: Na Excretion 5-8% • Dose: 20-40mg bid Up to 400mg as max dose If Clcr>30ml/min dose up to 1-3g/d

  21. Loop Diuretics Used in HF

  22. Spironolactone • Aldosterone, preload,ventricular remodeling • Morbidity &mortality(Rales study) • Used if Scr<2.5mg/dl & K<5meq/L • Aplerenone • No gynecomastia • Mortality & morbiity in acute MI

  23. ANGIOTENSIN RECEPTOR BLOCKER • Persistent cough &angioedema due to ACE inhibitors • If persistent HTN Add ARB or CaCh blocker (amlodepine) • If concomitant angina: add nitrate or amlodepine

  24. New Drug Investigation Natriuretic Peptides: Atrial Natriuretic Peptides (ANP) Brain Natriuretic Peptides (BNP C-type Natriuretic Peptides (CNP) Neseritide: Recombinant BNP

  25. New Drug Investigation Omapatrilat: Vasopeptidase Inhibitor ACE inhibitor INH neutral endopeptidas Bradykinin & NP SE: Angiodema

  26. Precipitating factors in Heart failure Decompensation • Noncompliance with drugs or diet • Cardiac Ischemia • Inadequate therapy at time of admission • Cardiac arrhythmias • Uncontrolled hypertension

  27. Thank YOU

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