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Management of Heart Failure

Management of Heart Failure. Prof. Karen Sliwa Department of Cardiology Chris Hani Baragwanath Hospital Johannesburg, South Africa. Definition: Imbalance between volume of blood supplied and the tissue requirements

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Management of Heart Failure

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  1. Management of Heart Failure Prof. Karen Sliwa Department of Cardiology Chris Hani Baragwanath Hospital Johannesburg, South Africa

  2. Definition: • Imbalance between volume of blood supplied and thetissue requirements • Definition of heart failure: Criteria 1 and 2 should be fulfilled in all cases • 1 Symptoms of heart failure (at rest or during exercise)like breathlessness, ankle swelling and fatigue • and2 Objective evidence of cardiac dysfunction (at rest) • and(in cases where the diagnosis is in doubt) 3 Response to treatment directed towards heart failure • Guidelines from European Society of Cardiology Task ForceW.J. Remme and K. Swedberg, European Heart Journal 2001; 22:1528

  3. How big is the Problem? • 2% of the total western population has heart failure • ( no data available for SA population) • Patients over 70 years, the prevalence is > 10 % • Only 50 % of all patients survive 4 years • Increasing prevalence due to ageing population and increasing survivors of MI

  4. Major Causes • Valvular heart disease • CAD • HT • Cardiomyopathy • Idiopathic • Ethanol • Viral • Infiltrative • Metabolic-hypothyroidism/DM • Pericardial dx • High output states • Incessant tachyarrythmias

  5. Evolution of Heart Failure Hunt SA et al J Am Coll Cardiol 2001;38:2101

  6. New York Heart Association (NYHA) 1 year Classes Description Survival Rate Early failure, no symptoms with regular exercise or restrictions Grade I > 95% Ordinary activity results in mild symptoms,but comfortable at rest Grade II 80 - 90% Advanced failure, comfortable only at rest;increased physical restrictions Grade III 55 - 65% Severe failure;patient has symptoms at rest 5 - 15% Grade IV  Heart failure is a chronic progressive disease Functional Classification

  7. Assessment of the patient with heart failure • Objectives of initial evaluation of a patient with possible or definitive heart failure: • Early diagnosis is important • In symptomatic patients can be in: • 1. Left heart failure • 2. Right heart failure • 3. Low cardiac output • 4. High cardiac output • Cause of heart failure • Identification of precipitating factors and reversible causes • Identify markers of prognosis: left ventricular function

  8. Investigations • Electrocardiogram • Most pts with CHF due to systolic dysfunction have a significant abnormality on ECG • Normal ECG 98% neg. predictive value • Evidence of • Ischeamic heart dx • LVH • Arrythmias eg atrial fib • DCMO – limb leads low voltage/precordial LVH, wide QRS, LBBB

  9. Investigations • CXR • Diff HF from lung dx • CTR>50% • Upper lobe diversion • Kerley-B • Pleural effusions

  10. Investigations • Routine blood tests: • Full blood count- Anemia • Blood urea nitrogen and creatinine- Renal Dysfunction • Electrolytes-Hyponatraemia,hypokalemia,hyperkalemia • Albumin-Hypoalbuminemia • Blood glucose-Diabetis mellitus • Thyroxine ( in patients with AF or who are >65 years and • the heart failure has no obvious etiology- Hyper • and Hypothyroidism

  11. Investigations • Echocardiography • Essential in all newly diagnosed • Detect • LV size & EF • Wall thickness / ‘texture’ • RWMA • Valve dx • Pericardial dx • Septal shunts • RV size, pressures & fn • LV thrombus • Expensive/Expertise

  12. LV thrombus postpartum

  13. Naturetic Peptides Features ANP BNP CNP Urodilatin Amino acids 28 32 22 or 53 32 (= ANP + 4) Main source cardiac atria cardiac vascular kidney ventricle endothelium Hormone type endocrine endocrine autocrine paracrine paracrine Main function Regulation of homeostasis of salt Regulation of Regulation of and water excretion and blood vascular tone water and sodium pressure (natriuretic, vasodilatory, reabsorbtion in renin-and aldosterone inhibitory collecting duct properties) Cardiac specific

  14. Sensitivity and specificity of clinical signs in HF 100 patients presenting to casualty with signs or symptoms of congestive heart failure(eg,dyspnea,edema, wt gain) Dao et al, 49th AnnualScientific Session ofthe American College of Cardiology

  15. Summary-Assessment of Heart Failure Heart failure is a composite of clinical symptoms, physical signs, and abnormalities on the hemodynamic, neurohormonal, biochemical, anatomic and cellular levels It’s a large problem both in the developed and developing world A thorough history is vital in identifying cause and precipitating factors Combination of clinical examination and basic investigations will aid in diagnosis, assessing severity and prognosis Echocardiography essential in newly diagnosed patients

  16. Acute heart failure and shock ( not discussed within this lecture): clinical presentation is regardless of the cause, with hypotension, tachycardia, tachypnea, oliguria causes: -acute MI ( 8% of all cases) -acute mitral regurgitation, eg. post MI -acute AR, eg. SBE, Aortic dissection, -Acute myocarditis -pericardial tamponade, -pulmonary embolism Chronic heart failure TREATMENT OF HEART FAILURE

  17. GOALS OF THERAPY IN CHRONIC HEART FAILURE

  18. Diuretics: • WHO ? • -Those with signs of Na and water retention • I.e. peripheral or pulmonary oedema,↑JVP Pharmacological Treatment-Diuretics

  19. Pharmacological Treatment-Diuretics • Spironolactone: • RALES TRIAL reduction in all cause mortality by • 27% in NYHA III-IV heart failure on conventional • treatment, 17% reduction in hospitalisations • WHO ? • -NYHA III-IV on diuretics/ACE/digoxin

  20. Pharmacological Treatment-Digoxin • Digoxin: • - DIG TRIAL: no net effect on mortality in CHF, does improve symptoms and reduce hospitalisations • - WHO ? • -Those with CHF in AF who need rate control • -Those with moderate or severe symptoms • despite optimal treatment

  21. Pharmacological Treatment-Neurohormonal antagonists • Angiotensin Converting Enzyme Inhibitors: • Several randomised controlled clinical trials as CONSENSUS I, SOLVD, VHeFT II have shown that in patients with CHF they reduce- • -mortality • -hospitalisation • -improve symptoms and signs • -slow progression from mild to congestive cardiac • failure

  22. Pharmacological Treatment-Neurohormonal antagonists • Angiotensin II Type I receptor antagonists: • WHO? • - Those intolerant to ACE-inhibitors ( especially because of • cough)

  23. Over 13,000 patients evaluated in placebo-controlled clinical trials Consistent improvement in cardiac function, symptoms and clinical status Decrease in all-cause mortality by 30–35% (p<0.0001) Decrease in combined risk of death and hospitalisation by 25–30% (p<0.0001) Pharmacological Treatment-Beta-blockers • Beta-blockers:

  24. US Carvedilol Study Survival 1.0 0.9 0.8 0.7 0.6 0.5 Carvedilol (n=696)  blockers in heart failure - all-cause mortality Placebo (n=398) Risk reduction = 65% p<0.001 0 50 100 150 200 250 300 350 400 Days Packer et al (1996) Survival Mortality % CIBIS-II 1.00.80.6 0 20 MERIT-HF Placebo Bisoprolol 15 Metoprolol CR/XL 10 Placebo Risk reduction = 34% Risk reduction = 34% 5 p=0.0062 p<0.0001 0 0 200 400 600 800 0 3 6 9 12 15 18 21 Months of follow-up Lancet (1999) Time after inclusion (days) The MERIT-HF Study Group (1999)

  25. Consensus recommendations All patients with stable class II or III heart failure due to left ventricular systolic dysfunction should receive a beta-blocker (in addition to an ACE inhibitor) unless they have a contraindication to its use or cannot tolerate treatment with the drug  blockers in heart failure

  26. Implications for public health Lives saved by treating 1000 patients for 1 year HOPE (ramipril) <1 SOLVD Prevention (enalapril) 7 SOLVD Treatment (enalapril) 17 MERIT-HF (metoprolol) 38 CIBIS-II (bisoprolol) 42 RALES (spironolactone) 52 COPERNICUS (carvedilol) 70 Packer, AHA 2000

  27. Management of acute exacerbation of chronic heart failure • Investigation and treatment of precipitating factors: infections, thiamine deficiency ( alcohol abuse), anaemia • Intermittent use of positive inotropic drugs: • WHO? • - patients admitted to hospital with severely decompensated heart failure, particular those with ‘ cardiorenal syndrome’ in which sufficient diuresis cannot be obtained without progressive deterioration of renal function

  28. New concepts in the treatment of heart failure • -Anti-inflammatory/cytokine therapy • -Modification of cardiac matrix • -Myocyte/Myoblast implant • -Biventricular pacing • -Anti-remodeling strategies • -Cardiac transplantation

  29. Summary-Treatment of CHF Heart failure is a composite of clinical symptoms, physical signs, and abnormalities on the hemodynamic, neurohormonal, biochemical, anatomic and cellular levels Therapy should aim: • To improve symptoms • Prevent progression of disease • Early diagnosis is important! • All patients should be on a beta-antagonists ( preferentially • carvedilol

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