Transcript IN THE NAME OF GOD

IN THE NAME OF GOD
A.Soleimani MD
Assistant professor of cardiology
Medical university of Isfahan
HF definition
 Heart failure (HF) is a complex clinical syndrome
resulting from structural and functional impairment
of ventricular filling or ejection of blood
 Most patients have impairment of myocardial
performance, with findings ranging from normal
ventricular size and function to marked dilation and
reduced function.
 Although symptoms of HF frequently depend on the
presence of elevated left- or right-sided heart filling
pressures, the designation “congestive” in this context
is no longer preferred
Stages, Phenotypes and Treatment of HF
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
appropriate
· Beta blockers as
appropriate
remodeling
Drugs
· ACEI or ARB as
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
STAGE D
Refractory HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· Control symptoms
· Patient education
· Prevent hospitalization
· Prevent mortality
Drugs for routine use
· Diuretics for fluid retention
· ACEI or ARB
· Beta blockers
· Aldosterone antagonists
Drugs for use in selected patients
· Hydralazine/isosorbide dinitrate
· ACEI and ARB
· Digoxin
In selected patients
· CRT
· ICD
· Revascularization or valvular
surgery as appropriate
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Classification of Heart Failure
A
B
C
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
NYHA Functional Classification
None
I
I
II
III
IV
D
Refractory HF requiring specialized
interventions.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
Definition of Heart Failure
Classification
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
Ejection
Fraction
≤40%
Description
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
HFpEF
 Approximately half of the patients with HF
have normal left ventricular function, that
is, HF with preserved ejection fraction
(HFpE)
 HFpEF generally is defined as a left
ventricular ejection fraction of 50% or
greater, whereas HFrEF is defined as an
ejection fraction below 40%.
Dyspnea
 Worsening dyspnea is a cardinal symptom
of HF and typically is related to increases in
cardiac filling pressures but also may
represent restricted cardiac output.
 The absence of worsening dyspnea,
however, does not necessarily exclude the
diagnosis of HF, because patients may
accommodate symptoms by substantially
modifying their lifestyle.
Dyspnea
 Patients may sleep with the head elevated to
relieve dyspnea while recumbent
(orthopnea)
 Paroxysmal nocturnal dyspnea, shortness of
breath developing in recumbency, is one of
the most highly reliable indicators of HF.
 Nocturnal cough is a frequently overlooked
symptom of HF.
 These symptoms all typically reflect
pulmonary congestion
Congestion
history of weight gain, increasing abdominal
girth, early satiety, and the onset of edema in
dependent organs (extremities or scrotum)
indicate right heart congestion
Nonspecific,right upper quadrant pain due to
congestion of the liver is common in those
with significant right-sided HF and may be
incorrectly attributed to other conditions
Fatigue
 Another cardinal symptom of HF is fatigue,
generally held to be reflective of reduction in
cardiac output as well as abnormal skeletal muscle
metabolic responses to exercise.
 Other causes of fatigue in HF may include major
depression, anemia, renal dysfunction, and
endocrinologic abnormalities, as well as side
effects of medications.
 Cachexia may be prominent and lead to an
extensive workup for malignancy
History
 The presence of hypertension, coronary artery disease
and/or diabetes is particularly helpful since these
conditions account for approximately 90% of the
population attributable risk for HF in the United States.
 The medical history should also focus on what drugs are
taken by the patient; agents associated with incident HF
include cancer chemotherapy, diabetes drugs (e.g.,
thiazolidinediones), ergot-based antimigraine drugs,
appetite suppressants, certain antidepressants and
antipsychotic agents (notably including clozapine),
decongestants such as pseudoephedrine (owing to its
ability to trigger severe hypertension), and
antiinflammatory agents such as the antimalarial drug
hydroxychloroquine and NSAIDs.
History
 A history of use of herbal remedies and dietary
supplements should be obtained.
 Environmental or toxic exposures including
alcohol or drug abuse should be carefully sought.
 A multigenerational family history should be
taken for previous HF or sudden cardiac death.
 Although most disorders causing HF are cardiac, it
is worth remembering that some systemic illnesses
(e.g., anemia, hyperthyroidism) can cause this
syndrome without direct cardiac involvement
P/E
 An evaluation for the presence and severity
of HF should include consideration of the
patient’s general appearance, measurement
of vital signs in the seated and standing
positions, examination of the heart and
pulses, and assessment of other organs for
evidence of congestion or hypoperfusion or
indications of comorbid conditions.
P/E
 Cheyne-Stokes respiration (also referred to as periodic
or cyclic respiration) is common in advanced HF and
usually is associated with low cardiac output and
sleep-disordered breathing :adverse prognosis.
 By observing or palpating the apical impulse, the
examiner can rapidly determine heart size and quality
of the point of maximal impulse. In cases of severe HF,
a palpable third heard sound may be present. Cardiac
auscultation is a crucial part of HF evaluation.
 A characteristic holosystolic murmur of mitral
insufficiency is heard in many patients with HF.
Tricuspid insufficiency, also is common
P/E
 The presence of a third heart sound is a
crucially important finding and suggests
increased ventricular filling volume; although
difficult to identify, a third heart sound is
highly specific for HF and carries a
substantial prognostic meaning.
 A fourth heart side usually indicates
ventricular stiffening.
 In advanced HF, the third and fourth heart
sounds may be superimposed, resulting in a
summation gallop.
P/E
 A key objective of the examination in patients with
HF is to detect and quantify the presence of
volume retention, with or without pulmonary
and/or systemic congestion. As with symptoms,
evidence of congestion does not always indicate
with certainty that HF is present, nor does absence
of manifest congestion definitively exclude the
diagnosis.
 Patients with HFpEF and those with HFrEF do not
generally show significant differences in frequency
or significance of the stigmata of volume overload.
P/E
 The most definitive method for assessing a patient’s
volume status by physical examination is by the
measurement of jugular venous pressure (JVP).
 An elevated JVP has good sensitivity (70%) and
specificity (79%) for elevated left-sided filling
pressure.
 The sensitivity and specificity of the JVP in detecting
congestion can be considerably improved by exerting
pressure on the right upper quadrant of the abdomen
while assessing venous pulsations in the neck
(hepatojugular reflux).
 Changes in JVP with therapy usually parallel changes
in left-sided filling pressure.
P/E
 Limitations of JVP assessment include difficulties in
its evaluation due to body habitus as well as significant
interobserver variability in its estimation.
 Increase in the JVP may lag behind left sided heart
filling pressures or may not rise at all if pulmonary
artery pressure is increased to the extent that right
ventricular failure or tricuspid insufficiency occur.
 Conversely, the JVP may be elevated without an
increase in left ventricular filling pressures in patients
with pulmonary arterial hypertension, in those with
isolated right ventricular pressure, or when isolated
severe tricuspid regurgitation is present.
P/E
 Bilateral pleural effusions are most
common but when an effusion is
present unilaterally, it is usually right
sided
 only approximately 10% occurring
exclusively on the left side.
P/E
 Leakage of fluid from pulmonary capillaries into the alveoli
can be manifested as rales or rhonchi, and wheezing may
occur with reactive bronchoconstriction.
 Pulmonary rales due to HF usually are fine in nature and
extend from the base upwards, whereas those due to other
causes (e.g., pulmonary fibrosis) tend to be coarser. Rales
or rhonchi may be absent in congested patients with
advanced HF; this may reflect compensatory increase in
local lymphatic drainage.
 Cardiac asthma is due to the physical presence of fluid in
the bronchial wall, as well as secondary bronchospasm, and
can commonly result in an incorrect diagnosis of
obstructive airways disease exacerbation, with consequent
mistriage and incorrect therapy with bronchodilators and
increased risk of death.
P/E
 Lower-extremity edema is a common
finding in volume-overloaded patients with
HF but may commonly be the result of
venous insufficiency (particularly after
saphenous veins have been harvested for
coronary artery bypass grafts) or as a side
effect of medications (e.g., calcium channel
blockers).
 Careful inspection of the JVP will help
improve the specificity of pedal edema for
HF.
P/E
 Detection of reduced cardiac output and systemic
hypoperfusion is a key component of the examination.
 Although patients with poor systemic perfusion
usually have low systolic and narrow pulse pressures as
well as weak and thready pulses, this relationship is
not exact
 Many patients with systolic blood pressures in the
range of 80 mm Hg (or even lower) may have adequate
perfusion, whereas others with reduced cardiac output
may maintain blood pressure in the normal range at
the expense of tissue perfusion by greatly increasing
systemic vascular resistance.
P/E
 Findings suggesting reduced cardiac output include
poor mentation, reduced urine output, mottled skin,
and cool extremities. Of these, cool extremities are the
most broadly useful.
 Assessment for systemic congestion, taken together
with evaluation for reduced cardiac output, may be
useful to separate patients with HF into 4 categories:
 “dry/warm” (uncongested with normal perfusion)
 “wet/warm”(congested with normal perfusion):most
common in DHF
 “dry/cold”(uncongested but hypoperfused)
 “wet/cold” (cardiogenic shock)
Acute HF