Academic Presentation Chronic Heart Failureจั�ดทำ��โดยนสภ . ม�รุ�ตต� ตรุ�อิ�นทำอิง รุหั�ส 47210463นสภ . ชฎ�พรุ พรุมปั�ญญ� รุหั�ส 47230007แหัล่�งฝึ!ก : โรุงพย�บ�ล่เช�ยงรุ�ยปัรุะช�น�เครุ�ะหั�

Chronic Heart Failure (CHF)

• complex clinical syndrome that can result f rom any structural or functional cardiac di

sorder that impairs the ability of the ventri cle to fill with or eject blood

• a condition in which the heart cannot pum p enough blood to meet the tissue needs of

the body

Symptoms and signsSymptoms• Dyspnoea• Orthopnoea• Paroxysmal nocturnal

dyspnoea• Reduced exercise tole

rance, lethargy, fatigue

• Nocturnal cough• Wheeze• Ankle swelling• Anorexia

Signs• Cachexia and muscle w

asting• Tachycardia• Pulsus alternans• Elevated jugular venou

s pressure• Displaced apex beat• Right ventricular heave• Crepitations or wheeze• Third heart sound• Oedema• Hepatomegaly (tender)• Ascites

Causes of heart failure•สาเหตุ�ที่ที่�าให เกิ�ดพยาธิ�สภาพของกิล้ ามเนื้��อห�วใจ

▫ ischemic heart disease▫cardiomyopathies▫myocarditis

•สาเหตุ�ที่เกิยวข องกิ�บล้��นื้ห�วใจ▫valvular stenosis▫valvular regurgitation

•สาเหตุ�ที่เกิยวข องกิ�บจ�งหวะกิารเตุ นื้ของห�วใจ•สาเหตุ�อ�นื้ๆ

▫hypertension▫pulmonary hypertension▫shunt (e.g. ASD, VSD)

Evaluation of Patients

•medical history•physical examination•echocardiography with Doppler flow study•laboratory testing•hemodynamic monitoring

ปัรุะเภทำขอิงโรุคหั�วใจัล่*มเหัล่วแบ%งตุามล้�กิษณะกิารที่�างานื้ที่ผิ�ดปกิตุ�ของ

ห องห�วใจ•systolic heart failure

▫EF < 40% : systolic heart failure▫EF 40-60% : mild systolic dysfunction

•diastolic heart failure▫EF > 60% (normal EF)

•combination of systolic and diastolic heart failure

Classification: NYHA(แบ�งต�มคว�มส�ม�รุถในก�รุทำ��ก�จักรุรุมขอิงผู้-*ปั.วย)

•Class I: ผิ* ป+วยไม%มอากิารใดๆ สามารถกิระที่�ากิ�จกิรรมปกิตุ�ได โดยไม%มอากิารหายใจล้�าบากิ หอบเหนื้�อย

•Class II: ผิ* ป+วยมข อจ�ากิ�ดบ างเพยงเล้/กินื้ อยในื้กิารกิระที่�ากิ�จกิรรมปกิตุ� โดยผิ* ป+วยม�กิมอากิารเม�อกิระที่�ากิ�จกิรรมที่ตุ องออกิแรงมากิๆ

•Class III: ผิ* ป+วยมข อจ�ากิ�ดมากิพอควรในื้กิารกิระที่�ากิ�จกิรรมปกิตุ� โดยมอากิารหายใจล้�าบากิหร�อหอบเหนื้�อยอย%างรวดเร/วเม�อกิระที่�ากิ�จกิรรมที่ไม%ตุ องออกิแรงมากิ แตุ%จะไม%มอากิารขณะพ�กิ

•Class IV: ผิ* ป+วยมข อจ�ากิ�ดอย%างมากิในื้กิารกิระที่�ากิ�จกิรรมปกิตุ� มอากิารหอบเหนื้�อยขณะพ�กิ

Classification: ACC/AHA(แบ�งต�มสภ�วะก�รุด��เน�นไปัขอิงโรุค)

•Stage A: ผิ* ป+วยย�งไม%ได ร�บกิารว�นื้�จฉั�ยด วยโรคห�วใจล้ มเหล้ว ไม%มความผิ�ดปกิตุ�ของกิล้ ามเนื้��อห�วใจ แล้ะไม%มอากิารของภาวะห�วใจล้ มเหล้ว แตุ%มความเสยงส*งตุ%อกิารพ�ฒนื้าไปเป3นื้โรคห�วใจล้ มเหล้ว

•Stage B: ผิ* ป+วยย�งไม%ได ร�บกิารว�นื้�จฉั�ยด วยโรคห�วใจล้ มเหล้ว แล้ะไม%มอากิารของภาวะห�วใจล้ มเหล้ว แตุ%พบความผิ�ดปกิตุ�ของห�วใจ

•Stage C: ผิ* ป+วยได ร�บกิารว�นื้�จฉั�ยด วยโรคห�วใจล้ มเหล้ว ค�อ มอากิารของภาวะห�วใจล้ มเหล้ว แล้ะม�กิมความผิ�ดปกิตุ�ของโครงสร างห�วใจถ*กิตุรวจพบด วย

•Stage D: ผิ* ป+วยได ร�บกิารว�นื้�จฉั�ยด วยโรคห�วใจล้ มเหล้ว โดยเป3นื้ผิ* ป+วยที่มอากิารห�วใจล้ มเหล้วข��นื้ร�นื้แรง รวมถ4งผิ* ป+วยที่จะเป3นื้ตุ องอาศั�ยเคร�องม�อหร�อว�ธิกิารพ�เศัษที่ช่%วยให ด�ารงช่ว�ตุได

stage A: at high risk for HF but w/o structural heart disease or symptom of HF THERAPY

Goals

-treat hypertension- encourage smoking cessation- treat lipid disorder- encourage regular exercise- discourage alcohol intake, illicit drug use- control metabolic syndrome

Drug

- ACEI or ARB in appropriate pt for vascular disease or diabetes

e.g. patients with- hypertension- atherosclerotic disease- diabetes- obesity- metabolic syndrome

Or

Patients- using cardiotoxins with FHx CM

stage B: structural heart disease but w/o signs or symptoms of HF

THERAPY

Goals

-all measures under stage A

Drug

- ACEI or ARB in appropriate pt- beta-blocks in appropriate pt

e.g. patients with- previous MI- LV remodeling inducing LVH and low EF- asymptomatic valvular disease

stage C: structural heart disease with prior or current symptoms of HF

THERAPY

Goals

- all measures under stage A and B- dietary salt restriction

Drugs for routine use

-diuretic for fluid retention- ACEI- beta-blockers

Drugs in selected patients

- aldosterone antagonist- ARBs- digitalis- hydralazine/nitrate

Devices in selected patients

- biventricular pacing- implantable defibrillators

e.g. patients with- known structural heart diseaseAnd- Shortness of breath and fatigue, reduced exercise tolerance

stage D: refractory HF requiring specialized interventions

THERAPY

Goals

-appropriate measures under stages A, B, C- decision re: appropriate level of care

Options

-compassionate end-of-life care/hospice- extraordinary measures +heart transplant +chronic inotropes +permanent mechanical support +experimental surgery or drugs

e.g. patientswho have maked symptoms at rest despite maximal medical therapy (e.g. those who are recurrently hospitalized or cannot be safety discharged from the hospital without specialized interventions)

Non-pharmacological management

•General advice and measures•Rest, exercise, and exercise training

Pharmacological therapy

Angiotensin-converting enzyme inhibitors•first-line therapy in patients with a

reduced left ventricular systolic function expressed as a subnormal ejection fraction

•ACE-inhibition improves survival, symptoms, functional capacity, and reduces hospitalization in patients with moderate and severe heart failure and left ventricular systolic dysfunction

Diuretics

•Diuretics are essential for symptomatic treatment when fluid overload is present and manifest as pulmonary congestion or peripheral oedema

Potassium-sparing diuretics

•Potassium-sparing diuretics should only be prescribed if hypokalaemia persists despite ACE inhibition, or in severe heart failure despite the combination ACE inhibition and low-dose spironolactone

•The use of all potassium-sparing diuretics should be monitored by repeated measurements of serum creatinine and potassium

Diuretics

Diuretic oral: dosages and side effects

Beta-adrenoceptor antagonists•Treatment of all patients (in NYHA class

II–IV) with stable, mild, moderate, and severe heart failure from ischaemic or non-ischaemic cardiomyopathies and reduced LVEF on standard treatment

The recommended procedure for starting a beta-blocker

Initiating dose, target dose, and titration scheme of beta-blocking agents as used in recent large, controlled trials

Angiotensin II receptor blockers•used as an alternative to ACE inhibition in

symptomatic patients intolerant to ACE-inhibitors to improve morbidity and mortality

Cardiac glycosides (Digoxin)•Cardiac glycosides are indicated in atrial

fibrillation and any degree of symptomatic heart failure, whether or not left ventricular dysfunction is the cause

•Digoxin has no effect on mortality but may reduce hospitalizations

•The usual daily dose of oral digoxin is 0.125–0.25 mg if serum creatinine is in the normal range (in the elderly 0.0625–0.125 mg, occasionally 0.25 mg)

Hydralazine-isosorbide dinitrate•In case of intolerance for ACE-inhibitors

and ARBs, the combination hydralazine/nitrates can be tried to reduce mortality and morbidity and improved quality of life

Anti-thrombotic agents

•In CHF associated with atrial fibrillation, a previous thromboembolic event or a mobile left ventricular thrombus, anti-coagulation is firmly indicated

•There is little evidence to show that anti-thrombotic therapy modifies the risk of death or vascular events in patients with heart failure.

Pharmacological therapy

GuidelineDrugs

ACC/AHA NYHA

ACEIs Stage A, B, C irrespective of symptoms

ARB Stage A, B, C class II – IV

β- Blocker Stage B, C class II – IV

Aldosterone antagonist

Stage C class III – IV

Diuretics Stage C for fluid retention

irrespective of symptoms

H-ISDN Stage C Alternative

Digoxin Stage C Class II – IV and AF

Stroke and systemic embolism in heart failure

• Patients with chronic HF are at increased risk of thromboembolic events due to

▫ stasis of blood in dilated hypokinetic cardiac chambers and in peripheral blood vessels

▫ perhaps due to increased activity of procoagulant factors

Stroke and systemic embolism in heart failure

• - in large scale studies, the risk of thromboembolism in clinically stable

patients has been low (1% to 3% per year)• These rates are sufficiently low to limit the

detectable benefit of anticoagulation in th ese patients

Stroke and systemic embolism in heart failure

• In several retrospective analyses, the risk of thromboembolic events was not lower in

patients with HF taking warfarin than in p atients not treated with antithrombotic dr

ugs• The use of warfarin was associated with a

reduction in major cardiovascular events a nd death in patients with HF in one retrosp

ective analysis but not in another

Heart failure - warfarin

มกิารล้ดล้งของเล้�อดที่ไปย�งตุ�บ

decrease warfarin elimination

increase INR

Thank & Questions