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”
1
Cardiac Failure-Relevance
 Common
disorder
 Increasing prevalence
 Cost
 Morbidity and Mortality
2
What is Cardiac Failure?
 Clinical
Syndrome(Not a single diagnosis)
 Multiple Aetiology(Causes)
“
Many roads lead to a broken heart”
3
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
4
Pathogenesis
– Abnormality in Myocardial
Contractility
 Majority
5
Primary Heart
Muscle
Myocardial Dysfunction
Ischaemic
Heart
Disease
Long standing
Haemodynamic
overload
6
Muscle Dysfunction
 Primary


heart muscle disease
Cardiomyopathies
Viral myocarditis
 Longstanding



haemodynamic Overload
Congenital
Valve pathology
Hypertension
 Ischaemic
heart Disease
7
Myocardial
Dysfunction
Pericardial
Disease
Heart Failure
Arrhythmias
Valvular
Abnormalities
8
Important causes of cardiac
failure
Hypertension
Ischaemic Heart Disease
Valvular Pathology
9
Absence of Myocardial Abnormality
10
Clinical types of Cardiac
Failure
 Acute
vs Chronic
 Left Heart Failure
 Right Heart Failure
 Right and Left Heart Failure
11
Adaptive/Maladaptive Responses
Impaired cardiac Perfomance
Hypoperfusion
Of kidney
Activation of
RAAS
System
Activation
Adrenergic
System
Vasodilator
Peptides
BNP
ANP
TNF
Endothelin
12
13
EVALUATION OF PATIENT WITH
CARDIAC FAILURE
14
EVALUATION
 Symptomatology
 Clinical
features
 Supportive
Investigations
15
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
16
Dyspnoea
Shortness of breath
Effort/Activity
Non Specific
Other Causes
Orthopnoea
Specific
symptom
Paroxysmal
Nocturnal dyspnoea
Specific
Symptom
17
Oedema and Fluid Retention

Common
 Dependent
 Non Specific
 Helpful in Male than Female
 Other – (Fluid accumulation pleural space)
18
Other Causes of Oedema
Idiopathic – Females
 Hypoalbuminaemia
 Chronic venous insufficiency
 Chronic lymphatic obstruction
 Drugs

19
Fatigue
Perfusion to skeletal
Muscle
Cardiac
Output
Poor Effort
Tolerance
O2 delivery
20
Abdominal Symptoms
 Right
upper quadrant pain/discomfort
 Nausea
 Diffuse abdominal discomfort
 Early satiety
21
Cerebral symptoms
 Altered


mental state
Confusion
Memory Impairment
22
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
23
CLINICAL FEATURES
24
General features
Neck veins – Jugular Venous Pressure
Pulse
Blood Pressure/Pulse Pressure
“Clues”
Precordium
Pulmonary
Abdomen
25
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)
26
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
27
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
28
GENERAL MEASURES

Education
 Dietary Modification
 Smoking
 Physical Activity ,Exercise training and
rehabilitation
 Vaccination
 Weight Management
 Other
29
Correction of the Underlying cause
Removal of Precipitating Cause
30
Pharmacological Treatment
(Medicines)
31
Medicines
Symptom relief
Mortality
32
33
Diuretics
 First
line of treatment
 Reduces Preload
 Improve Pulmonary and Systemic
venous Congestion
(Symptom
Relief)
34
Diuretics
Thiazide
Loop
Na + and Cl – reabsorbtion
DCT
Na + and Cl – reabsorbtion
Ascending Limb of Henle
Other – K+ Sparing
Spironolactone(RALES)
35
Angiotensin Converting Enzyme Inhibitors
(ACEI)
Arterial and Venodilator
Lower Systemic Vascular
Resistance and Venous pressure
Reduces Catecholamines/Angiotensin/Aldosterone
Myocardial Contractility
MORTALITY
36
ACE Inhibitors
Captopril
Enalapril
Ramipril
Perindopril
Side Effects
Adverse Events
Lisinopril
Quinapril
Other
Angiotensin Receptor Blocker
37
B – Blockers
B – Adrenoceptor Blocking Agents
Improve Symptoms
Improve Exercise Tolerance
Improve Left Ventricular Function
Reduce Mortality
38
B - Blockers
Bisoprolol – B1 ( CIBIS 2 )
Metoprolol – B1 ( MERIT )
Carvedilol – B1
B2
Alpha receptor blocking properties
ADVERSE EVENTS
39
Inotropic agents
Digoxin/Digitalis – Symptom relief
Atrial Fibrillation
NO IMPACT ON MORTALITY
(Symptoms)
Other
40
Other
Vasodilators
Nitrates
Hydralazine
(Nesiretide)
41
Other Pharmacological Measures
Role of Anticoagulation
Role of Antiarrhythmics
Medicines to avoid
NSAIDS
Ca Channel Blockers ( Ist generation)
Other
42
Other Therapeutic Interventions
– Cardiac Resynchronization
 Left Ventricular Assist Devices
 Cardiac Transplantation
 Pacing
 “When All
Fails - Comfort”
43
Prognosis
Death
100
Progression
Sudden death 40%
Worsening CF 40%
Other
20%
Annual Mortality
<5%
10%
20 –30%
Mild
Moderate
30-80%
0
Asympt
Severe
44
CONCLUSION
Cardiac Failure
Common disorder
Multiple Causes
Mortality and Morbidity remains high
Preventable/Retardation of progression
Therapeutic Intervention –Pathophysiology
Identification of risk conditions
45
46
Take Home Message
Prevention!!!!
Prevention!!!!
Prevention!!!!
Early intervention strategies to prevent further
Myocardial damage
“ When All Fails – Comfort”
47
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
48