Systolic Heart Failure

1. Systolic Heart Failure Eugene Yevstratov MD http://www.ctsnet.org/home/eyevstratov

2. Definition Inability to pump an adequate volume of blood and/or to do so only from an abnormally elevated filling pressure,is that heart failure, can be caused by an abnormality in systolic function leading to a defect in the expulsion of blood i.e. Systolic Heart Failure http://www.ctsnet.org/home/eyevstratov

3. Causes • Coronary artery disease • Valvular heart disease • Hypertension and aging • Diabetes • Dilated cardiomyopathy http://www.ctsnet.org/home/eyevstratov

4. NYHA classification of heart failure symptoms • Class 1: No limitations, ordinary physical activity does not cause undue fatige, dyspnoea or palpitation (asymptomatic LVD) • Class 2: Slight limitation of physical activity, such patients are comfortable at rest (symptomatically ¨mild¨heart failure) • Class 3: Marked limitation od physical activity, less then ordinary physical activity will lead to symptoms (symptomatilcally ¨moderade¨heart failure) http://www.ctsnet.org/home/eyevstratov

5. Echo Morphological Classification • Segmental dysfunction Focal scarring/dyskinesis most likely ischemic origin,but significant regional asymmetry (even without LBBB) often seen in DCM • Global dysfunction May be due to any of the causes of systolic dysfunction, including CAD http://www.ctsnet.org/home/eyevstratov

6. SHF vs Normal Heart Value • End diastolic volume 135 mVm2 (N80) • End Systolic volume 105 ml/m2 (N40) • Stroke volume 30 ml/m2 (N40) • Ejection fraction 20 % (N50) • End diastolic pressure 25 mmHg (N10) http://www.ctsnet.org/home/eyevstratov

7. Left ventricular systolic dysfunction is defined as an ejection fraction of less than 40% http://www.ctsnet.org/home/eyevstratov

8. Clinical Symptoms • Dyspnoea • Fatigue • Periferal oedema • Orthopnoea • Paroxysmal nocturnal dyspnoea Hallmark symptoms Spesific symptoms http://www.ctsnet.org/home/eyevstratov

9. Nearly 50% of patients with heart failure die within five years of the onest of symptoms http://www.ctsnet.org/home/eyevstratov

10. Identification of SHF http://www.ctsnet.org/home/eyevstratov

11. CAD producing ischemic cardiomyopathy is the most common cause of left ventricular systolic dysfunction http://www.ctsnet.org/home/eyevstratov

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13. Physiology http://www.ctsnet.org/home/eyevstratov

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15. Preload http://www.ctsnet.org/home/eyevstratov

16. Afterload http://www.ctsnet.org/home/eyevstratov

17. - - LV remodeling Pressure overload Volume overload normal Increased DP Increased SP Icreased Sσ Icreased Dσ + Series addition of new safcomeres Parallel addition of new myofibrils Chamber enlargement Wall thickening http://www.ctsnet.org/home/eyevstratov Concentric hypertrophy Eccentric hypertophy

18. 2 1 4 5 3 Ventricular Hypertrophy 3 http://www.ctsnet.org/home/eyevstratov

19. Systolic vs Diastolic Dysfunction http://www.ctsnet.org/home/eyevstratov

20. Treatment of SHF • Diuretics • Positive Inotropics Drugs • Direct-Acting Vasodilators • Neurohormonal Antagonists http://www.ctsnet.org/home/eyevstratov

21. Treatment of SHF http://www.ctsnet.org/home/eyevstratov

22. Tailored Therapy for Advanced Heart Failure • IV nitroprusside and diuretics tailored to hemodynamics goals • PCW <15mmHg • Measurment of baseline hemodynamics • SVR< 1200 dynes/s/cm-5 • RA < 8mmHg • SBP > 80 mmHg http://www.ctsnet.org/home/eyevstratov

23. Definition of optional hemodynamics by 23 – 48 hours • Titration of high-dose oral vasodilators as nitroprusside weaned • (combination of captopril, ISDN, hydralazine as needed as alternative or addition) • Monitored ambulation and diuretic adjustment for 24 – 48 hours • Maintain digoxin levels 1.0 – 2.0 ng/dl if no contraindication http://www.ctsnet.org/home/eyevstratov

24. Eugene Yevstratov MD http://www.ctsnet.org/home/eyevstratov