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HEART FAILURE Prevalence increasing in our ageing population

HEART FAILURE Prevalence increasing in our ageing population Incidence doubles with each decade between 40 and 80 At any age more common in men than women One of the commonest causes of hospital admission. Heart Failure

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HEART FAILURE Prevalence increasing in our ageing population

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  1. HEART FAILURE Prevalence increasing in our ageing population Incidence doubles with each decade between 40 and 80 At any age more common in men than women One of the commonest causes of hospital admission

  2. Heart Failure A cardiac disorder that prohibits delivery of sufficient output to meet the perfusion requirements of metabolizing tissues 2. A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic and hormonal responses

  3. Causes of heart failure • Coronary artery disease • Hypertension • Cardiomyopathy • Valvular heart disease • Other causes

  4. Heart failure: aggravating factors • Cardiac arrhythmias (esp AF) • Hypertension • Anaemia • Chest infection

  5. Compensatory Physiology in Heart failure Sympatho-adrenal activation Renin-angiotensin activation Redistribution of venous flow Salt and water retention Ventricular dilatation Inotropic state Myocardial mass  Contractile Function

  6. Heart failure: symptoms and signs Symptoms Signs cardiac output fatigue cool skin (peripheral hypoperfusion) peripheral cyanosis Fluid retention dyspnoea basal crackles (congestion) oedema JVP ankle swelling, ascites sympathetic activity - tachycardia sweating Other findings - S3, alternating pulse

  7. Heart failure: S3, alternating pulse S3

  8. Heart failure: ECG (never normal) Inferior Q waves Anterior T wave + ectopics Left bundle branch block

  9. Heart failure: CXR Pulmonary oedema Pulmonary congestion

  10. Heart failure: m-mode echo Cardiomyopathy: global LV dysfunction S3 Coronary heart disease: regional LV dysfunction

  11. Heart failure: 2D echo 4 chamber view LV Long axis view RV RV RA LV LA LA

  12. Heart failure: brain natriuretic peptide (BNP) • Secreted by myocardial cells in response to raised left atrial pressure • Promote natriuresis, vasodilatation • Inhibit ADH and aldosterone release • Levels >50pg/ml indicate heart disease as cause of dyspnoea and fluid retention

  13. Heart failure: Complications • Intravascular thrombosis • pulmonary embolism • systemic embolism • Infection • chest infection • ulcerated cellulitic legs • Functional valvular dysfunction • MR, TR • Multi-organ failure • renal failure • liver failure • Cardiac Arrhythmias • AF • VT VF • Sudden death

  14. Heart failure: non-drug treatment • Severely oedematous patient • bed rest • nurse in head up position • oxygen therapy • aspiration of large pleural effusions • salt restriction • Ambulant patient • no added salt • regular walking exercise

  15. Heart failure: treat aggravating factors • Atrial fibrillation • rate control + warfarin • DC cardioversion • Hypertension • ACE-Is + beta blockers + diuretics • Anaemia • haematinics • erythropoetin (?) • blood transfusion (?) • Chest infection • physiotherapy • antibiotics

  16. Treatment of Heart failure Sympatho-adrenal activation Renin-angiotensin activation Redistribution of venous flow Salt and water retention Beta-blockers ACE-Is, ARBs Spironolactone Ventricular dilatation Inotropic state Myocardial mass  Contractile Function

  17. Treatment of Heart failure: Evidence base Beta-blockers Carvedilol in the COPERNICUS trial Circulation 2002 ACE-Inhibitors Meta-analysis of all randomized trials Lancet 2000 ARBs Losartan in ELITE II Placebo Captopril Losartan ACE-I Lancet 2000 Spironolactone RALES trial NEJM 1999

  18. Heart failure: treatment • Fluid retention • diuretics • Symptoms and prognosis in systolic heart failure • Drugs • ACE-Is (all grades of heart failure) • ARBs (if ACE-Is cannot be tolerated) • beta-blockers (all grades of heart failure) • spironolactone (NYHA grade III and IV only) • Devices • Cardiac resynchronization therapy (CRT)

  19. Heart failure: treatment of • complications • Atrial fibrillation • cardioversion (often not possible) • rate control (beta-blockers ± digoxin) • warfarin • Ventricular arrhythmias • implantable defibrillator

  20. Canadian Implantable Defibrillator Study Circulation 2004

  21. Heart Transplantation • Indications: resistant ccf without: • major organ failure • major co-morbidity • psychological disability • severe pulmonary hypertension • Procedure • orthotopic transplant • Prognosis • 80% 1 year survival

  22. Prognosis of Heart Failure

  23. The End

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