Transcript Heart Failure

Anna Jaatinen MD
Rotary Doctor Bank Finland
Ilembula Hospital
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Heart failure patophysiology and reasons for
heart failure
Clinical presentation
How to treat
◦ Acute cardiac failure
◦ Chronic cardiac failure
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Patient education
Heart failure is a clinical syndrome in which
the heart impair its ability to meet the
metabolic demands of the body
= heart function is not enough to provide
blood to the body
There is always reason for heart failure!
Heart failure is NOT a disease by itself!
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Prevalence
◦ In Europe and USA
 2-3% of adult population, mean age 75 years
 Leading cause of the hospitalization in people over
than 65 years
◦ In developing countries
 2-3% of population
 20-30 % in people over 70 years
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Prognosis is poor if not treated
◦ Even when treated 1-year mortality is 30%, and 5year mortality 50%
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Systolic dysfuntion
◦ Abnormal myocardial contraction
 Coronary artery disease, dilated cardiomyopathy
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Diastolic dysfuntion
◦ Abnormal realaxation and filling
 Hypertension, hypertrofic cardiomyopathy, infiltrative
cardiomyopathies, constictive pericarditis
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Systolic + diastolic dysfuntion
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Left side cardiac failure
Right side cardiac failure
◦ Pulmonary hypertension, pulmonar stenosis,
pulmonary embolism
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Acute
Chronic
> 80%
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Coronary artery
disease
Hypertension
Valvular heart disease
< 20%
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Myocarditis
◦ Infectious, Autoimmune
Familial cardiomyopathy
Infiltrative disease
◦ Amyloidosis, Sarcoidosis
◦ Hemochromatosis
Hypertrofic cardiomyopathy
Constrictive pericardial
disease
High-output states; arteriovenous malformation
Tacycardia-induced
cardiomyopathy
Idiopathic cardiomyopathy
Toxins; alkohol, cocaine,
chemotherapy
Heart
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Myocardial ischemia
Hypertension
Arrythmias
◦ Atrial fibrillation!
Other
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Infection
Volume overload
Anemia
Alkohol/toxins
Thyroid disease
Drugs
◦ NSAID!
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Pulmonary embolism
Medication noncompliance
Dietary noncompliance
◦ Salt overload, water overload
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Alcohol
Heart failure begins with injury or stress on
the heart
 Remodelling
Increase in left ventricular size or/and mass
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(dilatation or hypertrophy)
 Stress on the heart, function of the heart
 Compensatory adaptation
Reduction
in cardiac output results organ
hypoperfusion and pulmonary and systemic
venous congestion
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Symptoms
◦ Dyspnea
 First on exertion, later also on rest
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Exercise intolerance
Fatique
Ortopnea, paroxyxmal nocturnal dyspnea
Cough, wheezing
Lower extremity swelling
Presyncope, palpitation
Angina pectoris (chest pain) can be present
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Physical examination and findings
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Lower extremity edema
Pulmonary cracles
Jugular venous distension
Diminished carotic upstrokes
Pleural and pericardial effusions
Hepatic congestion
Ascites
Third or fourth heart sound may be present as well
as holosystolic murmur (tricuspic or mitral
regurgitation)
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Extreme decompensation
◦ Cardiogenic shock
◦ Renal failure, decreased urine output
◦ Confusion, lethargy
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Laboratories
◦ Reason for heart failure?
◦ Hb (anemia?)
◦ B/S, WBC, Urinalysis if you suspect infection
◦ Also when possible: metabolic panel (electrolytes,
creatinine, liver function tests, calcium, fasting glucose),
lipid profile, urinalysis, thyroid function tests
◦ If new oncet and clinically suspected: test for HIV,
hepatitis, hemochromatosis, rheumatologic diseases
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Electrocardiogram ECG
◦ Iscemia? Arrhytmias? Conduction delays?
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Imaging
◦ Chest X-ray
 Pulmonary edema?
 Cardiomegaly?
 Rule out other etiologies of dyspnea (pneumonia,
pneumothorax)
◦ Echocardiogram
 LV funtion and structure?
 Valvular heart disease?
 Exclude cardiac tamponade
NYHA I
No symptoms or limitation while
performing ordinary physical activity
NYHA II
Mild symptoms and slight limitation
when performing ordinary physical
activity
NYHA III
Marked limitation in activity due to
symptoms, even durin less-than –
ordinary
activities. Comfortable only at
rest.
NYHA IV
Severe limitations with symptoms even
while at rest.
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Goal: blocking the neurohormonal pathways
that contribute to the progression of heart
failure
◦ Reducing symptoms
◦ Reducing hospitalization
◦ Reducing mortality
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Most patients reguire multidrug regimen
Treatment shoud be maintained even the
clinical status improves!
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Β-blockers
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Angiotensin-converting enzyme inhibitors (eg ACEinhibitors)
◦ Carvedilol, bisoprolol, metoprolol, (propranolol, atenolol)
◦ Captopril, enalapril, perindopril, lisinopril….
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Vasodilators
◦ Isosorbide mononitrate, Isosorbide dinitrate, Glyceryl
trinitrate
◦ Hydralazine
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Diuretic therapy
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Digoxin
◦ Furosemide (loop-diuretic)
◦ Thiazide diuretics: Hydrochlorothiazide, chlortialidone
◦ Spironolactone (potassium-sparing diuretic, aldosterone
receptor antagonist)
(Angiotensin receptore blockers:
Valsartan, Candesartan)
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Spironolactone with ACE-inhibitor: Potential
risk for life-threatening hyperkalemia
◦ Renal insufficiency and NSAIDs increase the risk
◦ Serum potasium-level should be monitored
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Β-blockers are contraindicated patients with
◦ Symptomatic bradycardia or hypotension
◦ Bronchial Asthma
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Digoxin
◦ Increaces myocardial contractility, may attenate
neurohormonal activation of HF
◦ Dose 0.125 to 0.25 mg/day
 Even lower dose: renal insufficiency, women, elderly,
low body weight
 Narrow therapeutic range!
◦ Drug interactions!
 Eryhromycin and tetracycline may increase digoxin
levels up to 40%
 Verapamil, flecainide, amiodarone also increace levels
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Clinical manifestation on CPE can occur
rapidly
◦ Dyspnea, anxiety, restlessness, coughing pink foam
◦ Psysical signs: decreased peripheral perfusion,
pulmonary congestion, use of accessory respiratory
muscels, wheesing
◦ Chest-X-ray: cardiomegaly, interstitial and perihilar
vascular engorgement, pleural effusions
 Radiographic abnormalities may follow the
development of symptoms by several hours
Cardiac failure and pulmonary
edema
Acute treatment
 Supplemental oxygen (Keep oxygen saturation
>90%, even >95%)
 Patient in a sitting position; improves pulmonal
function
 Bed rest, pain control and relief of anxiety can
decrease cardiac work load
 Precipitating factors should be indetificated and
corrected
◦ Hypertension? Acute iscemia? Tachyarrythmias? Volume
overload? Severe anemia? Infection?
Acute Medications
 Morphine 2-5 mg i.v. (4-8 mg s.c., 5-10 mg
p.o.) can be repeated 10-25 min until the effect
is seen
 Furesemide 20 (-80)mg i.v. may be repeated in
10-15 min
 Nitroglyseride i.v. (or p.o.) if systolic blood
pressure is >100
 (If rapid arrythmia and possible iscemia consider
β-blocker with small dose)
 Sometimes also fluid-resuscitation is needed
when cardiogenic shock and decreased preload
Treatment after acute phase
 Β-blocker, ACE-inhibitor
◦ If patient has the medication before acute oncet
pulmonary edema, treatment should not be
stopped
◦ When starting as a new medication be careful and
start when the condition is stabilized
◦ If myocardial ischemia, start as soon as possible (in
48 h)
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Treat possible anemia: Blood transfusion if
needed (slowly!)
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In the ward
◦ Monitor BP, pulse, ventilation rate, temperature
◦ Weight every day!
 Or monitor diuresis and calculate the balance
(remember also evaporation)
 Weight should go down 0.5-1 kg/day
◦ Is breathing easier? Are swellings decreasing?
◦ Physiotherapy after the acute phase if needed
◦ Patient education before going home
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Medications wich has been shown to reduce
morbidity and re-hospitalization
◦ Β-blocker, ACE-inhibitor, Digoxin, spironolactone
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Medications wich reduce symptoms
◦ Diuretics, Vasodilators (Nitrates+hydralazine)
NYHA 1-2: ACE-inhibitor, B-blocker, furosemide
(+spironolactone)
NYHA 3-4: Add vasodilator, spironolactone, Digoxin
Consider anti-thrombotic agents
And remember to take care of the cause of the HF,
hypertension, diabetes…
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Explain
◦ What heart failure is and why symptoms occurs
◦ Cause of heart failure
◦ How to recognize symptoms and what to do when they
occur
◦ Daily self-weighting and what to do if weight gains
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Drugs
◦ Encourage to maintain the medication, give information
about the dose and effect
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Dietary treatment and social habit
◦ Control sodium intake, avoid excessive fluid intake (in
severe cases limit fluid intake 1-1.5 l/day)
◦ No excessive alcohol, no smoking!
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Regular exercise within limits of symptoms
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NSAIDs (also Coxibs): Ibuprofein, Diclofenac
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Trisyclic anti-depressants: Amitriptylin
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Some anti-arrythmic drugs: Verapamil
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Systemic corticosteroids
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Lithium
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Nature medications?
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Heart failure is a sydrome, not a isolated
disease!
Cause of the heart failure should be
considered!
Ask and examine: dyspnea, swellings, heart
and pulm auskultation, chest-x-ray
Treatment is usually multidrug treatment and
it should be mantained even the patient is
improving
Patient education is crucial!