Cardiac failure in the 21st century

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Transcript Cardiac failure in the 21st century

Cardiac Failure in the 21st
century and beyond
Tshimbi Mathivha
2007
“Many roads lead to a broken heart”
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Cardiac Failure-Relevance
 Common
disorder
 Increasing prevalence
 Cost
 Morbidity and Mortality
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What is Cardiac Failure?
 Clinical
Syndrome(Not a single diagnosis)
 Multiple Aetiology(Causes)
“
Many roads lead to a broken heart”
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Cardiac Failure
 An Abnormality
of Cardiac Function
which leads to the heart not being able
to pump blood at a Sufficient Output to
meet the requirements of Metabolizing
Tissues
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Pathogenesis
– Abnormality in Myocardial
Contractility
 Majority
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Primary Heart
Muscle
Myocardial Dysfunction
Ischaemic
Heart
Disease
Long standing
Haemodynamic
overload
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Muscle Dysfunction
 Primary


heart muscle disease
Cardiomyopathies
Viral myocarditis
 Longstanding



haemodynamic Overload
Congenital
Valve pathology
Hypertension
 Ischaemic
heart Disease
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Myocardial
Dysfunction
Pericardial
Disease
Heart Failure
Arrhythmias
Valvular
Abnormalities
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Important causes of cardiac
failure
Hypertension
Ischaemic Heart Disease
Valvular Pathology
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Absence of Myocardial Abnormality
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Clinical types of Cardiac
Failure
 Acute
vs Chronic
 Left Heart Failure
 Right Heart Failure
 Right and Left Heart Failure
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Adaptive/Maladaptive Responses
Impaired cardiac Perfomance
Hypoperfusion
Of kidney
Activation of
RAAS
System
Activation
Adrenergic
System
Vasodilator
Peptides
BNP
ANP
TNF
Endothelin
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EVALUATION OF PATIENT WITH
CARDIAC FAILURE
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EVALUATION
 Symptomatology
 Clinical
features
 Supportive
Investigations
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Symptoms
 Related
to Left sided and Right sided
pressures and impaired cardiac output





Dyspnoea
Oedema and fluid retention
Fatigue and Poor Effort Tolerance
Abdominal and Cerebral symptoms
other
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Dyspnoea
Shortness of breath
Effort/Activity
Non Specific
Other Causes
Orthopnoea
Specific
symptom
Paroxysmal
Nocturnal dyspnoea
Specific
Symptom
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Oedema and Fluid Retention

Common
 Dependent
 Non Specific
 Helpful in Male than Female
 Other – (Fluid accumulation pleural space)
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Other Causes of Oedema
Idiopathic – Females
 Hypoalbuminaemia
 Chronic venous insufficiency
 Chronic lymphatic obstruction
 Drugs

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Fatigue
Perfusion to skeletal
Muscle
Cardiac
Output
Poor Effort
Tolerance
O2 delivery
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Abdominal Symptoms
 Right
upper quadrant pain/discomfort
 Nausea
 Diffuse abdominal discomfort
 Early satiety
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Cerebral symptoms
 Altered


mental state
Confusion
Memory Impairment
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Severity of Symptoms
New York Heart Association Classification
I = No limitation
Ordinary physical exercise does not cause undue fatigue dyspnoea or palpitation
II = Slight limitation of physical activities
Comfortable at rest but ordinary activities result in fatigue palp or dyspnoea
III = Marked limitation of physical activities
Comfortable at rest but less than ordinary activities result in symptoms
IV = Unable to carry physical activities without
discomfort
Symptoms of heart failure are present even at rest , with increased discomfort
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CLINICAL FEATURES
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General features
Neck veins – Jugular Venous Pressure
Pulse
Blood Pressure/Pulse Pressure
“Clues”
Precordium
Pulmonary
Abdomen
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INVESTIGATIONS
Basic Tests
a) Urine Analysis
b) Blood Analysis
c) Electrocardiogram
d) Chest Radiograph
Specialized Tests
a)Pro BNP
b)Transoesophageal Echo(Cardiac U/sound)
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TREATMENT STRATEGIES
 Preventative
 General
measures
 Correction of the underlying cause
 Removal of precipitating cause
 Prevention of deterioration of cardiac
function
 Control of congestive CF state
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PREVENTION
Decrease the risk of initial cardiac injury
i.e. Treatment of risk factors for IHD
Treatment of Hypertension
Decrease the likelihood of developing cardiac
Failure after cardiac injury
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GENERAL MEASURES

Education
 Dietary Modification
 Smoking
 Physical Activity ,Exercise training and
rehabilitation
 Vaccination
 Weight Management
 Other
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Correction of the Underlying cause
Removal of Precipitating Cause
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Pharmacological Treatment
(Medicines)
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Medicines
Symptom relief
Mortality
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Diuretics
 First
line of treatment
 Reduces Preload
 Improve Pulmonary and Systemic
venous Congestion
(Symptom
Relief)
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Diuretics
Thiazide
Loop
Na + and Cl – reabsorbtion
DCT
Na + and Cl – reabsorbtion
Ascending Limb of Henle
Other – K+ Sparing
Spironolactone(RALES)
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Angiotensin Converting Enzyme Inhibitors
(ACEI)
Arterial and Venodilator
Lower Systemic Vascular
Resistance and Venous pressure
Reduces Catecholamines/Angiotensin/Aldosterone
Myocardial Contractility
MORTALITY
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ACE Inhibitors
Captopril
Enalapril
Ramipril
Perindopril
Side Effects
Adverse Events
Lisinopril
Quinapril
Other
Angiotensin Receptor Blocker
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B – Blockers
B – Adrenoceptor Blocking Agents
Improve Symptoms
Improve Exercise Tolerance
Improve Left Ventricular Function
Reduce Mortality
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B - Blockers
Bisoprolol – B1 ( CIBIS 2 )
Metoprolol – B1 ( MERIT )
Carvedilol – B1
B2
Alpha receptor blocking properties
ADVERSE EVENTS
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Inotropic agents
Digoxin/Digitalis – Symptom relief
Atrial Fibrillation
NO IMPACT ON MORTALITY
(Symptoms)
Other
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Other
Vasodilators
Nitrates
Hydralazine
(Nesiretide)
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Other Pharmacological Measures
Role of Anticoagulation
Role of Antiarrhythmics
Medicines to avoid
NSAIDS
Ca Channel Blockers ( Ist generation)
Other
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Other Therapeutic Interventions
– Cardiac Resynchronization
 Left Ventricular Assist Devices
 Cardiac Transplantation
 Pacing
 “When All
Fails - Comfort”
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Prognosis
Death
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Progression
Sudden death 40%
Worsening CF 40%
Other
20%
Annual Mortality
<5%
10%
20 –30%
Mild
Moderate
30-80%
0
Asympt
Severe
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CONCLUSION
Cardiac Failure
Common disorder
Multiple Causes
Mortality and Morbidity remains high
Preventable/Retardation of progression
Therapeutic Intervention –Pathophysiology
Identification of risk conditions
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Take Home Message
Prevention!!!!
Prevention!!!!
Prevention!!!!
Early intervention strategies to prevent further
Myocardial damage
“ When All Fails – Comfort”
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References
1.Davidson principles and Practice of Medicine
2.Cecil Essentials of Medicine
3.Harrisons textbook of Medicine
4.Oxford Textbook of Medicine
5.Cecil textbook of Medicine
6.CME January 2004 Treating Heart Failure
7.others – on request
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