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Approach To Heart Failure - MedicosNotes-com
Approach To Heart Failure - MedicosNotes-com
Heart Failure
Heart Failure
Heart Failure, is a clinical syndrome in
which an abnormality of cardiac structure
or function is responsible for the inability
of the heart to eject or fill with blood at a
rate commensurate with the requirements
of metabolizing tissues
CAD
C.M.PATHY
HTN
DISEASE
DCM
Valvular heart disease
Congenital heart disease
Conditions
restrict filling
RESTRICTIVE
PERICARDIAL
Precipitating causes
1. Increased salt intake
2. Non compliance with anti CHF
medications
3. Acute myocardial infarction
4. Aggravation of Hypertension
5. Acute arrhythmias
6. Infections and or fever
1.
2.
3.
4.
5.
Pulmonary Embolism
Anemia
Thyrotoxicosis
Pregnancy
Rheumatic, Viral, and Other Forms of
Myocarditis
6. Infective Endocarditis
7. Physical, Environmental, and Emotional
Excesses
Pathogenesis
1. Myocardial cell loss myocyte
hypertrophy and elongation.
2. An increase in ventricular volume (the
Starling effect) helps maintain cardiac
output (CO), but at the cost of increasing
ventricular filling pressures.
3. The increase in diastolic stretch and
pressure produces further damage
stretch-induced myocyte death
(apoptosis)
CARDIACOUTPUT
OUTPUT
CARDIAC
DEC.RENAL
RENALBLD
BLDFLOW
FLOW
DEC.
SYMPATHETICDISCHARGE
DISCHARGE
SYMPATHETIC
RAA.ACTIVATION
ACTIVATION
RAA.
INC.FORCE
INC.FORCE
RATE
RATE
PRELOAD
PRELOAD
AFTERLOAD
AFTERLOAD
REMODELLING
exertional dyspnea
orthopnea
paroxysmal nocturnal dyspnea
dyspnea at rest
acute pulmonary edema.
Symptoms.
URINARY SYMPTOMS.
1. Nocturia may occur early in the course of heart
failure.
2. Oliguria is a sign of late cardiac failure.
. CEREBRAL SYMPTOMS.
1. Confusion, impairment of memory, anxiety,
headache, insomnia, bad dreams or nightmares,
and, rarely, psychosis with disorientation,
delirium, and hallucinations.
Symptoms of predominant
right-sided Heart Failure
1. Breathlessness is not very prominent because
pulmonary congestion is usually absent.
2. Congestive hepatomegaly - dull ache or heaviness in
epigastrium.
3. Other gastrointestinal symptoms, including anorexia,
nausea, bloating, a sense of fullness after meals, and
constipation due to congestion of the liver and
gastrointestinal tract.
4. In severe, preterminal heart failure, inadequate bowel
perfusion can cause abdominal pain, distention, and
bloody stools.
Physical examination
1. JVP
2. S3
3. Pulmonary congestion (rales,
dullness over pleural effusion)
4. Peripheral edema
5. Hepatomegaly
6. Ascites
Laboratory Investigations
1.
2.
3.
4.
5.
6.
7.
CBC, ESR
Urine routine
LFT
RFT
CXR
ECHO
Measurement of BNP
Major Criteria
1.
2.
3.
4.
5.
6.
7.
Minor Criteria
1. Extremity edema
2. Night cough
3. Dyspnea on exertion
4. Hepatomegaly
5. Pleural effusion
6. Vital capacity reduced by one-third
from normal
7. Tachycardia (120 bpm)
NYHA GRADING
Class 1 :
Class 2 :
activity
Class 3 :
Class 4 :
no symptoms
symptoms with ordinary
less than ordinary activity
even at rest
Staging of systolic HF
1. STAGE A- ASYMPTOMATIC/ MILD HF NYHA
CLASS 1 / 2
2. STAGE B- MILD /MODERATE HF ,NYHA
CLASS 2 / 3
3. STAGE C- ADVANCED HF , CLASS 3 / 4
4. STAGE D- REFRACTORY HF ,CLASS 3 / 4
5. SUSTAINED DECOMPENSATION,
FREQUENT HOSPITALISATION
Liver disease
Varicose veins
Cyclic edema
Renal dysfunction
General measures
1. Prevent HF
2. Daily measurement of weight
3. Immunization with influenza and
pneumococcal vaccines
4. Education of the patient and family
5. Avoid Excessive alcohol, temperature
extremes, and tiring trips
6. Meals - small in quantity, frequent
7. Reduce sodium intake
Activity
1. Releive anxiety.
2. Physical and emotional rest
3. Anticoagulants, leg exercises,
and elastic stockings.
4. Absolute bed rest is rarely
required
5. Regular isotonic exercise
6. Weight reduction in obese
Administration of oxygen
Sleep apnoea - nocturnal
continuous positive airway pressure
Dialysis or ultrafiltration in
patients with severe HF and renal
dysfunction
Other mechanical methods theraputic thoracocentesis or
paracentesis .
CORRECTION OF PRECIPITATING FACTORS
Thiazide diuretics
Loop diuretics
Metalazone
Potassium sparing
diuretics
Role of diuretics
1. Rapid relief of symptoms
2. Controls fluid retention
3. Appropriate use of diuretics is
the key element in the
success of other drugs
DIURETICS
THIAZIDE DIURETICS -useful alone or in
combination with other diuretics
In chronic mild HF
K+ depletion and metabolic alkalosis
Suited only if GFR >50%of normal
METALAZONE
Site of action and potency similar to the thiazides
Effective in the presence of moderate renal failure
Both metolazone and thiazides potentiate
intravenous
loop diuretics
FUROSEMIDE, BUMETANIDE,
AND TORSEMIDE
Useful in all forms of HF, particularly in
refractory HF and pulmonary edema.
Effective in patients with
hypoalbuminemia, hyponatremia,
hypochloremia, and with reductions in
glomerular filtration rate
The action may be potentiated by I.V.
administration and by the addition of other
diuretics
POTASSIUM-SPARING
DIURETICS
Spironolactone acts by competitive
inhibition of aldosterone
Amiloride and triamterene act
directly on the distal
tubule/collecting duct.
Most effective with loop and/or
thiazide diuretics.
Lower dose of spironolactone (25
mg/d), prolong life in patients with
advanced HF
Angiotensin-Converting Enzyme
(ACE) Inhibitors
1. Prevention and treatment of HF at
almost all stages
2. Slows remodeling .
3. Cardiac output rises
4. Pulmonary wedge pressure falls,
5. Afterload is reduced with no or only
mild reduction of arterial pressure.
6. Signs and symptoms of HF are
relieved
ARB
1. Equally effective
2. ACE inhibitor
intolerance
BETA BLOCKERS
Drug
Start
Target
Carvedilol 3.125 bd
25bd
Bisoprolol
1.25 od
10 od
Metoprolol
12.5 -25 od
200bd
As ADD on therapy with diuretics and ACEI
Improves ejection fraction,exercise
tolerance lowers rate ,dec.myo O2
demand,,reduces arrythmias reverse
LVH,prevents sudden deaths
Enhancement of Cardiac
contractility
1. Digitalis,digoxin oubain
2. Sympatho mimetic
amines
3. Phosphodiesterase
inhibitors
DIGOXIN
1. Positive inotropic response
2. Inhibit Na+, K+-ATPase
3. Effective in systolic HF complicated by
atrial flutter and fibrillation and a rapid
ventricular rate
4. Does not improve survival in patients with
systolic HF and sinus rhythm, it reduces
symptoms of HF
5. No value in diastolic HF.
Sympathomimetic
Amines
1. Dopamine and dobutamine
,dopexamine
2. Act on -adrenergic receptors
3. Improve myocardial contractility
4. In severe, acute HF
5. Constant intravenous infusion
6. Can be given for several days
7. Used in refractory HF as a bridge
to cardiac transplantation.
8. Downregulation of adrenergic
receptors
Phosphodiesterase
Inhibitors
1. Amrinone,milrinone,enoximone,pir
oximone,fenoximone
2. Inhibit phosphodiesterase III
3. Positive inotropic and vasodilator
actions
4. Administered intravenously
5. Reverse the major hemodynamic
abnormalities associated with HF
Vasodilators
1. Useful in severe, acute HF with significant
systemic vasoconstriction despite ACE inhibitor
therapy.
2. Rapid onset and brief duration of action
3. Sodium nitroprusside
4. Intravenous nitroglycerin 20micg/min max
400micg/min
5. Nesiritide iv bolus 2micg/kg+0.01micg/kg/min
6. Combination of hydralazine and isosorbide
dinitrate - for chronic oral administration
Nesiritide, a recombinant
analog of BNP
1. The newest therapeutic option for ADHF.
2. Increase natriuresis, diuresis, and cardiac index
3. Reduce pulmonary capillary wedge pressure,
pulmonary artery pressure, pulmonary vascular
resistance, and systemic blood pressure in a
dose-dependent manner.
4. Reversal of the deleterious neurohormonal
response associated,with HF
5. Reduces levels of endothelin 1, aldosterone,and
norepinephrine.
Reduce mortality
1. Beta Blockers
2. A.C.E. Inhibitors
3. Angiotensin Receptor
Blockers
4. Spironolactone
5. Amiodarone
1. betablockers&Amiodarone
3. Calcium Channelblockers
4. High dose Digoxin
LVEF <40 %
Fluid retention +
No fluid retention
ACE 1
Beta blockers
VENTRICULAR
RESYNCHRONIZATION
1. Intraventricular conduction is depressed
in about one-fourth of patients with
chronic HF
2. Resynchronization with a device that
has three pacing leads (right atrium,
right ventricle, and cardiac vein, which
provides left ventricular stimulation)
improve performance in patients with HF
3. Increase ejection fraction
MANAGEMENT OF
ARRHYTHMIAS
1. Premature ventricular contractions
and episodes of asymptomatic
ventricular tachycardia are common
in advanced HF
2. VT/VF is responsible for about onehalf of all deaths
3. Correction of electrolyte and acidbase disturbances
Amiodarone
1. Amiodarone, a class III
antiarrhythmicis the drug of
choice for patients with HF and
atrial fibrillation.
2. Implantable automatic defibrillator
prevent sudden deaths
Anticoagulants
1. Increased risk of pulmonary emboli
secondary to venous thrombosis and of
systemic emboli secondary to
intracardiac thrombi
2. Patients with HF and atrial fibrillation,
previous venous thrombosis, and
pulmonary or systemic emboli are at
high risk
3. Heparin followed by warfarin
Management of Diastolic HF
1.
2.
3.
4.
5.
6.
7.
8.
9.
Management Of ADHF
Administration of oxygen
Morphine sulfate
Mechanical ventilation is indicated
A sitting position improves pulmonary
function.
Placing the patient on strict bed rest and
reducing pain and anxiety decrease cardiac
workload.
SURGICAL THERAPY
CARDIAC TRANSPLANTATION best
predictor peak O2 consumption with
maximal exercise (VO2max)NI
>20ml/kg/min,<10ml/kg/min
transplantation ideal
Novel surgeries
Ventricular remodelling surgeries
Dynamic cardiomyoplasty
Mitral valve repair
NEWER DRUGS
B N P analogue
Nesiritide
Endopeptidase inhibitor(ACE+neutral
peptidases)
Omapatrilat
Calcium Sensitiser
Pimobendan,Levosibendan
LEVOSIBENDAN is a novel agent with
inotropic properties developed
specifically for the management of
ADHF.
It acts by sensitizing troponin C to
calcium
to DIURETIC IN ADVANCED
BLOCKERS
PROGNOSIS
1. Depends primarily on the nature of the
underlying heart disease
2. Presence or absence of a precipitating
factor
3. Prognosis can be estimated by observing
the response to treatment.
4. When patients can be rendered free of
congestion, survival may be 80% at two
years.