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Heart Failure• Final common pathway for many cardiovascular diseases
whose natural history results in symptomatic or asymptomatic left ventricular dysfunction
• Cardinal manifestations of heart failure include dyspnea, fatigue and fluid retention
• Risk of death is 5-10% annually in patients with mild symptoms and increases to as high as 30-40% annually in patients with advanced disease
Main causes
• Coronary artery disease• Hypertension• Valvular heart disease• Cardiomyopathy• Cor pulmonale
Compensatory changes in heart failure
• Activation of SNS• Activation of RAS• Increased heart rate• Release of ADH• Release of atrial natriuretic peptide• Chamber enlargement• Myocardial hypertrophy
NYHA Classification of heart failure
• Class I: No limitation of physical activity• Class II: Slight limitation of physical activity• Class III: Marked limitation of physical activity• Class IV: Unable to carry out physical activity
without discomfort
New classification of heart failure
• Stage A: Asymptomatic with no heart damage but have risk factors for heart failure
• Stage B: Asymptomatic but have signs of structural heart damage
• Stage C: Have symptoms and heart damage• Stage D: Endstage disease
ACC/AHA guidelines, 2001
Types of heart failure
• Diastolic dysfunction or diastolic heart failure• Systolic dysfunction or systolic heart failure
Factors aggravating heart failure• Myocardial ischemia or infarct• Dietary sodium excess• Excess fluid intake• Medication noncompliance• Arrhythmias• Intercurrent illness (eg infection)• Conditions associated with increased metabolic demand (eg
pregnancy, thyrotoxicosis, excessive physical activity)• Administration of drug with negative inotropic properties or fluid
retaining properties (e. NSAIDs, corticosteroids)• Alcohol
Goals of treatment
• To improve symptoms and quality of life• To decrease likelihood of disease progression• To reduce the risk of death and need for
hospitalisation
Approach to the Patient with Heart FailureAssessment of LV function (echocardiogram,
radionuclide ventriculogram)
EF < 40%
Assessment ofvolume status
Signs and symptoms of fluid retention
No signs and symptoms offluid retention
Diuretic(titrate to euvolemic state)
ACE Inhibitor
-blockerDigoxin
NEJM 1984; 311: 819-823
C um ula tive m orta lity (% )100
80
60
40
20
00 12 24 36 48 60
M onths
Overallp<0.0001
N oradrena line > 600 pg /m land 900 pg/m l<
N oradrena line 600 pg /m l<
N oradrena line > 900 pg /m l
Relation between plasm a noradrenaline andm ortality in patients with heart failure
Effects of SNS Activation in Heart Failure
Dysfunction/death of cardiac myocytes Provokes myocardial ischemia Provokes arrhythmias Impairs cardiac performance
These effects are mediated via stimulation
of and 1 receptorsAm J Hypertens 1998; 11: 23S-37S
*
*
*p < 0.05
Idiopathic dilated cardiom yopathy
Norm al m yocardium
70
60
50
40
30
20
10
0
1
1
Rec
epto
r den
sity
(fm
ol/m
g)
Receptor densities in human left ventricular myocardium
Scand Cardiovasc J 1998; Suppl 47:45-55
Carvedilol in Heart Failure
Effective receptor-blockade approach to heart failure
Negative inotropic effect counteracted by vasodilation
Provides anti-proliferative, anti-arrhythmic activity and inhibition of apoptosis
Prevents renin secretionDrugs of Today 1998; 34 (Suppl B): 1-23.
US Multicenter Program
Placebo Carvedilol % Risk(n=398) (n=696) Reduction
All-cause 31 22 65%mortality (7.8%) (3.2%)
Death due to progressive 13 5heart failure (3.3%) (0.7%)Sudden death 15 12
(3.8%) (1.7%)
Risk of hospitalization for 78 78 27%cardiovascular reasons (19.6%) (14.1%)
Combined risk of 98 110 38%mortality & hospitalization (25%) (16%)NEJM 1996; 334:1349-1355
ANZ Multicentre Heart Failure Trial
Placebo Carvedilol % Risk(n=208) (n=207) Reduction
All-cause 26 20 24%mortality (12.5%) (10%)
Risk of hospitalization for 84 64 28%cardiovascular reasons (40%) (31%)
Combined risk of 97 74 29%mortality & hospitalization (47%) (36%)
Lancet 1997; 349: 375-380.
Effect of carvedilol on progressionof congestive heart failure
All randomized patients
Endpoint Placebo Carvedilol (n=134) (n=232)
Primary endpoint 28 (21%) 25 (11%)*
Death due to CHF 4 (3%) 0 (0%)
Hospitalization due to worsening CHF 8 (6%) 9 (4%)
Increase in CHF medication 16 (12%) 16 (7%)
* Placebo vs. carvedilol, p = 0.008
Drugs of Today 1998; 34 (Suppl B): 1-23.
COPERNICUS: Effect on Mortality
11.4%
18.5%
02
46
8
1012
1416
18
20
Carvedilol (n=1156) Placebo (n=1133)
35%
Mor
talit
y (%
)
22nd Congress of European Society of Cardiology, August 2000
COPERNICUS: Mortality reduction inspecial patient groups with carvedilol
36%42%
-60
-50
-40
-30
-20
-10
0
Mor
talit
y re
duct
ion
(%)
22nd Congress of European Society of Cardiology, August 2000
EF<20%, hospitalised for heart failure in year prior
to study entry
EF < 15%, hospitalised3 or more times during
prior year for worsening heart failure
Carvedilol vs. Metoprolol
11.4%
18.5%
0
2
4
6
8
10
12
Metoprolol Carvedilol
Cha
nge
in L
VE
F (%
) fro
m
base
line
Circulation 2000; 102: 546-551
Dosage guidelines for Carvedilol in heart failure
Patient selection• Stable on background medications
(diuretics, digoxin and/or ACE inhibitors)• Not in a fluid-overload state• Not hypotensive
Before dose increaseEvaluate for• Worsening heart failure• Vasodilation• Bradycardia
After each new dose initiation• Observe for signs of dizziness or
light headedness for one hour
3.125 mgbid
2 weeks Doubled every
2 weeks
Max dose 25 mg bid (<85 kg); 50 mg bid (>85 kg)
Management of Complications
Transient worsening of heart failure (e.g. increasing dyspnea,decreasing exercise capacity) Increase dose of diuretic and/or ACE inhibitor If necessary, reduce carvedilol dose and/or prolong titration
interval Search for other possible causes (e.g. thyroid malfunction,
infection, non-compliant drug intake, excessive liquid intake, etc.)
Vasodilatory Symptoms (dizziness, light headedness,symptomatic hypotension) Decrease diuretic dose and, if necessary, ACE inhibitor dose If the cessation of both is not successful, reduce carvedilol dose
and/or prolong titration interval
Management of Complications (Contd.)
Bradycardia (Pulse rate below 55 beats/min) Check and eventually reduce digitalis dose If necessary, reduce carvedilol dose and/or prolong
titration interval Withdraw carvedilol only in the event that hemodynamics
are affected
Symptoms of Bronchial obstruction Search for other possible causes (e.g., concurrent
infection, subacute pulmonary edema) Reduce dose of, or withdraw, carvedilol only after
possible causes for symptoms have been ruled out
The role of angiotensin II in the progression of heart failure
Coronary artery disease Cardiac overloadCardiomyopathy
Left ventricular dysfunction
Arterial blood pressure
Angiotensin II
Peripheral organ blood flow
Skeletal muscleblood flow
Exercise intolerance
Renalblood flow
Oedema
Cardiac remodelling
Renin release
Aldosterone release
Vasoconstriction Na+ and water retention Inotropy and hypertrophy ofvascular and cardiac cells
Left ventriculardilation & hypertrophy
Pump failure
ACE Inhibitors: physiologic benefits
Arteriovenous Vasodilatation• pulmonary arterial diastolic pressure• pulmonary capillary wedge pressure• left ventricular end-diastolic pressure• systemic vascular resistance• systemic blood pressure • maximal oxygen uptake (MVO2)
ACE Inhibitors: physiologic benefits
• LV function and cardiac output• renal, coronary, cerebral blood flow
• No change in heart rate or myocardial contractility• no neurohormonal activation• resultant diuresis and natriuresis
ACE Inhibitors: clinical benefits
• Increases exercise capacity• improves functional class• attenuation of LV remodeling post MI• decrease in the progression of chronic HF• decreased hospitalization• enhanced quality of life• improved survival
Asymptomatic Patients
Enalapril SOLVD Prevention Trial
EF<35% HF progression, hospitalization
CaptoprilSAVE, GISSI-3, ISIS-4 Post MI, EF <40%
overall mortality, re-infarction hospitalization, HF progression
Symptomatic Patients
Hydralazine + Isosorbide dinitrate
VHeFT-I mortality, improved functional classas compared with use of digoxin and diuretics
VHeFT-IIproved less effective than enalapril
Dosage of ACE inhibitors: ATLAS study
Low-dose High-dose(2.5-5 mg) (32.5-35mg)
Cardiovascular 44.9% 42.5%mortalityAll-cause mortality+ hospitalisation for 83.8% 79.7% cardiovascular reasonAll-cause mortality +hospitalisation for 60.4% 55.1%heart failure
Circulation 1999;100:2312-18
AIRE
AIRE Study demonstrated efficacy of ramipril on mortality and morbidity in CHF post-MI NYHA class I-III patients
• 2006 patients enrolled in a double-blind,randomized, placebo-controlled study
• 27% reduction in the risk of death• 23% decrease in progression to severe / resistant heart
failure
Lancet. 1993; 342:821-828
Guidelines to ACE Inhibitor Therapy
• Contraindications– Renal artery stenosis– Renal insufficiency (relative)– Hyperkalemia– Arterial hypotension– Cough– Angioedema
• Alternatives– Hydralazine + ISDN, AT-II inhibitor
Guidelines to ACE Inhibitor Therapy• All patients with symptomatic heart failure and those in
functional class I with significantly reduced left ventricular function should be treated with an ACE inhibitor, unless contraindicated or not tolerated
• ACE inhibitors should be continued indefinitely• It is important to titrate to the dosage regimen used in the
clinical trials … in the absence of symptoms or adverse effects on end-organ perfusion
• In very severe heart failure, hydralazine and nitrates added to ACE inhibitor therapy can further improve cardiac output
ACE Inhibitor Therapyin Heart Failure Patients(Ejection Fraction < 0.40)
Systolic Blood Pressure
<100 mmHg (or elevated creatinine)
100-139 mmHg (or recent intense diuresis)
>140 mmHg
Lowest Dose,Short-Acting
Usual Starting Dose, Long-or Short-Acting
Intermediate Dose, Long- or Short-Acting
Follow-Up Every 1-2 Weeks
Stable BP and Creatinine Level
Symptomatic Low BP or Rising Creatinine Level
Residual Excess Fluid?
Stop Diuretic and ACE Inhibitor Therapy
Return to Baseline BP and Creatinine Level ?
Increase ACE Inhibitor Dose; Follow-Up Every 1-2
Weeks
Target DoseResume ACE
Inhibitor Titration
Refer to specialist
Stop ACE Inhibitor Therapy
Y
NY
N
Diuretics
• Indicated in patients with symptoms of heart failure who have evidence of fluid retention
• Enhance response to other drugs in heart failure such as beta-blockers and ACE inhibitors
• Therapy initiated with low doses followed by increments in dosage until urine output increases and weight decreases by 0.5-1kg daily
Digoxin• Enhances LV function, normalizes baroreceptor-mediated reflexes
and increases cardiac output at rest and during exercise• Recommended to improve clinical status of patients with heart
failure due to LV dysfunction and should be used in conjunction with diuretics, ACE inhibitors and beta-blockers
• Also recommended in patients with heart failure who have atrial fibrillation
• Digoxin initiated and maintained at a dose of 0.25 mg daily• Adverse effects include cardiac arrhythmias, GI symptoms and
neurological complaints (eg. visual disturbances, confusion)
Summary of drug treatment for CHFAsymptomaticMild to moderate ModerateLV dysfunction CHF to severe CHFACE inhibitor Digoxin DigoxinBeta blocker Diuretics Diuretics
ACE inhibitor ACE inhibitorBeta blocker Beta blockerSpironolactone
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