Management of Heart failure

2017 - ACC/AHA/HFSA
 Heart Failure
A clinical syndrome that results from any structural
or functional impairment of ventricular filling or
ejection of blood.

Normal Heart HF with Reduced Ejection HF with Preserved

(HFrEF) Fraction (HFpEF)
HF Severity: ACC/AHA Stages and
NYHA Functional Classification
 Treatment of HF
• Treatment of HF divided into two type
according to stages :

• 1- Prevention Therapy ( for Stage A ,B )

• 2- Essential Therapy (for Stage C , D)
Treatment according to Stages of
Heart Failure

Refer
to
figure
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 Case
• A 48-year-old 70 kg woman with history of heart failure. Her
most recent LVEF is 29%; her daily activities are limited by
dyspnea and fatigue and also these symptoms ocuure at
rest. Her medications include lisinopril 40 mg daily,
carvedilol 25 mg twice daily, spironolactone 25 mg/day,
• Her most recent laboratory results include sodium (Na) 140
mEq/L, potassium (K) 4.0 mEq/L, SCr 0.8 mg/Dl and her
vital signs include BP 125/80 mm Hg and HR 68
beats/minute. She has normal breath sounds and no
peripheral edema.
• Physician need to insert cardiac resynchronization
therapy–device to control symptoms of heart failure,
what is your opinion regarding the case ?
• her daily activities are limited by dyspnea and
fatigue occure at rest >>>>>>HF class is (NYHA
class Iv)
• Her medications include lisinopril 40 mg daily,
carvedilol 25 mg twice daily, spironolactone
25 mg/day >>>>>> On GDMT therapy
• Doses in maximum dose >>> Check
• If patient symotoms not relieved by treatment
that you are recommended ,how can you
manage this patient ??
 Case
• A 68-year-old woman 70 kg with a history of
hypertension, chronic kidney disease ( baseline
creatinine= 3) , coronary heart disease, myocardial
infarction (MI) 4 months ago, An echocardiogram
reveals a left ventricular ejection fraction (LVEF) of
35%. She is in (NYHA) class III. Her medications
include aspirin 81 mg/day, metoprolol succinate 150
mg/day, lisinopril 5 mg / day and atorvastatin 40 mg
every night.
• Her vital signs include blood pressure (BP) 138/80mm
Hg and heart rate (HR) 78 beats/minute, She has no
worsening signs or symptoms of dyspnea or edema
compared with her baseline. she presents to the clinic
for a follow-up. Physician add spironolactone 25 mg
once daily to control symptoms of heart failure, what
is your opinion regarding the case ?
• HR = 78
• Ivabradine is good choice to add in that case

• Suitable dose ??? Lexicomp

Acute decompensated Heart
Failure

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Acute Decompensated Heart
Failure (ADHF(
ADHF Recommendation Guidelines

Diuretics Inotropes

Invasive
Vasodilators hemodynamic
monitoring

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 Acute Decompensated Heart
Failure (ADHF(
-Diuretics:
Fluid overload = IV loops Switch to

oral before discharge

Adverse effects: Electrolyte depletion (potassium,

magnesium), worsening renal function

Response is minimal ???

Think of resistance…..

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 Acute Decompensated Heart
Failure (ADHF(
-Diuretics:
Loop Diuretics
) ascending limb of loop of Henle)
Most widely used and most potent
effective at low CrCl (< 30 mL/minute)
Furosemide (Lasix) most commonly used
furosemide 40 mg PO = furosemide 20 mg IV =
bumetanide 1 mg IV/PO = torsemide 10 mg IV/PO

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 Acute Decompensated Heart
Failure (ADHF(
-Diuretics:
Thiazides (distal tubule(
Relatively weak diuretics if alone
not effective at low glomerular filtration
rate
Reserved for add-on therapy if refractory
to loops

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Acute Decompensated Heart
Failure (ADHF(
Diuretics Resistance:
Fluid and sodium restriction

Increase dose or infusion

Add second diuretic

Ultra filtration

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Acute Decompensated Heart
Failure (ADHF(
-Diuretics Resistance:
Increase dose before increasing frequency of loop diuretic
→Ceiling effect at about 160–200 mg IV furosemide
Add a second diuretic with a different mechanism of action
(a)Hydrochlorothiazide 12.5–25 mg PO daily,

(b) metolazone 2.5–5 mg PO daily (30 minutes before loop diuretic

administration)
(c) Chlorothiazide 250–500 mg IV daily → in gastrointestinal edema
(d) Reserve for NPO or refractory to other alternatives
Continuous infusion of loop diuretic – Furosemide 0.1 mg/kg/hr
IV doubled every 4–8 hours, maximum 0.4 mg/kg/hr
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Acute Decompensated Heart
Failure (ADHF(
-Inotropes:

When to use???
systolic BP < 90 mm Hg
Symptomatic hypotension despite adequate
filling pressure, or
No response to, or intolerance of, intravenous
vasodilators
fluid overload if they respond poorly to
intravenous diuretics or
diminished or worsening renal function 16
 Acute Decompensated Heart
Failure (ADHF(
-Inotropes:

Why to use???
relieve symptoms and
improve end-organ function in patients with reduced
LVEF and diminished peripheral perfusion or end-organ
dysfunction (low output syndrome)
manage subset III or IV HF.

confirm that patients in subset III have adequate filling

pressures (i.e., PCWP 15–18 mm Hg) before administering
inotropic therapy 17
Acute Decompensated Heart
Failure (ADHF(
Levosimendane

A calcium sensitiser
it increases the sensitivity of the heart to calcium, thus
increasing cardiac contractility without a rise in intracellular
calcium.

It also has a vasodilatory effect, by opening (ATP)-sensitive

potassium channels in vascular smooth muscle to cause
smooth muscle relaxation.

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Acute Decompensated Heart
Failure (ADHF(
Levosimendane
The combined inotropic and vasodilatory actions result in an
increased force of contraction, decreased preload and
decreased afterload.

for the short-term treatment of acutely decompensated severe

chronic heart failure (ADHF) in situations where conventional
therapy is not sufficient, and in cases where inotropic support
is considered appropriate

infusion is for IV use only and can be administered by the

central route.

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Acute Decompensated Heart
Failure (ADHF(
Levosimendane
Recommended duration of infusion in patients with ADHF is 24
hours.

No signs of development of tolerance or rebound phenomena

have been observed following discontinuation of Simdax infusion.

Simdax should not be used in patients with severe renal

impairment (CrCl<30 ml/min)

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 Acute Decompensated Heart
Failure (ADHF(
Vasodilators:

Added to IV loop diuretics → rapidly improve symptoms in acute

pulmonary edema or severe hypertension

In persistent symptoms despite aggressive diuretics and oral

therapy

Preferred over inotropes If adjunctive therapy is required

manage pulmonary congestion or ―wet‖ (subset II or IV) HF.

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 Acute Decompensated Heart
Failure (ADHF(
Vasodilators:
Venous vasodilation → in a reduction in pulmonary capillary wedge
pressure (PCWP) acute relief of shortness of breath while awaiting
the onset of diuretic effects.

Arterial vasodilators alternative to inotropes in patients with

elevated systemic vascular resistance and low (CO(

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