heart failure 2
TRANSCRIPT
Heart FailureDefinitionHeart Failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
Myocardial failure, a term used to denote abnormal systolic or diastolic function, may be asymptomatic or progress to heart failure
Circulatory failure is not synonymous with heart failure because a variety of noncardiac conditions can lead to circulatory collapse while cardiac function is preserved
The Heart Failure MilieuFrom Molecular Biodynamic to a Clinical Syndrome
Treatment
NecrosisToxins
Volume overload/Pressure overloadHormone signal transduction
Heritable disorders
Compensation
Physiologic milieu
Pump
Contraction
Contractile proteins
DNA
De-compensation
Compensatory responses
Remodeling
Prevention
Remodeling
MOLECULAR,GENETIC
CELLULAR,ORGANELLE
INTEGRATEDORGANISM:
MAN
HEART
CELL
The Heart Failure MilieuDisease Process
Mechanical DysfunctionPressure overload Hypertension Aortic / pulmonic valve stenosis Pulmonary HypertensionVolume overload Aortic, mitral, tricuspid valve insufficiency Impaired Heart Filling
Pericardial diseaseVentricular hypertrophyMyocardial restrictionMitral / tricuspid stenosis
Direct Cell InjuryMyocardial infacrtionCardiomyopathyMyocarditisDrug / toxin-inducedSystemic disease effects
DiseaseProcess
The Heart Failure MilieuVentricular Dysfunction
DiseaseProcess
VentricularDysfunction
Diastolic dysfunctionImpaired ventricular filling
Systolic dysfunctionImpaired myocardial contractility
The Heart Failure MilieuHemodynamic Abnormalities
Diseaseprocess
Ventriculardysfunction
IncreasedLVEDP,PCWP,RAP (preload)Pulmonary artery pressurePulmonary blood volume(afterload)
DecreasedStroke volumeCardiac output
Regional blood flow
Hemodynamicabnormalities
The Heart Failure MilieuCompensatory Mechanisms
Diseaseprocess
RenalRenin-angiotensin-aldosterone
Salt / water retentionVentricular
DilationHypertrophy
SympatheticIncreased contractilityTachycardiaIncreased venous toneIncreased arterial tone
Ventriculardysfunction
Hemodynamicabnormalities
Compensatorymechanism
Diseaseprocess
Ventriculardysfunction
Hemodynamicabnormalities
Metabolicchanges
Symptoms andPhysical findings
The Heart Failure MilieuClinical Presentation
Physical findingsPeripheral edemaAscitesVascular congestionJugular venous distentionRalesTachycardiaHypotensionCachexiaDisease-spesific findings
Metabolic changesAzotemia
HyponatremiaHypocalcemia
HypomagnesemiaHyperuricemia
Acidosis/alkalosisHypoxia/O2 desaturation
Decreased MVO2
SymptomsFatique and weaknessDyspnea and fluid retention syndromesNocturiaGastrointestinal symptomsDiminished mentation
Compensatorymechanism
Diseaseprocess
Ventriculardysfunction
Hemodynamicabnormalities
Metabolicchanges
Symptoms andPhysical findings
The Heart Failure MilieuEnd-Organ Failure and Death
Compensatorymechanism End-Organ
Failure
SUDDENDEATH
DEATH
Lethal arrhythmiaElectrolyte abnormalitiesElevated cathecolamine levelsIschemiaDrug-proarrhythmia
Systemic organ failureRenal failureHepatic failure Respiratoric failureMulti-organ failurePulmonary embolismPeripheral (cerebral) embolism,
The Evaluation of Heart Failure Patients Recognize the milieu Clarify precipitating disease Define syndrome severity Establish patient prognosis Create therapeutic protocol
PHYSICALEXAMINATION
DIAGNOSTICSTUDIES
LABORATORYTESTS
HISTORY
Pulmonary
Neuro-psychiatric Systemic
Gastro-intestinal
Patient history
Neurologic
Abdominal
Physical examinationCardiac Cardiac
Pulmonary
Diagnostic studiesLaboratory
tests
Echo-cardiography
RadionuclidestudiesCardiac
catheterization
Chestroentenogtam
Exercisetesting
Electro-cardiography
Renal
Assessment of Heart Failure
Framingham criteria for Congestive Heart Failure
Definite : - 2 major - 1 major + 2 minor
Major Criteria Minor CriteriaParoxysmal nocturnal dyspneaNeck-vein distensionRalesAcute pulmonary edemaS3 gallopIncreased venous pressure > 16 cm H2OCirculation time > 25 secHepatojugular reflux
Ankle edemaNight coughDyspnea on exertionHepatomegalyPleural effusionVital capacity increased 1/3 from maximunTachycardia ( rate > 120/min)
Major or Minor CriteriaWeight loss > 4.5 kg in 5 days in response to treatment
New York Heart Association Functional Classification
Class I : No symptoms with ordinary activity Class II : Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginaClass III : Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal painClass IV : Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest
NORMALAsymptomatic LV Dysfunction
CompensatedCHF
DecompensatedCHF
No symptomsNormal exerciseNormal LV fx
No symptomsNormal exerciseAbnormal LV fx
No symptoms ExerciseAbnormal LV fx
Symptoms ExerciseAbnormal LV fx
RefractoryCHF
Symptoms not controlled with treatment
Chronic Congestive Heart Failure
Evolution of Clinical Stages
Stages of Heart Failure and Treatment Options for Systolic Heart Failure
HTCADDM
Tx CardiotxicAlc abuse
FH cardiomyopathy
LVHAsymp.RHDPrevious MI
FatiqueDOE
Prior symp. HF
Frequent HF hosp.Awaiting for transplant
Cont.inotropic or mec.support
Assess LV Function (echo, gated RNA)• EF < 40%-systolic dysfunction
• EF 40-55%-systolic/diastolic dysfunction
• EF >55%-diastolic dysfunction
Assess Volume Status
Signs and Symptoms of Fluid Retention
No Signs and Symptoms of Fluid Retention
Loop Diuretic± Thiazide
(titrate to euvolemic state)
ACE inhibitor/ARB if ACE intolerantCombination Rx if HF, hospitalization or -blocker
intolerant
Spironolactone (NYHA Class III-IV CHF/EF<35%/Cr<200/K<5)
Add Digoxin for symptom control
Symptoms Prognosis & Symptoms
-blocker (NYHA II-IV)
Inotropes, mitral repair, VAD, Tx
General Rx Strategies in HF
Angiotensin Converting Enzyme Inhibitors
Carvedilol/ -Blockers
Diuretics (Spironolactone)
Digoxin
No Added Salt 2 gm NaActivity as Tolerated Customized Ex Training
Tailored RxCorrect Cause:ArrhythmiasIschemiaPressure Load
Asymptomatic Mild/Mod Severe Refractory
Modified from Warner-Stevenson, ACC HF Summit
Management of Heart FailurePrimary Targets of Treatment in Heart Failure.
The Donkey Analogy
Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…
Digitalis CompoundsLike the carrot placed in front of the donkey
Diuretics, ACE Inhibitors
Reduce the number of sacks on the wagon
ß-BlockersLimit the donkey’s speed, thus saving energy
Treatment Approach for the Patient with Heart Failure
Stage A
At high risk, no structural disease
Stage B
Structural heart disease,
asymptomatic
Stage D
Refractory HF requiring
specialized interventions
Therapy
• Treat Hypertension
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake
• ACE inhibition
Therapy
• All measures under stage A
• ACE inhibitors in appropriate patients
• Beta-blockers in appropriate patients
Therapy
• All measures under stage A
Drugs:
• Diuretics
• ACE inhibitors
• Beta-blockers
• Digitalis
• Dietary salt restriction
Therapy
• All measures under stages A,B, and C
• Mechanical assist devices
• Heart transplantation
• Continuous (not intermittent) IV inotropic infusions for palliation
• Hospice care
Stage C
Structural heart disease with prior/current
symptoms of HF
Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001
Cardiac Resynchronization Therapy
Increase the donkey’s (heart) efficiency
Summary• Heart failure is a chronic, progressive disease
that is generally not curable, but treatable
• Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors, beta blockers, digoxin, and diuretics
• It is estimated 15% of all heart failure patients may be candidates for cardiac resynchronization therapy (see later section for details)
• Close follow-up of the heart failure patient is essential, with necessary adjustments in medical management