Professional Documents
Culture Documents
Review of Advancements in Heart Failure 81220
Review of Advancements in Heart Failure 81220
RECENT
ADVANCES
IN HEART
FAILURE
PRESENTED BY
DEFINITION AND TYPES
– Complex clinical syndrome that results from structural and
functional impairment of ventricular filling or ejection of
blood, which in turn leads to cardinal clinical symptom of
dyspnoea and fatigue and signs of heart failure (HF), namely
edema and rales.
– Types:
1. Presrved EF (HFpEF) : EF > 50 %
2. Mid-range EF (HFmrEF) : EF 40-50 %
3. Reduced EF (HFrEF) : EF < 40 %
ETIOLOGY
Depressed EF Preserved EF
• CAD • Primary hypertrophic
• Chronic pressure/volume cardiomyopathies
overload- HTN, valvular • Pathologic hypertrophy
heart disease, septal defects secondary to HTN
• Chronic lung disease • Restrictive cardiomyopathy–
• DCMP amyloidosis, sarcoidosis,
• Toxin/drug induced hemochromatosis etc.
• Viral • Aging
• Chagas’ disease • Endomyocardial disorders
• Arrythmias
Pathogenesis:
• Activation of compensatory mechanisms like adrenergic
nervous system, renin angiotensin aldosterone system
Index event and the cytokine system.
• LV remodelling
Long term
• Excessive salt and water retention
Biomarkers in heart failure- useful in
cases of clinical uncertainity
Soluble ST-2
Galectin-3
ACUTE DECOMPENSATED
HEART FAILURE
-Rapid onset or worsening of symptoms and/or signs of
HF.
-Heterogeneous clinical syndrome.
Decreased cardiac
performance - Life threatening medical
condition requiring urgent
Confluence of inter
hospital admission.
related
-Associated with excessive
abnormalities
morbidity and mortality.
Alteration in
Renal dysfunction vascular
compliance.
Factors triggering acute heart
failure:
Acute
coronary Arrythmias
syndrome
Pulmonary Hyper
Infection
embolism tension
Metabolic/
Drugs hormonal
derangements
Pulmonary Hypertensive Low output Cardiogenic
Edema AHF shock
• Vasodilators
• O2 and non- • Vasodilato • Inotropic • Inotropic
invasive
ventilation r therapy therapy
• Diuretics • diuretic • Mechanical
• Ultrafiltratio circulatory
n
• Vasodilators
support
• Opiates
Recommendations for O2
therapy and ventilatory
support:
– Oxygen therapy is recommended in patients with SpO2
<90% or PaO2 <60 mmHg.
– Non-invasive positive pressure ventilation (CPAP, BiPAP)
should be considered in patients with respiratory distress
(respiratory rate >25 breaths/min, SpO2 <90%).
– Intubation is recommended, if respiratory failure, leading
to hypoxaemia (PaO2 <60 mmHg (8.0 kPa)), hypercapnia
(PaCO2 >50 mmHg (6.65 kPa)) and acidosis (pH <7.35),
cannot be managed non-invasively.
Volume management
– Randomized clinical trials of high- versus low-dose or
bolus versus continuous infusion diuresis have not
provided clear justification for the best diuretic strategy in
ADHF.
– Continuous infusion of a diuretic may be useful when large
doses are required or the effect is suboptimal.
– Thus in cases of severe congestion, consider continuous
infusion (not trial supported).
– Reduced toxicity with the use of continuous infusion.
– Continue diuresis until euvolemia has been achieved.
– Torsemide has a higher oral bioavailability, thus can be
given orally in advanced heart failure if furosemide
becomes less bioavailable due to gut congestion.
– Role of adjuvant diuretics for augmentation: Addition of a
thiazide diuretic in combination provides a synergistic
effect. Metolazone in doses of 2.5-10 mg can cause severe
electrolyte imbalance.
– Dose of commonly used diuretics: Furosemide: 20-240 mg
daily (maximum dose that can be used in a day: 600 mg);
Torsemide: 10-100 mg daily.
Ultrafiltration (UF)
– There is no evidence favouring ultrafiltration over loop
diuretics as first-line therapy in patients with AHF. Role of
ultrafiltration in the management of ADHF is limited to
those patients who are diuretic unresponsive.
– Benefits over diuretics: controlled rates of fluid removal, no
direct neurohormonal activation and neutral effects on
serum electrolytes. Thus, it is also referred to as
aquapheresis. It has also been shown to restore diuretic
sensitivity.
Vascular therapy
– Includes iv nitrates, nitroprusside and nesiritide.
– I.V. vasodilators should be considered for symptomatic
relief in AHF with SBP >90 mmHg (and without
symptomatic hypotension).
– In patients with Hypertensive AHF, i.v. vasodilators should
be considered as initial therapy to improve symptoms and
reduce congestion.
NESIRITIDE SERELAXIN (recomb. URODILATIN
(recombinant BNP) human relaxin-2) (natriuretic peptide)
• More rapid and greater • There is evidence of • Inferior to existing
reduction in PCWP as reduced signs and therapies in terms of
compared to nitrates. symptoms of
• Side effect is
clinical outcome with
congestion and lower higher rate of
hypotension, rates of
more with bolus dose. hypotension and
rehospitalization and worsening serum
• ASCEND-HF trial concluded
cardiovascular mortality creatinine.(TRUE-AHF
that its use is not
associated with an (RELAX-AHF trial). trial)
increase in rates of death
or rehospitalisation but
Routine use of this drug
cannot be advocated due
to lack of significant
efficacy.
Vasodilator Dose Main side effect/
limitation
Nitroglycerine Start with 10-20 Hypotension,
µg/min, increase up to headache, tolerance on
200 µg/min continuous use
Eplerenone 25 qd 50 qd
2. Primary prevention
An ICD is recommended to reduce the risk of sudden death and all-cause
mortality in patients with symptomatic HF (NYHA Class II–III), and an
LVEF ≤35% despite ≥3 months of OMT, provided they are expected to
survive substantially longer than one year with good functional status,
and they have:
o IHD (unless they have had an MI in the prior 40 days).
o DCMP
– ICD implantation is not recommended within 40 days of an
MI, as implantation at this time does not improve
prognosis.
– ICD therapy is not recommended in patients in NYHA Class
IV with severe symptoms refractory to pharmacological
therapy.
– A wearable ICD may be considered for patients with HF
who are at risk of sudden cardiac death for a limited period
or as a bridge to an implanted device.
Therapeutic algorithm
for a patient with
symptomatic heart
failure with reduced
ejection fraction:
Treatments not recommended
(unproven benefit) in symptomatic
patients of HFrEF
– Statins
– Oral anticoagulants and antiplatelet therapy
– Renin inhibitors (ASTRONAUT trial)
– EPO for anaemia
– SSRI for depression
Following drugs are associated with
non-favourable outcome in HFrEF