Transcript Heart failure and breathlessness in end stage care

HEART FAILURE AND BREATHLESSNESS
IN END STAGE CARE
Dr K Ranjadayalan, Consultant Cardiologist
BMI The London Independent Hospital
Newham University Hospital
A Breathless patient
 57 yr old Male
 P/C
Effort Dyspnoea for 6 weeks
 Bilateral leg swelling
v
 P/H
H/T for 4 years
 S/H - Non smoker, moderate alcohol intake
A Breathless Patient
 O/E No “JACC”, bilateral pitting oedema
 CVS
o
o
o
o
Pulse-110/min, BP I 145/96, Raised JVP
Normal heart sounds
Increased respiratory rate
Scattered wheeze
 RHC tenderness with hepatomegaly
v
 Investigations ? In the community
 Cause of breathlessness –
o ? Cardiac (Heart Failure)
o ? Respiratory
Most likely Cause of his breathlessness is:
1.
2.
3.
4.
5.
Left Heart failure
Late onset bronchial asthma
Chest infection
Right Heart failure
v
Congestive Heart failure
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Heart Failure

Definition

Different types of HF

Pathophysiology of HF

Causes of HF

When to suspect HF

Investigations & management of HF
v
Natural History of Heart Failure
Mechanism of Death
Sudden Death 40%
100%
Worsened HF
Other
Survival
Progression
v
Annual Mortality
0%
< 5%
10%
Asymptomatic
Mild
20 - 30 %
Moderate
30 - 80%
Severe
Left Ventricular Dysfunction and Symptoms
40%
20%
Definition of HF
A clinical syndrome due to failure of the heart to maintain
adequate cardiac output (blood flow) due to a structural
or functional defect of the heart.
Structural defect - Common
o Ventricular Dysfunction or Valve malfunction
v
Structural defect - Uncommon
o Abnormal shunts or Pericardial disease
What happens when the Cardiac output
drops?
Body
 Activation of Neurohormonal system
 Diversion of blood flow to brain
Heart
 Increase in intracardiacv pressures
 Dilatation or hypertrophy of ventricles
 Dilatation of atria
 Fibrosis, Hypertrophy & apoptosis
Neurohormonal activation in HF
1. Sympathetic activation
 Vasoconstriction (Afterload)
 Sinus tachycardia (Preload)
2. Renin Angiotensin Aldosterone system
 Vasoconstriction
(Afterload)
v
 salt & water retention (Preload)
Preload - volume of blood in the LV immediately before systole
Afterload - resistance to blood flow in arteries
Why ?
 Cardiac Output = Stroke Volume (SV) X Heart Rate (HR)
 Blood Pressure = Cardiac Output X Peripheral Resistance
(PR)
 SV - Increase in fluid retention, Sympathetic activation
 HR - Sympathetic activationv
 PR – Vasoconstriction - Angiotensin 11 & sympathetic
activation
Neurohormonal activation in HF
3. Natriuretic peptides
Atrial natriuretic peptides ( ANP)
 Secreted from atria
Brain natriuretic peptides ( BNP)
v (cardiac)
 Secreted from ventricles
Diuresis, vasodilatation (by reducing angiotensin,
aldosterone, & endothelin)
Types of Heart failure
 *Left heart failure – Acute or Chronic
 Right heart failure – Acute or Chronic
 Congestive heart failure
– Chronic
v
* Functionally - Systolic or Diastolic
Causes of Left Heart Failure (Acute or Chronic)
1.. Coronary artery disease
2. Hypertension
3. Valvular disease (congenital or acquired)
v
4. Cardiomyopathy – HCM, DCM, RCM, AF induced
CM
Hypertension to HF
Obesity
Diabetes
IGT
LVH
Diastolic
Dysfunction
HTN
CHF
CAD
Smoking
Lipids
Diabetes
MI
Systolic
Dysfunction
v
Overt HF
Normal LV
Structure
and Function
LV
Remodeling
Subclinical LV
Dysfunction
Adapted with permission from: Vasan RS, Levy D. Arch Intern Med. 1996;156:1790.
Causes of Dilated Cardiomyopathy
1.
2.
3.
4.
5.
6.
7.
8.
Alcohol, cocaine
Connective tissue diseases
Drugs - Herceptin, Antidepressant
Endocrine causes – Thyroid, acromegaly, diabetes
Familial – 10 to 20%
v
Infiltration – Sarcoid, Fe deposits
Infection – viral
Pregnancy
Causes of Right Heart Failure (Chronic)
1. Left Heart Failure - CCF
2. Chronic Lung disease – Cor Pulmonale
3. Recurrent Pulmonary embolism
v
4. Congenital Heart Disease
5. Idiopathic Pulmonary H/T
When to suspect HF ?
v
Left heart failure
•
Breathlessness on exertion
•
Fatigue
•
Paroxysmal nocturnal dyspnoea -2am
v
 Orthopnoea (indicative of fluid overload)
 Cough & wheezing (Cardiac)
Signs of Left heart failure (1)
 Increased respiratory rate
 Increased heart rate (Sinus or atrial fib or flutter)
 Sweating
 Cyanosis
 Cold extremities
 BP- High, low, normal
v
Signs of Left heart failure (2)
 Cardiomegaly – Displaced apex
 Third heart sound
 Mitral or Aortic murmur
 Crackles
v
 Wheeze
 Pleural effusion – bilateral or unilateral
Symptoms of Right heart failure
 Dyspnoea
 Peripheral oedema
 Abdominal distension
v
 GI symptoms- Nausea, vomiting, loss of
appetite
Signs of Right heart failure
 Raised JVP
 Parasternal heave – RV enlargement
 Murmur, third heart sound
 Hepatomegaly with signs ofv liver dysfunction
 Leg or sacral oedema
 Ascites
 Basal crackles – specific for fluid overload-High PCWP
Clear lung fields tell you veryv little about the fluid status in
heart failure
 Examination of the neck veins is the best physical exam
technique for determining the fluid status in heart failure
Investigations of Heart Failure (Chronic)

ECG

Brain Natriuretic Peptides –BNP or NTpro BNP

CXR

Echocardiography
 Blood tests
v
 Angiography – Non invasive or invasive
 Cardiac MRI – Ischaemic or Nonischaemic
 Myocardial biopsy
ESC Guidelines for Heart Failure Diagnosis
Suspected Heart Failure
because of symptoms & signs
Assess presence of cardiac disease by ECG, X-ray or
BNP (where available)
Normal
Heart Failure
unlikely
Test abnormal
Imaging by echocardiographyv
Normal
Heart Failure
unlikely
Test abnormal
Assess aetiology, degree, precipitating
factors & type of cardiac dysfunction
Additional diagnostic tests
Where appropriate
(e.g. coronary angiography)
Choose therapy
Eur Heart Journal (2001)22, 1527-1560
Breathless patient 1
v
Breathless patient 2
v
Role of Echocardiography in HF
 Gold standard investigation
 Differentiates Systolic and diastolic dysfunction
 Quantifies Systolic dysfunction - LVEF
v
 Quantifies Diastolic dysfunction – Grade 1 to 4
 Identifies the cause of heart failure
Treatment of Heart failure (Chronic)

Non pharmacological
 Pharmacological
 Surgical
v
 Device therapy
 Transplant
Non pharmacological

Avoid alcohol, smoking & stress
 Bed rest during acute exacerbations
 Counseling
 Diet low in salt
 Exercise
 Fluid restriction
v
How Do We Make Heart Failure Patients
(LVSD) Live Longer?
 Angiotensin II
(Renin-Angiotensin Aldosterone
System [RAAS]
 Norepinephrine
(Sympathetic Nervous System [SNS])
-Blockade
RAAS Inhibition
v
Disease Progression
Devices
How do we make Heart Failure patients
Feel Better & Live longer?
 Diuretics – Furosemide, metolazone
 RASS Inhibition – ACEI or ARBs, Anti Aldosterone
v
 Beta blockers – Bisoprolol, Carvedilol, Metoprolol,
Nebivolol
Beta blocker in HF
• Indicated for symptomatic & asymptomatic LVSD
• Start low and go slow
v
• Aim for heart rate 55 to 60/min
• Benefit more in sinus rhythm than in AF patients
Benefits of Beta blocker in HF
• Reduce SCD and total death
• Improve LV size and Function
v
• Reduce onset of AF and VT
• Meta analysis of 19,000 patients
Spironolactone in HF
• Aldosterone antagonist spironolactone at low dose (12.5
mg to 25 mg once daily) should be considered for NYHA
Class 11 or IV Heart failure
• Serum potassium concentration should be monitored after
the first week and at regular intervals thereafter and after
any change in dose of spironolactone
v
• For spironolactone intolerant patients or young males
consider Eplerenone
• Avoid in significant renal dysfunction
Digoxin in HF
• No prognostic benefit
• Cardiac tonic – reduce symptoms and
admissions
v
• Can be used for rate control of AF if rhythm
control not possible
Device therapy in HF
1. ICD
v
2. Biventricular pacing- CRT
Why ICD ?

Sudden cardiac arrest is 6 to 9 times more likely
in HF than in the general population
 Sudden death is caused most commonly by VT or
VF in patients with LV dysfunction
v
 90% of patients do not survive their first cardiac
arrest
Indications for ICD

Impaired LV with sustained or non sustained VT

Resuscitated VF/VT arrests not due to reversible
cause
v

Patients with Previous MI , LVEF<35%,QRS
>120
3. LVAD
v
4.Heart transplant
Summary
 Heart failure is common and the prevalence is increasing
 The main cause of systolic HF is CAD & Diastolic HF- H/T
 The burden of HF is the disabling symptoms, activity
limitation, arrhythmias, frequent hospitalisations and high
mortality
 Pharmacological treatment and device therapy have been
shown to improve the outcome
v in systolic but not diastolic
HF
 Patients with advanced Heart failure and their families
should be offered supportive care