HEART FAILURE

Dr. Ali Nafiah Nst, SpJP

Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

Definition
Heart failure is defined as the inability of the heart to pump blood forward at a sufficient rate to meet the metabolic demands of the body (forward failure), or the ability to do so only if the cardiac filling pressures are abnormally high (backward failure), or both.

Pathophysiology

Frank-Starling Law

PULMONARY CIRCULATION
Blood

flows from the right ventricle through the pulmonary artery Blood reaches the capillaries surrounding alveoli where gas exchange occurs Oxygenated blood returns by pulmonary veins to the left ventricle where it is pumped into systemic circulation

LV BACKWARD EFFECTS
Decreased emptying of the left ventricle Increased volume and end-diastolic pressure in the left ventricle Increased volume (pressure) in the left atrium Increased volume in pulmonary veins

LV BACKWARD EFFECTS cont

Increased volume in pulmonary capillary bed = increased hydrostatic pressure
Transudation of fluid from capillaries to alveoli

Rapid filling of alveolar spaces

Pulmonary edema

LV FORWARD EFFECTS
Decreased cardiac output Decreased perfusion of tissues of body Decreased blood flow to kidneys and glands

Increased reabsorption of sodium and water and vasoconstriction

LV FORWARD EFFECTS cont

Increased secretion of sodium and water-retaining hormones Increased extracellular fluid volume Increased total blood volume and increased systemic blood pressure

RV BACKWARD EFFECTS
Decreased emptying of the right ventricle Increased volume and end-diastolic pressure in the right ventricle Increased volume (pressure) in right atrium Increased volume and pressure in the great veins

RV BACKWARD EFFECTS cont

Increased volume in the systemic venous circulation Increased volume in distensible organs (hepatomegaly, splenomegaly) Increased pressures at capillary line

Peripheral, dependant edema and serous infusion

RV Forward Effects
Decreased volume from the RV to the lungs Decreased return to the left atrium and subsequent decreased cardiac output All the forward effects of left heart failure

Causes of left ventricular failure

Volume over load: Pressure overload: Loss of muscles:
Regurgitate valve High output status Systemic hypertension Outflow obstruction Post MI, Chronic ischemia Connective tissue diseases Infection, Poisons
(alcohol,cobalt,Doxorubicin)

Restricted Filling:

Pericardial diseases, Restrictive cardiomyopathy, tachyarrhythmia

Diagnosis

IDENTIFICATIONS OF HF PATIENTS

With a Syndrome of Decrease Exercise Tolerance With a Syndrome of Fluid Retention

With No Symptoms or Symptoms of Another Cardiac or Non Cardiac Disorder (MI, Arrythmias, Pulmonary or Systemic Thromboembolic Events)

SYMPTOMS AND SIGN

Breathlessness, Ankle Swelling, Fatique Characteristic Symptoms Peripheral Oedema, JVP , Hepatomegaly Signs of Congestion of Systemic Veins

S3 , Pulmonary Rales , Cardiac Murmur

Framingham Criteria

Major Criteria:

PND JVD Rales Cardiomegaly Acute Pulmonary Edema S3 Gallop Positive hepatic Jugular reflex venous pressure > 16 cm H2O

Framingham Criteria

Minor Criteria:

Extremitas edema Night cough Dyspnea on exertion Hepatomegaly Pleural effusion vital capacity by 1/3 of normal Tachycardia Weight loss 4.5 kg over 5 days management

Precipitating Factors

Increased metabolic demand Increased circulating volume Condition that increased afterload Condition that impaired contractility Failure to take prescribe medication Arrhytmia

ECG

A low Predictive Value LAH and LVH maybe Associated wit LV Dysfunction

Anterior Q-wave and LBBB a good predictors

of EF Detecting Arrhytmias

CHEST X-RAY
A Part of Initial Diagnosis of HF

Cardiomegaly, Pulmonary Congestion

Relationship Between Radiological Signs and Haemodynamic Findings may Depend on the

Duration and Severity HF

HAEMATOLOGY & BIOCHEMISTRY

A Part of Routine Diagnostic Hb, Leucocyte, Platelets Electrolytes, Creatinine, Glucose, Hepatic Enzyme, Urinalysis TSH, C-RP, Uric Acid

ECHOCARDIOGRAPHY
The Preferred Methods Helpful in Determining the etiology Follow Up of Patients Heart Failure

PULMONARY FUNCTIONS

A Little Value in Diagnosis Heart Failure Usefull in Excluding Respiratory Diseases

EXERCISE TESTING
Focused on Functional, Treatment Assessment and Prognostic

STRESS ECHOCARDIOGRAPHY

For Detecting Ischaemia Viability Study

NUCLEAR CARDIOLOGY
Not Recommended as a Routine Use

( CARDIAC MAGNETIC RESONANCE IMAGING)

Recommenmded if Other Imaging Techniques not Provided Diagnostic Answer

CMR

INVASIVE INVESTIGATION
Elucidating the Cause and Prognostic Informations Coronary Angiography : in CADs Patients Haemodynamic Monitoring : To Assess Diagnostic and Treatment of HF

Endomyocardial Biopsy : in Patients with Unexplained HF

NATRIURETIC PEPTIDES

Cardiac Function (LV Function ) Plasma Natriuretic Peptide Concentration (Diagnostic Blood Use for HF) Natriuretic Peptide : Greatest Risk of CV Events Natriuretic Peptide : Improve Outcome in Patients with Treatment Identify Pts. With Asymptomatic LV Dysfunction (MI, CAD)

ALGORITHM FOR THE DIAGNOSIS OF THE HF

(ESC, 2001)
Suspected Heart Failure Because of symptoms and signs If Normal Heart Failure Unlikely

Assess Presence of Cardiac Disease by ECG, X-Ray or NatriureticPeptides (Where Available)

Tests Abnormal

Imaging by Echocardiography (Nuclear Angiography or MRI Where Available)

If Normal Heart Failure Unlikely

Tests Abnormal

Assess Etiology, Degree, Precipitating Factors and Type of Cardiac Dysfunction

Choose Therapy

Additional Diagnosis Tests Where Appropriate (e.g. Coronary Angiography)

Aims of treatment 1. Prevention

a) Prevention and/or controlling of diseases leading to cardiac dysfunction and heart failure b) Prevention of progression to heart failure once cardiac dysfunction is established

2. Morbidity
Maintenance or improvement in quality of life

3. Mortality
Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Treatment options
Non-pharmacological management General advice and measures Exercise and exercise training
Pharmacological therapy Angiotensin-converting enzyme (ACE) inhibitors Diuretics Beta-adrenoceptor antagonists Aldosterone receptor antagonists Angiotensin receptor antagonists Cardiac glycosides Vasodilator agents (nitrates/hydralazine) Positive inotropic agents Anticoagulation Antiarrhythmic agents Oxygen Devices and surgery Revascularization (catheter interventions and surgery), other forms of surgery Pacemakers Implantable cardioverter defibrillators (ICD) Heart transplantation, ventricular assist devices, artificial heart Ultrafiltration, haemodialysis
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Pharmacological therapy

Angiotensin-Converting Enzyme Inhibitors

Recommended as first-line therapy.

Should be uptitrated to the dosages shown to be effective in the large, controlled trials, and not titrated based on symptomatic improvement. Moderate renal insufficiency and a relatively low blood pressure (serum creatinine 250 mol.l-1 and systolic BP 90 mmHg) are not contraindications.
Absolute contraindications: bilateral renal artery stenosis and angioedema.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Diuretics

Essential

for symptomatic treatment when

fluid overload is present and manifest.

Always

be administered in combination

with ACE inhibitors if possible.

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

-Blocker

Has been traditionally contraindicated in pts with CHF Now they are the main stay in treatment on CHF & may be the only medication that shows substantial improvement in LV function In addition to improved LV function multiple studies show improved survival Contraindication: decompensated HF, Bradicardia/ AV Block, Asma bronchiale
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Aldosterone Receptor Antagonists - Spironolactone

Recommended in advanced HF (NYHA III-IV), in addition to ACE inhibition and diuretics to improve survival and morbidity

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Angiotensin II Receptor Antagonists

ARBs could be considered in patients who do not tolerate ACE inhibitors for symptomatic treatment.

It is unclear whether ARBs are as effective as ACE inhibitors for mortality reduction. In combination with ACE inhibition, ARBs may improve heart failure symptoms and reduce hospitalizations for worsening heart failure.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560

Cardiac Glycosides

indicated in atrial fibrillation and any degree of symptomatic heart failure. A combination of digoxin and beta-blockade appears superior than either agent alone. In sinus rhythm, digoxin is recommended to improve the clinical status of patients with persisting heart failure despite ACE inhibitor and diuretic treatment.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Vasodilator Agents In Chronic Heart Failure

No specific role for vasodilators in the treatment of HF Used as adjunctive therapy for angina or concomitant hypertension.

In case of intolerance to ACE inhibitors ARBs are preferred to the combination hydralazinenitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE

Hydralazine (up to 300 mg) in combination with ISDN (up to 160 mg) without ACE inhibition may have some beneficial effect on mortality, but not on hospitalization for HF. Nitrates may be used for the treatment of concomitant angina or relief of acute dyspnoea.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Positive Inotropic Therapy

Commonly

used to limit severe episodes of HF or as a bridge to heart transplantation in end-stage HF. or prolonged treatment with oral inotropic agents increases mortality. insuffcient data are available to recommend dopaminergic agents for heart failure treatment.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560

Repeated

Currently,

Anticoagulation
Recommendation
1.

All pts with HF and AF should be treated with warfarin unless contraindicated. Patients with LVEF 35% or less.

2.

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left Ventricular Systolic Dysfunction - Pharmacological Approaches 2000

Antiplatelet Drugs
Recommendation There is insufficient evidence concerning the potential negative therapeutic interaction between ASA and ACE inhibitors. Antiplatelet agent for pts with HF who have underlying CAD.

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left Ventricular Systolic Dysfunction - Pharmacological Approaches 2000

Antiarrhythmics

No indication for the use of antiarrhythmic agents in HF

Indications for antiarrhythmic drug therapy include AF (rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS

should be avoided

CLASS II ANTIARRHYTHMICS

Beta-blockers reduce sudden death in heart failure

CLASS III ANTIARRHYTHMICS

Amiodarone is the only antiarrhythmic drug without clinically relevant negative inotropic effects.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Classification of HF
Activity Levels (NYHA Classification) I asymptomatic at rest symptoms with heavy exercise II asymptomatic at rest symptoms with moderate exercise III asymptomatic at rest symptoms with activities of daily living IV symptoms at rest Exercise testing and O2 consumption

ACC/AHA A New Approach To The Classification of HF

Stage
A

Descriptions
Patient who is at high risk for developing HF but has no structural disorder of the heart. Patient with a structural disorder of the heart but who has never developed symptoms of HF.

Examples
Hypertension; CAD; DM; rheumatic fever; cardiomyopathy. LV hypertrophy or fibrosis; LV dilatation; asymptomatic VHD; MI.

patient with past or current symptoms of HF associated with underlying structural heart disease.
Patient with end-stage disease

Dyspnea or fatigue ec LV systolic dysfunction; asymptomatic patients with HF.

Frequently hospitalized pts ; pts awaiting heart transplantation etc

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Stages in The Evolution of HF and Recommended Therapy by Stage

Stage A
Pts with : Hypertension CAD DM Cardiotoxins FHx CM

Stage B
Pts with : Previous MI LV systolic dysfunction Asymptomatic Valvular disease

Stage C
Pts with : Struct. HD

Stage D
Pts who have marked symptoms at rest despite maximal medical therapy.

Struct. Heart Disease

Develop Symp.of HF

Refract. Shortness of Symp.of breath and fatigue, HF at rest

reduce exercise tolerance

THERAPY Treat Hypertension Stop smoking Treat lipid disorders Encourage regular exercise Stop alcohol & drug use ACE inhibition

THERAPY All measures under stage A ACE inhibitor Beta-blockers

THERAPY All measures under stage A Drugs for routine use: diuretic ACE inhibitor Beta-blockers digitalis

THERAPY All measures under stage A,B and C Mechanical assist device Heart transplantation Continuous IV inotrphic infusions for palliation

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Chronic Heart Failure Choice of Pharmacological Therapy

ACE inhibitor Diuretic Beta-blocker Aldosterone Antagonist Not indicated

LV systolic dysfunction Asymptomatic LV dysfunction

Indicated

Not indicated

Post MI

Symptomatic HF (NYHA II)

Indicated

Indicated if Fluid retention Indicated comb. diuretic Indicated comb. diuretic

Indicated

Not indicated

Worsening HF (NYHA III-IV)

Indicated

Indicated

Indicated

End-stage HF (NYHA IV)

Indicated

Indicated

Indicated

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Chronic Heart Failure Choice of Pharmacological Therapy

Angiotensin II receptor antagonists Not indicated Vasodilator (hydralazine/ Potassium -sparing Cardiac glycosides isosorbide diuretic dinitrate) With AF Not indicated Not indicated If persisting hypokalaemia

LV systolic dysfunction Asymptomatic LV dysfunction

Symptomatic HF (NYHA II)

Worsening HF (NYHA III-IV)

End-stage HF (NYHA IV)

(a) when AF If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated (b) when improved from more severe II antagonists and not on betaare not HF in sinus blockade tolerated rhythm If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated indicated II antagonists and not on betaare not blockade tolerated If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated indicated II antagonists and not on betaare not blockade tolerated

If persisting hypokalaemia

If persisting hypokalaemia

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Intervention

Surgical

Revascularization
Non Surgical

Pts with heart failure of ischaemic origin revascularization

symtomatic improvement.

A strong negative correlation of operative mortality and LVEF, a low LVEF (<25%) was associated with increased

operative mortality. Advance HF symptoms (NYHA IV)

resulted in a greater mortality rate.

Off pump coronary revascularization may lower the surgical risk for HF. Heart Transplantation is an accepted mode of treatment for end-stage HF.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Algorithm for Management HF

Conclusion
DIAGNOSIS OF HEART FAILURE Clinical Signs and Symptoms Echocardiography (LVEF) The Preferred Method Natriuretic Peptide Helpful in The Diagnosis Process Additional Test Should be Perfomed Where Diagnosis Doubt Persist

Conclusion
Management

of HF must be starting from the earlier stage (AHA/ACC stage A). Treatment at each stage can reduce morbidity and mortality. initiating therapy :

Before

Established the correct diagnose. Consider management outline.

NO MATTER WHAT,

PREVENTION

IS BETTER THAN
TREATMENT

Thank YoU