HF-Etiology-Dx- Rx_2

Diagnosis, Diagnosis, and Treatment of Chronic and Treatment of Chronic Congestive Heart FailureCongestive Heart FailureDr Lázaro Nicanor Rodríguez GonzálezDr Lázaro Nicanor Rodríguez González

Department of Internal Medicine Department of Internal Medicine Kimberley Hospital ComplexKimberley Hospital Complex

RSARSA

DEFINITION

“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodatemetabolic requirements and the venous return."

E. Braunwald

1 World Health Statistics, World Health Organization, 1995.1 World Health Statistics, World Health Organization, 1995.

2 American Heart Association, 2002 Heart and Stroke Statistical Update.2 American Heart Association, 2002 Heart and Stroke Statistical Update.

HF Incidence and PrevalenceHF Incidence and Prevalence

• Prevalence Prevalence – Worldwide, 22 millionWorldwide, 22 million11

– United States, 5 millionUnited States, 5 million22

• Incidence Incidence – Worldwide, 2 million new cases annuallyWorldwide, 2 million new cases annually11

– United States, 500,000 new cases annuallyUnited States, 500,000 new cases annually22

• HF afflicts 10 out of every 1,000 over age 65 in HF afflicts 10 out of every 1,000 over age 65 in the U.S.the U.S.22

Symptomatic heart failure continues to confer a worse prognosisthan the majority of cancers in USA, with one-year mortality of approximately 45 percent.

New York Heart Association classification of HFClass DescriptionI Patient with cardiac disease, but no limitation onordinary physical activityII Comfortable at rest, ordinary activity results insymptoms (slight limitation)III Comfortable at rest, less than ordinary activity resultsin symptoms (marked limitation)IV Symptomatic at rest, increased discomfort with anyphysical activity

HF Classification: Evolution and HF Classification: Evolution and Disease ProgressionDisease Progression

• Four Stages of HF (ACC/AHA Guidelines):Four Stages of HF (ACC/AHA Guidelines):Stage A: Patient at high risk for developing HF with no Stage A: Patient at high risk for developing HF with no structural disorder of the heartstructural disorder of the heart

Stage B: Patient with structural disorder without symptoms Stage B: Patient with structural disorder without symptoms of HFof HF

Stage C: Patient with past or current symptoms of HF Stage C: Patient with past or current symptoms of HF associated with underlying structural heart diseaseassociated with underlying structural heart disease

Stage D: Patient with end-stage disease who requires Stage D: Patient with end-stage disease who requires specialized treatment strategiesspecialized treatment strategies

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001Chronic Heart Failure in the Adult, 2001

30%30%

70%70%

Diastolic DysfunctionDiastolic DysfunctionSystolic DysfunctionSystolic Dysfunction

(EF < 40%)(EF < 40%)(EF > 40 %)(EF > 40 %)

Left Ventricular DysfunctionLeft Ventricular Dysfunction

• Systolic:Systolic: Impaired contractility/ejection Impaired contractility/ejection– Approximately two-thirds of heart failure patients have systolic Approximately two-thirds of heart failure patients have systolic

dysfunctiondysfunction11

• Diastolic:Diastolic: Impaired filling/relaxation Impaired filling/relaxation

1 Lilly, L. 1 Lilly, L. Pathophysiology of Heart DiseasePathophysiology of Heart Disease. Second Edition p 200. Second Edition p 200

ETHIOLOGIES OF HEART FAILUREDepressed Ejection Fraction (<40%)

• Coronary artery disease• Myocardial infarctiona

• Myocardial ischemiaa

• Chronic pressure overload• Hypertensiona

• Obstructive valvular diseasea

• Chronic volume overload• Regurgitant valvular disease• Intracardiac (left-to-right) shunting

ETHIOLOGIES OF HEART FAILUREDepressed Ejection Fraction (<40%)

No ischemic dilated cardiomyopathy

Familial/genetic disorders

Infiltrative disordersa

Toxic/drug-induced damage

Metabolic disordera

Viral

Chagas' disease

Disorders of rate and rhythm

Note: a Indicates conditions that can also lead to heart failure with a preserved ejection fraction.

Preserved Ejection Fraction (>40–50%)

Pathologic hypertrophy

Primary (hypertrophic cardiomyopathies)

Secondary (hypertension)

Restrictive cardiomyopathy

Infiltrative disorders (amyloidosis sarcoidosis)

Storage diseases (hemochromatosis)

Fibrotic Endomyocardial disorders

Left Ventricular DysfunctionLeft Ventricular DysfunctionSystolic and DiastolicSystolic and Diastolic

• SymptomsSymptoms

– Dyspnea on ExertionDyspnea on Exertion

– Paroxysmal Nocturnal Paroxysmal Nocturnal DyspneaDyspnea

– TachycardiaTachycardia

– CoughCough

– HemoptysisHemoptysis

• Physical SignsPhysical Signs

– Basilar RalesBasilar Rales

– Pulmonary EdemaPulmonary Edema

– S3 GallopS3 Gallop

– Pleural EffusionPleural Effusion

– Cheyne-Stokes RespirationCheyne-Stokes Respiration

Right Ventricular FailureRight Ventricular FailureSystolic and DiastolicSystolic and Diastolic

• SymptomsSymptoms

– Abdominal PainAbdominal Pain

– AnorexiaAnorexia

– NauseaNausea

– BloatingBloating

– SwellingSwelling

• Physical SignsPhysical Signs

– Peripheral EdemaPeripheral Edema

– Jugular Venous DistentionJugular Venous Distention

– Abdominal-Jugular RefluxAbdominal-Jugular Reflux

– HepatomegalyHepatomegaly

Modified Framingham clinical criteria for the diagnosis of heart failure

Major

Paroxysmal nocturnal dyspneaOrthopneaElevated jugular venous pressurePulmonary ralesThird heart soundCardiomegaly on chest x-rayPulmonary edema on chest x-rayWeight loss 4.5 kg in five days in response to treatment of presumed heart failure

Minor

Bilateral leg edemaNocturnal coughDyspnea on ordinary exertionHepatomegalyPleural effusionTachycardia (heart rate 120 beats/min)Weight loss 4.5 kg in five days


Diagnosis

The diagnosis of heart failure requires that 2 major or 1 major and 2 minor criteria if they cannot be attributed to another medical condition.

From Senni, M, Tribouilloy, CM, Rodeheffer, RJ, et al, Circulation 1998; 98:2282; ada pted from McKee, PA, Castelli, WP, McNamara, PM, Kannel, WB. N Engl J Med 1971


Diagnostic Evaluation of Diagnostic Evaluation of New Onset Heart FailureNew Onset Heart Failure

• Determine the type of cardiac dysfunction Determine the type of cardiac dysfunction (systolic vs. diastolic)(systolic vs. diastolic)

• Determine EtiologyDetermine Etiology

• Guide therapyGuide therapy

Diagnostic Evaluation of Diagnostic Evaluation of New Onset Heart FailureNew Onset Heart Failure

• Patient HistoryPatient History

• Physical ExaminationPhysical Examination

• ECGECG

• Chest x-rayChest x-ray

• Blood workBlood work

• Echocardiography Echocardiography

M-Mode EchoM-Mode Echo 2D Echo2D Echo

RARALALA

RVRVLVLV

SeptumSeptum

LV cavityLV cavity

LV WallLV Wall

Diagnostic Evaluation of Heart Failure

General MeasuresGeneral Measures

Lifestyle Modifications:Lifestyle Modifications:

• Weight reductionWeight reduction

• Discontinue smokingDiscontinue smoking

• Avoid alcohol and other Avoid alcohol and other cardiotoxic substancescardiotoxic substances

• ExerciseExercise

Medical Considerations:Medical Considerations:• Treat HTN, hyperlipidemia, Treat HTN, hyperlipidemia,

diabetes, arrhythmias, diabetes, arrhythmias, hyperthyroidism , infections , hyperthyroidism , infections , anemia , endocarditis.anemia , endocarditis.

• Surgical Repair of cardiac defectsSurgical Repair of cardiac defects

• Coronary revascularizationCoronary revascularization

• AnticoagulationAnticoagulation

• Sodium restrictionSodium restriction

• Daily weightsDaily weights

• Close outpatient monitoringClose outpatient monitoring

Pharmacologic ManagementPharmacologic Management

DiureticsDiuretics

• Used to relieve fluid retentionUsed to relieve fluid retention

• Improve exercise toleranceImprove exercise tolerance

• Facilitate the use of other drugs indicated for heart failure Facilitate the use of other drugs indicated for heart failure

• Patients can be taught to adjust their diuretic dose based on Patients can be taught to adjust their diuretic dose based on changes in body weightchanges in body weight

• Electrolyte depletion a frequent complicationElectrolyte depletion a frequent complication

• Should never be used alone to treat heart failureShould never be used alone to treat heart failure

• Higher doses of diuretics are associated with increased Higher doses of diuretics are associated with increased mortalitymortality


ACE Inhibitors ACE Inhibitors

• Blocks the conversion of angiotensin I to angiotensin II; Blocks the conversion of angiotensin I to angiotensin II; prevents functional deteriorationprevents functional deterioration

• Recommended for all heart failure patientsRecommended for all heart failure patients

• Relieves symptoms and improves exercise toleranceRelieves symptoms and improves exercise tolerance

• Reduces risk of death and decreases disease progressionReduces risk of death and decreases disease progression

• Benefits may not be apparent for 1-2 months after Benefits may not be apparent for 1-2 months after initiationinitiation


Beta-BlockersBeta-Blockers

• Cardioprotective effects due to blockade of excessive SNS Cardioprotective effects due to blockade of excessive SNS stimulation stimulation

• In the short-term, beta blocker decreases myocardial In the short-term, beta blocker decreases myocardial contractility; increase in EF after 1-3 months of usecontractility; increase in EF after 1-3 months of use

• Long-term, placebo-controlled trials have shown symptomatic Long-term, placebo-controlled trials have shown symptomatic improvement in patients treated with certain beta-blockersimprovement in patients treated with certain beta-blockers11

• When combined with conventional HF therapy, beta-blockers When combined with conventional HF therapy, beta-blockers reduce the combined risk of morbidity and mortality, or reduce the combined risk of morbidity and mortality, or disease progressiondisease progression

1 Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management 1 Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 p. 20.of Chronic Heart Failure in the Adult, 2001 p. 20.


Aldosterone AntagonistsAldosterone Antagonists

• Generally well-toleratedGenerally well-tolerated

• Shown to reduce heart failure-related morbidity and Shown to reduce heart failure-related morbidity and mortality mortality

• Generally reserved for patients with NYHA Class III-IV HFGenerally reserved for patients with NYHA Class III-IV HF

• Side effects include hyperkalemia and gynecomastia. Side effects include hyperkalemia and gynecomastia. Potassium and creatinine levels should be closely Potassium and creatinine levels should be closely monitoredmonitored


Angiotensin Receptor Blockers (ARBs)Angiotensin Receptor Blockers (ARBs)

• Block ATBlock AT11 receptors, which bind circulating angiotensin II receptors, which bind circulating angiotensin II

• Examples: valsartan, candesartan, losartanExamples: valsartan, candesartan, losartan

• Should not be considered equivalent or superior to ACE Should not be considered equivalent or superior to ACE inhibitorsinhibitors

• In clinical practice, ARBs should be used to treat patients In clinical practice, ARBs should be used to treat patients who are ACE intolerant due to intractable cough or who who are ACE intolerant due to intractable cough or who develop angioedemadevelop angioedema


DigoxinDigoxin

• Enhances inotropy of cardiac muscleEnhances inotropy of cardiac muscle

• Reduces activation of SNS and RAASReduces activation of SNS and RAAS

• Controlled trials have shown long-term digoxin therapy:Controlled trials have shown long-term digoxin therapy:– Reduces symptomsReduces symptoms– Increases exercise toleranceIncreases exercise tolerance– Improves hemodynamicsImproves hemodynamics– Decreases risk of HF progressionDecreases risk of HF progression– Reduces hospitalization rates for decompensated HFReduces hospitalization rates for decompensated HF– Does not improve survivalDoes not improve survival

NITRATES

CLINICAL USES

Pulmonary congestionOrthopnea and paroxysmal nocturnal dyspneaCHF with myocardial ischemiaIn acute CHF and pulmonary edema: NTG s.l. or i.v.

CALCIUM ANTAGONISTS

POSSIBLE UTILITY

Diltiazem contraindicatedVerapamil and Nifedipine not recommended

Vasoselective (amlodipine, nisoldipine),may be useful in ischemia + CHF

Amlodipine may be useful in nonischemic CHF

ANTICOAGULANTS

PREVIOUS EMBOLIC EPISODEATRIAL FIBRILLATIONIdentified thrombusLV Aneurysm (3-6 mo post MI)Class III-IV in the presence of:

- EF < 30- Aneurysm or very dilated LV

DVT’s

ANTIARRHYTHMICS

Sustained VT, with/without symptoms:- ß Blockers- Amiodarone

Ventricular Fibrillation:- Consider implantable defibrillator

Patient IndicationsPatient Indications

CRT device:CRT device:– Moderate to severe HF (NYHA Class III/IV) patients Moderate to severe HF (NYHA Class III/IV) patients

– Symptomatic despite optimal, medical therapySymptomatic despite optimal, medical therapy

– QRS QRS 130 msec 130 msec

– LVEF LVEF 35% 35%

CRT plus ICD:CRT plus ICD:– Same as above with ICD indicationSame as above with ICD indication

Cardiac Resynchronization TherapyCardiac Resynchronization Therapy

SummarySummary

• Heart failure is chronic, progressive , generally not Heart failure is chronic, progressive , generally not curable, but treatable.curable, but treatable.

• Most recent guidelines promote lifestyle modifications and Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors, beta blockers, medical management with ACE inhibitors, beta blockers, diuretics and digoxindiuretics and digoxin

• Close follow-up of the heart failure patient is essential, with Close follow-up of the heart failure patient is essential, with necessary adjustments in medical managementnecessary adjustments in medical management

Reference ArticlesReference Articles

Deedwania PC, Carbajal E. Deedwania PC, Carbajal E. Evidence based therapy for heart failure Evidence based therapy for heart failure Med clin N Am 96 Med clin N Am 96

(915-931(915-931))

2013 ACCF/AHA Guideline for theManagement of Heart FailureA Report of the American College of Cardiology Foundation/AmericanHeart Association Task Force on Practice Guidelines. 09/2012Circulation. 2013;128:e240-e327

Heart Failure Society of South Africa (HeFSSA) perspectiveon the European Society of Cardiology (ESC) 2012 chronicheart failure guidelineS Afr Med J 2013;103(9 Suppl 2):661-667. DOI:10.7196/SAMJ.7319

A TALK ABOUT ACUTE A TALK ABOUT ACUTE DECOMPENSATED HEART DECOMPENSATED HEART FAILURE HAS BEEN FAILURE HAS BEEN PREPARED TO BE PREPARED TO BE PRESENTED IN A NEAR PRESENTED IN A NEAR FUTURE.FUTURE.

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HF-Etiology-Dx- Rx_2

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