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management of heart failure




INTRODUCTION2DEFINITIONAn abnormality of cardiac structure or function leading to an impairment of ventricular filling or ejection of blood. It is a clinical syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling and fatigue) and signs (e.g. elevated jugular venous pressure, ankle edema, pulmonary crackles, and displaced apex beat). Occasionally some patients may present without signs or symptoms of volume overload.3PATHOPHYSIOLOGY4COHRSV=XAFTERLOADCONTRACTILITYPRELOAD (EDV)

5AFTERLOADCONTRACTILITYPRELOAD (EDV) AL SV CONT SV PL(EDV) SVEFSVEDV~ 55%=SV~EDVEF=Systolic HF(HFrEF)SVEDV=~EFDiastolic HF(HFpEF)Chronic hypertensionCAD/ chronic ischemicConstrictive pericarditisPathophysiological Classification of Heart Failure (HF)

6CLASSIFICATIONLVEF%I. Heart Failure with Reduced Ejection Fraction (HFrEF) 40%II. Heart Failure with Preserved Ejection Fraction (HFpEF),borderline 41-49%III Heart Failure with Preserved Ejection Fraction (HFpEF)50%ETIOLOGY7DIAGNOSISA clinical diagnosis based on a careful history and physical examination.SymptomsBreathlessness with orthopnoeaparoxysmal nocturnal dyspnoea (PND)reduced exercise toleranceankle swelling Signs Elevated jugular venous pulse (JVP)Third heart soundPeripheral edemaTachycardiaNarrow pulse pressure Pulmonary crepitationsHepatomegalyAscites. 8Acute HF - rapid onset of symptoms and signs of HF due to an acute deterioration of cardiac function. Chronic HF - chronic state when patients have stable symptoms. In these patients an acute precipitating or aggravating factor(s) may cause acute cardiac decompensation.Older terms such as congestive cardiac failure may be used if patients present with both right and left ventricular fluid overload.

9INVESTIGATION12 lead ECG Chest radiograph Blood testsEchocardiographyTests for myocardial ischemia and/or viability:treadmill exercise test, stress echocardiography (exercise or pharmacological), radionuclide studies, cardiac magnetic resonance imaging (CMR)Invasive tests: coronary angiography, cardiac catheterization, endomyocardial biopsyOthers: Holter, pulmonary function tests10PREVENTIONPrimary objective of managementWhat can be done?Optimize underlying diseaseSmoking cessationHealthy lifestyle and dietRegular physical exerciseAppropiate treat of coronary artery disease11

MANAGEMENTDivide into acute and chronic1213


CHRONIC HEART FAILURE NON PHARMACOLOGICAL MEASURESa) Educationb) Diet & Nutritionc) Lifestyled) Exercisee) Sleep Disordersf) Social SupportPHARMACOLOGICAL MEASURES1516

END OF LIFE CARERecognize patients who appear to be approaching the terminal phase of their illness:no identifiable reversible causebeen on optimum tolerated conventional drugsworsening renal functionfail to respond to appropriate changes in diuretic and vasodilator drugssustained hypotensionIn these patients it is important to :explore their wishes in terms of options for care and place of care. provide symptom relief. discuss with patient and family when it would be appropriate to switch off devices such as ICD or CRTavoid inappropriate invasive proceduresdiscuss issues of Allow Natural Death (Do Not Resuscitate) with patient and family. provide physical, psychological, social and spiritual support of patient and family support17REFERENCESCPG Management of Heart Failure (3rd Edition) 2014http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp2013 ACCF/AHA Guideline for the Management of Heart Failure - http://circ.ahajournals.org/content/128/16/e240.extract



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