Cardiology Review: Heart Failure and Valve Disease April 8, 2013

1. Cardiology Review:Heart Failure and Valve DiseaseApril 8, 2013 Dr. Lisa M Mielniczuk Assistant Professor Medicine University of Ottawa Heart Institute

2. Outline • Heart Failure • Causes • Symptoms • Treatments • Cardiomyopathies • Approach to valve disease • Mitral stenosis and regurgitation • Aortic stenosis and regurgitation

3. Define Heart Failure

4. Definition • Condition where the heart cannot pump an adequate supply of blood at normal filling pressures to meet the metabolic needs of the body • HF is a complex syndrome in which abnormal heart function results in • clinical symptoms and signs of • low cardiac output and/or • pulmonary or systemic congestion

5. Pathophysiology of Heart Failure Increased contractility Normal Stroke volume (cardiac output) A Heart Failure B C Hypotension Pulmonary congestion Left ventricular end diastolic pressure (volume)

6. Cardiomyopathy • Characterized by ventricular • Dilatation • Hypertrophy • Frank Starling: CO = SV x HR • Laplace: Tension = Press x rad/ 2 x thick

7. WHAT CAUSES HEART FAILURE?

8. Classification of Heart Failure Causes Multiple ways to consider classification: Etiologic Systolic vs. Diastolic Right vs. Left

9. General Causes of HF • Coronary artery disease / myocardial infarction • Valvular disease • Hypertension • Diabetes • Cardiomyopathy • A. DILATED • Idiopathic • Myocarditis / pericarditis • Arrhythmias • Thyroid disease • Pregnancy • Toxins (alcohol, chemotherapy) • B. HYPERTROPHIC • C. RESTRICTIVE

10. Mechanisms and Causes of HF Impaired Contractility • Myocardial infarction • Transient ischemia • Chronic volume overload • MR/AR • Dilated cardiomyopathy Increased Afterload • AS • Uncontrolled HTN Systolic Dysfunction Left Sided HF Diastolic Dysfunction Impaired ventricular relaxation • LVH • Hypertrophic cardiomyopathy • Restrictive cardiomyopathy • Transient ischemia Obstruction of LV filling • MS • Pericardial constriction or tamponade

11. Mechanisms and Causes of HF • Cardiac Causes • Left sided HF • Pulmonary stenosis • Right ventricular infarction Right Sided HF • Parenchymal pulmonary disease • COPD • Interstitial lung disease • Chronic infections • Adult respiratory distress syndrome • Pulmonary Vascular Disease • Pulmonary emobolism • Pulmonary HTN • Right ventricular infarction

12. The Heart Failure Continuum poor prognosis average 1-year mortality rate of 33%

13. HOW DO YOU DIAGNOSE HEART FAILURE ?

14. Diagnosis of HF Constellation of symptoms and signs CXR Echocardiogram MUGA Serum BNP testing

15. Symptoms and Signs of HF Increased filling pressures Poor Cardiac Output Congestion Poor Perfusion

16. Assessing Perfusion Symptoms Fatigue Confusion Dyspnea Signs Hypotension Tachycardia Cool extremities Altered mental status Rising creatinine Liver enzyme abnormalities

17. Congestion Left-Sided Symptoms Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Signs S3 gallop Displaced apex MR Pulmonary rales Loud P2 Right-Sided Symptoms Peripheral edema Abdominal bloating Nausea Anorexia Signs Elevated JVP Hepatomegaly Ascites Edema

18. Evaluating the JVP • Consensus: <2 cm above the sternal angle considred normal and >4cm ASA is abnormal • http://cal.fmc.flinders.edu.au/gemp/ClinicalSkills/clinskil/year1/cardio/cardio04.htm

19. Diagnosis of HF Constellation of symptoms and signs CXR Echocardiogram MUGA Serum BNP testing

20. Pulmonary Edema • General Considerations • Increase in the fluid in the lung • Generally, divided into cardiogenic and non-cardiogenic categories. • Pathophysiology • Fluid first accumulates in and around the capillaries in the interlobular septa (typically at a wedge pressure of about 15 mm Hg) • Further accumulation occurs in the interstitial tissues of the lungs • Finally, with increasing fluid, the alveoli fill with edema fluid (typically wedge pressure is 25 mm Hg or more)

22. Cardiogenic pulmonary edema Heart failure Coronary artery disease with left ventricular failure. Cardiomyopathy Obstructing valvular lesions -- for example Fluid overload -- for example, kidney failure. Non-cardiogenic pulmonary edema -- due to changes in capillary permeability LUNG Smoke inhalation Near-drowning Overwhelming aspiration Acute Respiratory Distress Syndrome (ARDS) Acute lung re-expansion High altitude pulmonary edema CAPILLARY Overwhelming sepsis Disseminated intravascular coagulopathy (DIC) Cardiogenic vs. Noncardiogenic pulmonary edema

23. cardiogenic pulmonary edema Kerley B lines (septal lines) Seen at the lung bases, usually no more than 1 mm thick and 1 cm long, perpendicular to the pleural surface Pleural effusions Usually bilateral, frequently the right side being larger than the left If unilateral, more often on the right Fluid in the fissures Thickening of the major or minor fissure Peribronchial cuffing Visualization of small doughnut-shaped rings representing fluid in thickened bronchial walls Non-cardiogenic pulmonary edema Bilateral, peripheral air space disease with air bronchograms or central bat-wing pattern Kerley B lines and pleural effusions are uncommon Typically occurs 48 hours or more after the initial insult Stabilizes at around five days and may take weeks to completely clear CXR Findings of Pulmonary Edema

26. Diagnosis of HF Constellation of symptoms and signs CXR Echocardiogram MUGA Serum BNP testing

27. SO YOUR PATIENT HAS HEART FAILURE… WHAT NOW?

28. Functional Classification ACC/AHA STAGES OF HEART FAILURE • STAGE A • High risk for developing HF (diabetes, CKD, HTN) • No structural disorder of the heart • STAGE B • Structural disorder of the heart (e.g.. Previous MI) • Not yet developed symptoms of HF • STAGE C • Past or current symptoms of HF • Symptoms associated with underlying structural heart disease • STAGE D • End stage disease • Requires specialized treatment strategies NYHA FUNCTIONAL CLASS • CLASS I • No symptoms and no limitations in physical activity • No shortness of breath when walking, climbing stairs etc. • CLASS II • Mild symptoms and slight limitation during ordinary physical activity • CLASS III • Marked limitation in activity due to symptoms (fatigue, shortness of breath) with less than ordinary activity (e.g.. Short distances or ADL’s) • CLASS IV • Severe limitation, may experience symptoms at rest INCREASING SEVERITY OF HEART FAILURE

29. HOW DO YOU TREAT HEART FAILURE?

30. Goals of Therapy • 1. Identify and Treat the Underlying Cause • Cardiac cath if necessary • 2. Eliminate the acute precipitant • 3. Manage HF symptoms • 4. Slow progression of LV disease • 5. Improve long-term survival

31. Precipitants of HF • Increased metabolic demands • Fever, anemia, infection, tachycardia, hyperthyroidism, pregnancy • Increased circulating volume • Excessive salt or fluid in diet • Renal failure • Increased afterload • Hypertension • PE • Impaired contractility • Negative inotropes • Ischemia • Failure to take medications Progression of underlying disease

32. sprionolactone BB ACE I diuretics

33. Management • 1. Education • Fluid and salt restriction • Daily weights • Avoid precipitants • 2. Diuretics if volume overloaded • 3. Neurohormonal modulation • ACE-I • bB • spironolactone • 4. Devices • CRT • ICD • 5. Referral for cardiac transplantation

34. Who needs an ACE-I? • All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists SOLVD Investigators. N Engl J Med 1991;325:293-302. Flather MD et al. Lancet 2000;355:1575-81. CONSENSUS Trial . N Engl J Med 1987;316:1429-35. These trials form the basis of ACE-I use in HF with LVEF < 40% and/or post-MI with reduced LVEF and/or HF

35. Who needs a bB? • All HF patients with LVEF 40% (use clinically proven beta-blocker) • In stabilized HF patients with NYHA Class IV symptoms MERIT-HF Study Group. Lancet 1999;353:2001-7. CIBIS II Investigators. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9.

37. Other Drugs ? • Nitrates • Digoxin • Spironolactone

38. Management Strategy Severe symptoms: refer to specialist, ER or HF clinic If EF>40%: treat cause (HTN) If EF<40% • Education • Risk factor reduction • Fluid/salt regimen intolerant Prescribe ARB ACE I +Beta blocker Consider nitrates Titrate to target doses If QRS>120, consider CRT Continue therapy Clinically stable If EF<30% consider ICD • Add ARB • Digoxin or nitrates NYHA III • Combo diuretics • spironolactone Class IIIb-IV Can J Cardiol 2007; 23

39. What does the MCC want? • How will you make the diagnosis? • Keep it on your differential of acute/chronic dyspnea • Look for the signs and symptoms of heart failure • Recognize the underlying causes of HF • Echo/ chest xray / labs

40. What does the MCC Want? • How will you treat? • Acutely: diuretics, identify and remove precipitant • Chronically: beta blocker, ACEI etc. • When to refer to a specialist? • Persistent or severe symptoms • Poor treatment response • Uncertain diagnosis

41. CARDIOMYOPATHY

42. Classification of Cardiomyopathy

45. Dilated Cardiomyopathy CAD is the most common cause of systolic dysfunction What are the other non-ischemic causes of a dilated cardiomyopathy? Idiopathic (50%) Familial Substance abuse Myocarditis Infiltrative disease Peripartum HIV Chemotherapy Electrolyte imbalance Nutritional: thiamine,scurvy

48. WHO Definition Left and or right ventricular hypertrophy which is usually asymmetric and involves the interventriucular septum Inappropriate ventricular hypertrophy without a cardiac or systemic cause

49. Restrictive CM What are some causes of restrictive CM? Amyloidosis Sarcoidosis Hemochromatosis Chemotherapy Endomyocardial fibrosis

50. Valvular Disease