curs ic- -ic si ci --final -11- nov 2013

8/9/2019 Curs Ic- -Ic Si Ci --Final -11- Nov 2013

http://slidepdf.com/reader/full/curs-ic-ic-si-ci-final-11-nov-2013 1/674



Clinical syndromeClinical syndromethat can result from anythat can result from anystructural or functional cardiac disorderstructural or functional cardiac disorder

that impairs the ability of the ventricle tothat impairs the ability of the ventricle to

fill with or eject bloodfill with or eject blood



De&nitionDe&nition%etiolog! %etiolog!

'eart failure is a clinical s!ndrome usuall!'eart failure is a clinical s!ndrome usuall!due to left ventricular d!sfunction$due to left ventricular d!sfunction$resulting in acute or chronic s!m"toms ofresulting in acute or chronic s!m"toms ofcardiac "um" failure.cardiac "um" failure.

The most common causes of heart failureThe most common causes of heart failureareare coronar! heart disease$ h!"ertension$coronar! heart disease$ h!"ertension$alcohol ause$ and idio"athic dilatedalcohol ause$ and idio"athic dilatedcardiom!o"ath!cardiom!o"ath!

(ther causes are(ther causes are valvular and "ericardial valvular and "ericardial

disease) or non%cardiac diseases causingdisease) or non%cardiac diseases causinghigh%out"ut cardiac failure$ such ashigh%out"ut cardiac failure$ such asanaemia$ th!roto#icosis$ se"ticaemia$anaemia$ th!roto#icosis$ se"ticaemia$Paget*s disease of one$ and arteriovenousPaget*s disease of one$ and arteriovenous&stulae.&stulae.



'EA+T FAI,U+E'EA+T FAI,U+E



Modern clinical de&nitionModern clinical de&nitionESC guidelineESC guideline

Typical symptoms

and signs of

heart failure

Cardiac dysfunction

confirmed

(ECG, imaging modalitie

Neurohumoral

aktivation confirmed

(BNP)

esponse to

heart failure

treatment



Heart FailureHeart Failure

HeartHeart

A heart failure heart has a reduced ability toA heart failure heart has a reduced ability to

pump blood.pump blood.



Ada"tation in heart failure Ada"tation in heart failure

-Com"ensator! Mechanism-Com"ensator! Mechanism



Ventricular remodelling Ventricular remodelling

LV mass↑, size↑, shape is altered



ongestive Heart Failurengest ve eart a ure

HF

HF

!! "olume overload#"olume overload# egurgitate valveegurgitate valve

$igh output status$igh output status

!! Pressure overload#Pressure overload# %ystemic hypertension%ystemic hypertension

&utflo' ostruction*%&utflo' ostruction*%

!! +oss of muscles#+oss of muscles# Post -, Chronic ischemiaPost -, Chronic ischemia

Connective tissue diseasesConnective tissue diseases

-nfection, Poisons-nfection, Poisons

(alcohol,coalt,.o/oruicin(alcohol,coalt,.o/oruicin))

!! estricted 0illing#estricted 0illing# Pericardial diseases,Pericardial diseases,

estrictiveestrictive cardiomyopathycardiomyopathy

TachyarrhythmiaTachyarrhythmia

Causes of C$0


http://slidepdf.com/reader/full/curs-ic-ic-si-ci-final-11-nov-2013 13/674 Adapted from Cohn JN. N Engl J Med . 1996;335:9!"9#.

Pathologic

remodeling

+o' e1ection

fraction .eath

%ymptoms#

.yspnea0atigue

Edema

Chronic

heartfailure

$Neurohormonalstimulation

$yocardialto/icity

%udden

.eath

Pumpfailure

Coronary arterydisease

$ypertension

Cardiomyopathy

"alvular disease

yocardial

in1ury

Pathologic Progression of C/Pathologic Progression of C/

DiseaseDisease

.iaetes




HF

HF

Pathophysiology

'emod!namic changes'emod!namic changes

0eurohormonal changes0eurohormonal changes

Cellular changesCellular changes



'emod!namic changes'emod!namic changes

From hemodynamic stand point HF From hemodynamic stand point HFcan be secondary tocan be secondary to systolicsystolic

dysfunction ordysfunction or

diastolic dysfunctiondiastolic dysfunction



Diagnosis of heart failureDiagnosis of heart failure

Physical examination

Medical history

Lab tests: BNP, …

X-ray, ECG,

Echo, Siro-

Er!ometry…



Cinical s!m"toms andCinical s!m"toms and

signssignsD!s"neaD!s"nea%% (rtho"nea(rtho"nea%%EdemaEdema$$CoughCough

,iver engorgement,iver engorgementdyspnoe fatigue

fluid

retention




HF

HF&T$&PNE*

J%&%lar Veno%s 'istentionJ%&%lar Veno%s 'istention

not dire(tl) related to LV*+not dire(tl) related to LV*+




HF

HF

E2G

(ld MI or recent MI(ld MI or recent MI

Arrh!thmia Arrh!thmia

Some forms of Cardiom!o"ath! areSome forms of Cardiom!o"ath! aretach!cardia relatedtach!cardia related

,111,11122may help in managementmay help in management

'eart 1loc3 'eart 1loc3




HF

HF

hythm prolems leading to C$0




HF

HF

Chest 34ray

Loo or !eart size"ulmonary #ascular marings$%"D& pneumonia& "neumothora'& widened

mediastinum"leural e(usions




HF

HF

Echocardiogram

Function of oth ventriclesFunction of oth ventricles

4all motion anormalit! that ma! 4all motion anormalit! that ma!

signif! CADsignif! CAD

/alvular anormalit! /alvular anormalit!

Intra%cardiac shuntsIntra%cardiac shunts

Pericardial e5usionPericardial e5usion+estrictive "ericarditis+estrictive "ericarditis

Pulmonar! h!"ertensionPulmonar! h!"ertension



!$)& !%$)!$)& !%$)



*estricti#e $)"*estricti#e $)"




HF

HF

+a Tests

Anemia Anemia

'!"erth!roid'!"erth!roid

Chronic renal insu5ienc!Chronic renal insu5ienc!

Electrol!te anormalit!%0a$ 6$ Mag$Electrol!te anormalit!%0a$ 6$ Mag$

CalciumCalcium

Pre%renal a7otemiaPre%renal a7otemia

'emochromatosis'emochromatosis

10P10P

TS'TS'

'gA8c'gA8c



Classif!ing 'eartClassif!ing 'eartFailure9Failure9

Terminolog! andTerminolog! andStagingStaging

++



A 6e! Indicator for Diagnosing A 6e! Indicator for Diagnosing

'eart Failure'eart Failure

E:ection Fraction -EFE:ection Fraction -EF E:ection Fraction -EF is theE:ection Fraction -EF is the

"ercentage of lood that is "um"ed"ercentage of lood that is "um"ed

out of !our heart during each eatout of !our heart during each eat



S!stolic vs. DiastolicS!stolic vs. Diastolic

Diastolic d!sfunctionDiastolic d!sfunction ,- normal or increased,- normal or increased

!ypertension!ypertension Due to chronic replacementDue to chronic replacement

fbrosis . ischemia/inducedfbrosis . ischemia/induceddecrease in distensibilitydecrease in distensibility

S!stolic d!sfunctionS!stolic d!sfunction ,- 0 23,- 0 23

4sually rom coronary disease4sually rom coronary disease Due to ischemia/induced decreaseDue to ischemia/induced decrease

in contractilityin contractility )ost common is a combination o)ost common is a combination o

bothboth




HF

HF

.iagnosis of diastolic C$0

$ -ncreased ventricular filling pressure 'ith-ncreased ventricular filling pressure 'ith

normal systolic functionnormal systolic function

$ -ncresed ventricular pressure 'ith preserved-ncresed ventricular pressure 'ith preservedsystolic function and normal ventricularsystolic function and normal ventricular

volumesvolumes

$ -ncreased left atrial and pulmonary capillary-ncreased left atrial and pulmonary capillary

'edge pressure'edge pressure

$ Clinical symptoms and signs6Clinical symptoms and signs6



Acute 'eart Failure Acute 'eart Failure

%ten precipitated by a myocardial%ten precipitated by a myocardialinarction+inarction+

Signs include9Signs include9 Se#ere breathlessnessSe#ere breathlessness -rothy pin sputum-rothy pin sputum $old clammy sin$old clammy sin 5achycardia5achycardia Low blood pressureLow blood pressure

Lung crepitationsLung crepitations *aised 6ugular #enous pressure*aised 6ugular #enous pressure 5hird heart sound5hird heart sound $onusion$onusion



70&8*. 0*-+9E: (+o'

Cardiac&utput)#.ecreased perfusion of the

rain (confusion)6kidneys (impaired renalfunction),

skin (cyanosis) etc6

7

7B*C28*.

0*-+9E:

#

-ncreased

pulmonary

venous pressure,

pulmonary edema



Chronic 'eart FailureChronic 'eart Failure

Ma3ing an accurate diagnosis of heart failure andMa3ing an accurate diagnosis of heart failure anddetermining its cause can e di5icultdetermining its cause can e di5icult

$linical diagnosis is confrmed to be accurate in$linical diagnosis is confrmed to be accurate inappro'imately hal o cases when in#estigated byappro'imately hal o cases when in#estigated byechocardiography+echocardiography+

The li3elihood of heart failure in the "resence ofThe li3elihood of heart failure in the "resence ofsuggestive s!m"toms and signs is increased if suggestive s!m"toms and signs is increased if there is athere is ahistory o myocardial inarction 7)89 or angina& an abnormalhistory o myocardial inarction 7)89 or angina& an abnormal,$:& or a chest ;/ray showing pulmonary congestion or,$:& or a chest ;/ray showing pulmonary congestion orcardiomegaly+cardiomegaly+

S!m"toms include9S!m"toms include9 Shortness o breath on e'ertion 7sensiti#ity <<3& specifcity =>39Shortness o breath on e'ertion 7sensiti#ity <<3& specifcity =>39

Decreased e#ercise tolerance -often sim"l! *fatigue*Decreased e#ercise tolerance -often sim"l! *fatigue* Paro#!smal nocturnal d!s"noea -sensitivit! ;;<$Paro#!smal nocturnal d!s"noea -sensitivit! ;;<$

s"eci&cit! =><s"eci&cit! =>< (rtho"noea -sensitivit! ?8<$ s"eci&cit! @8<(rtho"noea -sensitivit! ?8<$ s"eci&cit! @8< An3le selling -sensitivit! ?;<$ s"eci&cit! An3le selling -sensitivit! ?;<$ s"eci&cit! ?239?239



Acute vs. Chronic Acute vs. Chronic

Acute AcuteBan emergenc! situationBan emergenc! situation inin

which a patient was completelywhich a patient was completely

asymptomatic beore the onset oasymptomatic beore the onset oheart ailure@ seen in acute heartheart ailure@ seen in acute heart

in6ury such as )8in6ury such as )8

ChronicChronicAlong/term syndromeAlong/term syndrome inin

which a patient e'hibits symptomswhich a patient e'hibits symptoms

o#er a long period o time& usually aso#er a long period o time& usually as

a result o a pree'isting cardiaca result o a pree'isting cardiac



T!"esT!"es

SystolicSystolic -"um"ing "rolem-"um"ing "rolem9Ainability o the9Ainability o theheart to contract to pro#ide enough blood Bowheart to contract to pro#ide enough blood Boworwardorward

iastolic iastolic 7flling problem9A7flling problem9Ainability o the letinability o the let

#entricle to rela' normally& resulting in Buid bac #entricle to rela' normally& resulting in Buid bacup into the lungsup into the lungs

!eft"sided !eft"sidedAAinability o the let #entricle to pumpinability o the let #entricle to pump

enough blood& causing Buid bac up into the lungsenough blood& causing Buid bac up into the lungs

#ight"sided #ight"sidedAAine(icient pumping o the right sideine(icient pumping o the right sideo the heart& causing Buid buildup in the abdomen&o the heart& causing Buid buildup in the abdomen&

legs& and eetlegs& and eet

, f Sid d ' F il, ft Sid d ' t F il



,eft%Sided 'eart Failure,eft%Sided 'eart Failure

Signs S!m"tomsSigns S!m"toms

DyspneaDyspnea

4ne'plained cough4ne'plained cough

"ulmonary cracles"ulmonary cracles

Low o'ygenLow o'ygensaturationsaturation

5hird heart sound5hird heart sound

*educed urine output*educed urine output

Cltered digestion Cltered digestion

Dizziness and light/Dizziness and light/headednessheadedness

$onusion$onusion

*estlessness and*estlessness and

an'ietyan'iety

-atigue and weaness-atigue and weaness

+ g t%S e 'eartg t% e eart



+ g t%S e 'eartg t% e eartFailureFailure

Signs S!m"tomsSigns S!m"toms Lower e'tremityLower e'tremity

edemaedema

Li#er enlargementLi#er enlargement

Cscites Cscites

Cnore'ia Cnore'ia

Cbdominal pain Cbdominal pain

auseaausea

Eeight gainEeight gain

EeanessEeaness



i



Com"arison 1eteenCom"arison 1eteen

ACCA'A 'F Stage and ACCA'A 'F Stage and

0'A Functional Class0'A Functional Class

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2 New York Heart Association/ittle !rown an" #o$%an&' 19(). A"a%te" *ro$: +arrell ,H et al. JAMA. 2002;28-:890–89-.

"CC#"$" $% Sta!e& N'$" %(nctional Class)

" "t hi!h ris* +or heart +ail(re b(t itho(t

str(ct(ral heart disease or symtomso+ heart +ail(re e!, atients ith

hyertension or coronary artery disease.

B Str(ct(ral heart disease b(t itho(tsymtoms o+ heart +ail(re

C Str(ct(ral heart disease ith rior orc(rrent symtoms o+ heart +ail(re

/ 0e+ractory heart +ail(re re1(irin!seciali2ed inter3entions

4 "symtomatic

44 Symtomatic ith moderate exertion

45 Symtomatic at rest

444 Symtomatic ith minimal exertion

None



Current FuturePers"ectives in theTreatment of 'eart

Failure



Princi"les of TreatmentPrinci"les of Treatment

Systolic !-Systolic !-

↓↓ "reload"reload

↓↓ Cterload Cterload

↑↑ Ionotropy Ionotropy ↓↓ eurohumoraleurohumoral

acti#ityacti#ity

C$,/8& Feta/ C$,/8& Feta/

blocers& andblocers& and

aldosteronealdosterone

antagonist are theantagonist are themainstay omainstay o

treatmenttreatment

f h f ilT f h f il



Treatment of heart failureTreatment of heart failure

Pharmacologic

treatment

ozit74 inotrop

'i&italisNe%roh%mor8lis lo8d: 22, AC*i'i%reti(%mVasodilator

Antiarrh)thmi8s Non4pharmacologic treatment

es)n(hronization C<C'<A2 Assist de4i(e

%urgical;interventional

e4as(%larisationVal4e repla(ement

Ane%r)sm rese(tion%r&i(al remodelin&tem=(ell therap)

$eart transplantation



Drug Thera"! Drug Thera"!




HF

HF

Treatment of C$0

Correction of reversile causesCorrection of reversile causes

$ edicationsedications

.iuretics.iuretics,, *CE inhiitors, eta lokers etc6*CE inhiitors, eta lokers etc6$ -schemia-schemia

$ *rrhythmia# * fi, flutter, P<T*rrhythmia# * fi, flutter, P<T

$ "alvular heart disease"alvular heart disease

$ Thyroto/icosis and other high output statusThyroto/icosis and other high output status$ %hunts%hunts



iuretics A# re"uces te nu$er o*

sacks on te wa4on



DiureticsDiuretics

symptomssymptoms↓↓& oedema& oedema↓↓& prognosis& prognosis→→ only in case o Buid retentiononly in case o Buid retention *CCS acti#ation*CCS acti#ation→→add C$,i or C*FGadd C$,i or C*FG 5itrate& combine5itrate& combine

!yonatraemia& hypoalemia& #olume!yonatraemia& hypoalemia& #olumedepletion& renal dysunctiondepletion& renal dysunction

Diuretic resistanceDiuretic resistance



56 All a4ailale for oral or <V administration

,oo" Diuretics,oo" Diuretics

Agent Agent InitialInitialDail! DoseDail! Dose

Ma# TotalMa# TotalDail! DoseDail! Dose

EliminatioElimination9 +enal n9 +enal Met.Met.

DurationDurationof Actionof Action

FurosemidFurosemidee

?G%HGmg?G%HGmgd or idd or id

>GG mg>GG mg >J<+%>J<+%;J<M;J<M

H%> hrsH%> hrs

1umetanid1umetanidee

G.J%8.G mgG.J%8.G mgd or idd or id

8G mg8G mg >?<+;@<>?<+;@<MM

>%@ hrs>%@ hrs

TorsemideTorsemide 8G%?G mg8G%?G mgdd

?GG mg?GG mg ?G<+%?G<+%@G<M@G<M

8?%8> hrs8?%8> hrs

Ethacr!nicEthacr!nicacidacid

?J%JG mg?J%JG mgd or idd or id

?GG mg?GG mg >=<+%>=<+%;;<M;;<M

> hrs> hrs



Aldosterone antagonists Aldosterone antagonists

symptomssymptoms↓↓& prognosis& prognosis↑↑& mortality& mortality↓↓ H!C 888& ,-H!C 888& ,-00I=3I=3

*enal dysunction*enal dysunction

!yperalaemia!yperalaemia



ACE ACEI and A+1I and A+1

symptomssymptoms↓↓& prognosis& prognosis↑↑& mortality& mortality↓↓ remodellingremodelling↓↓& myocardial fbrosis& myocardial fbrosis↓↓ starting dose& target dosestarting dose& target dose

!ypotension!ypotension !yperlaaemia& renal dysunction!yperlaaemia& renal dysunction $ough$ough Cngio/oedema Cngio/oedema




HF

HF

"asodilators$ydrala5ine and Nitrates

$+eduction of afterload+eduction of afterload by arteriolarby arteriolar

#asodilatation 7 #asodilatation 7h!drala7inh!drala7in99 →→ reducereduce

LV,D"& %LV,D"& %>> consumption&impro#e myocardialconsumption&impro#e myocardialperusion&perusion& ↑↑ stroe #olume and $%"stroe #olume and $%"

$+eduction of "reload+eduction of "reload FyFy #enous #enous

dilationdilation

77 0itrate0itrate →

J the #enous returnJ the #enous return →→J theJ the

load on both #entricles+load on both #entricles+

$4sually the ma'imum beneft is achie#ed4sually the ma'imum beneft is achie#ed

by using agents with both action+by using agents with both action+



/i!italis Como(nds

ike te carrot %lace" in *ront o* te "onke&



4notroic "!ents

ike te carrot %lace" in *ront o* te "onke&




HF

HF

-notropic *gents

5hese are the drugs that impro#e5hese are the drugs that impro#e

myocardial contractility 7myocardial contractility 7β adrenergicβ adrenergic

agonists& dopaminergic agents&agonists& dopaminergic agents&

phosphodiesterase inhibitors9&phosphodiesterase inhibitors9& .opamine.opamine

.outamine.outamine

ilrinone,ilrinone,

*amrinone*amrinone

Se#eral studies showed K mortality with oral inotropicSe#eral studies showed K mortality with oral inotropic

agentsagents

So the only use or them now is in acute sittings such asSo the only use or them now is in acute sittings such as

cardiogenic shoccardiogenic shoc



Device Thera"!9Device Thera"!91iventricular1iventricular

PacingPacing



Device Thera"! Device Thera"!

8mplantable $ardio#erter/8mplantable $ardio#erter/

Defbrillators 78$D9Defbrillators 78$D9

$ardiac *esynchronization 5herapy$ardiac *esynchronization 5herapy

7$*597$*59 Let Ventricular Cssist De#icesLet Ventricular Cssist De#ices

7LVCD97LVCD9

Fi#entricular Cssist De#icesFi#entricular Cssist De#ices

8ntraaortic Faloon "ump8ntraaortic Faloon "ump



Cardiac 0esynchroni2ation 7heray

ncrease te "onke&5s 7eart e**icienc&

1iventricular Pacing1iventricular Pacing



69>4er4ie of 'e4i(e herap)

1iventricular Pacing1iventricular Pacing /entricular D!s!nchron! /entricular D!s!nchron!

Cbnormal #entricular conduction Cbnormal #entricular conduction

resulting in a mechanical delay andresulting in a mechanical delay and

dysynchronous contractiondysynchronous contraction



Thera"!Thera"!



Thera"! Thera"!

6e! Points6e! Points IndicationsIndications

)oderate to se#ere $!- who ha#e ailed)oderate to se#ere $!- who ha#e ailedoptimaloptimal medical therapymedical therapy

,-0I23,-0I23 ,#idence o electrical conduction delay,#idence o electrical conduction delay

5iming o *eerral 8mportant5iming o *eerral 8mportant "atients oten not on optimal )edical *'"atients oten not on optimal )edical *' "atients reerred too late/ ot a Fail %ut"atients reerred too late/ ot a Fail %ut



'o oes a e r atoro oes a e r ator



for sudden cardiac deathfor sudden cardiac death

or3K or3K

DeviceShown:

CombinationPacemaker&Defbrillator



VCD 8ssues VCD 8ssues

4hat is a /ADK4hat is a /ADK



4hat is a /ADK 4hat is a /ADK

C single system de#ice that is surgicallyC single system de#ice that is surgically

attached to theattached to the left ventricle of theleft ventricle of theheartheart and to the aorta or letand to the aorta or let

#entricular #entricular su""ortsu""ort

For +ight /entricular su""ortFor +ight /entricular su""ort& the& the

de#ice is attached to the right atrium andde#ice is attached to the right atrium and

to the pulmonary arteryto the pulmonary artery

Thoratec p"*.Thoratec p"*.




<arvik =>>> +"*.<arvik =>>> +"*.



,eft /entricular Assist,eft /entricular Assist



,eft /entricular Assist,eft /entricular Assist

Devices -,/ADDevices -,/AD *,)C5$! 5rial/*,)C5$! 5rial/ 1 yr sur#i#al =>31 yr sur#i#al =>3

7LVCD9 #s >3 7r'97LVCD9 #s >3 7r'9 > yr sur#i#al >I3 #s> yr sur#i#al >I3 #s

?3?3 ,nd/Stage 7$lass 8V9,nd/Stage 7$lass 8V9 !- pts ineligible or!- pts ineligible or

transplant due totransplant due to

M<=yoM<=yo D) with ,%DD) with ,%D $*8$*8

++

++



%urgery



%urgery

Coronar) e4as(%larization Val4%lar %r&er)

Ventri(%lar e(onstr%(tion for<s(haemi( Cardiom)opath) /itral epair for e&%r&itation LV Ane%r)sm li(ation?ese(tion Ventri(%lar emodellin& ost=infar(t V' repair

%9GE? TE*TENT -N $0%9GE? TE*TENT -N $0




,/ + i -D ,/ + t ti -D



,/ +econstruction -Dor,/ +econstruction -Dor

<econstruction & =atc =last&



Bockeria et al. Eur J Cardio-thorac Surg

2006;29:S25-!S.

>atene' or' +ontan

Novel echanical *nti4remodelingNovel echanical *nti4remodeling



Novel echanical *nti4remodelingNovel echanical *nti4remodeling

Therapies in $eart 0ailureTherapies in $eart 0ailure

*C&N*C&Nyosplintyosplint




Area of "revious infarct ith ru"ture of ventricular all



Cardiac $ransplantCardiac $ransplant

8t has become more widely used since the8t has become more widely used since the

ad#ances in immunosuppressi#ead#ances in immunosuppressi#e

treatmenttreatment

Sur#i#al rateSur#i#al rate

1 year ?23 / N231 year ?23 / N23 = years O23= years O23

Ch i ti 1 dCh i ti 1 d



Christian 1arnardChristian 1arnard

Born in South Africa in 1922Born in South Africa in 1922

Studied heart surgery at theStudied heart surgery at the

University of Minnesota thenUniversity of Minnesota then

returned to set up a cardiac unitreturned to set up a cardiac unit

in Cape Town.in Cape Town.

December 1967: transplanted theDecember 1967: transplanted the

heart of a road accident victimheart of a road accident victim

into a 59 year old patientinto a 59 year old patient Patient only survived 18 daysPatient only survived 18 days

due to infectious complicationsdue to infectious complications

( t ti t Th(ut"atient Thera"!



9

(ut"atient Thera"! (ut"atient Thera"!

THE END



THE END

Inca nu s-a terminat !!!Inca nu s-a terminat !!!



Ischemic 'eartIschemic 'eartDisease andDisease and

M!ocardialM!ocardialInfarctionInfarction

Prof Univ Dr Ion C.TintoiuProf Univ Dr Ion C.Tintoiu

Coronar! Arter esoronar! rter es0ormal Anatom0ormal Anatom!



0ormal Anatom! 0ormal Anatom!

Coronar! Angiogra"h!Coronar! Angiogra"h!



Coronar! Angiogra"h! Coronar! Angiogra"h!



Screening and DiagnosisScreening and Diagnosis



g gM!ocardial IschemiaM!ocardial Ischemia

%tress%tress

TestTest

m e a s u r e s

m e a s u r e s

( l o

o d

( l o

o d

s u p p l y

s u p p l y

t o h e a r t

t o h e a r t

CoronaryCoronary

*ngiography*ngiography

s

p e c i f i c

s

p e c i f i c

s h o ' s s h o ' s

c o r o n a r i

e s

c o r o n a r i e s

N a r ro ' i ng i n N a r ro ' i ng i n

% i t e

s o f

% i t e

s o f

Electro4Electro4

cardiogramcardiogram

m e a s u r e s

m e a s u r e s

e l

e c

t r

i c a

l

e l e

c t

r i c

a l

i m p u

l s e s

i m p u

l s e s

$ AnginaPectoris

ISC'EMIC C'EST PAI0ISC'EMIC C'EST PAI0




EE+TI(0A, A0LI0A EE+TI(0A, A0LI0A PP F*8,- ,"8S%D,S F*%4:!5 % FH ,;,*58% CDF*8,- ,"8S%D,S F*%4:!5 % FH ,;,*58% CD

*,L8,V,D FH *,S5 % 5:*,L8,V,D FH *,S5 % 5:

U0STA1,E A0LI0A U0STA1,E A0LI0A

P ,E %S,5P ,E %S,5

P $!C:, 8 -*,Q4,$HRS,V,*85H P $!C:, 8 -*,Q4,$HRS,V,*85H

P %$$4*S C5 *,S5P %$$4*S C5 *,S5

AMI AMI

P S,V,*, ",*S8S5,5 SH)"5%)SP S,V,*, ",*S8S5,5 SH)"5%)S

P ,L,VC5,D 5*%"%8P ,L,VC5,D 5*%"%8




DIAL0(SISDIAL0(SIS

8? ,EAD E6L8? ,EAD E6L

// ,oo3 for ST segment elevation -at,oo3 for ST segment elevation -at

leastleast

8mm in to contiguous leads8mm in to contiguous leads % ,oo3 for ST segment de"ression% ,oo3 for ST segment de"ression

% ,oo3 for T ave inversions% ,oo3 for T ave inversions

% ,oo3 for N aves% ,oo3 for N aves % ,oo3 for ne ,111% ,oo3 for ne ,111

% Ala!s com"are to old E6Ls% Ala!s com"are to old E6Ls

E6L C'A0LES I0ISC'EMIC 'EA+TISC'EMIC 'EA+T



ISC'EMIC 'EA+TISC'EMIC 'EA+T

DISEASEDISEASE

S5 S,:),5 5 ECV,S5 S,:),5 5 ECV,

D,"*,SS8% 88V,*S8%SD,"*,SS8% 88V,*S8%S




DIAL0(STIC TESTSDIAL0(STIC TESTS CA+DIAC E0OMESCA+DIAC E0OMES % M!ogloin% M!ogloin

P Eill rise within I hours& pea within /NP Eill rise within I hours& pea within /N

hours& and return to baseline within > hrs+hours& and return to baseline within > hrs+

// C6M1C6M1

P Eill rise within hours& pea within 1>/ >P Eill rise within hours& pea within 1>/ >

hours and return to baseline in >/I dayshours and return to baseline in >/I days

// T+(P(0I0 IT+(P(0I0 I

P Eill rise within < hours& pea in 1> hoursP Eill rise within < hours& pea in 1> hours

and return to baseline in I/ daysand return to baseline in I/ days



Coronar! Arter!Coronar! Arter!i h



Angiogra"h! Angiogra"h!



Echocardiogra"hEchocardiogra"h

! ! 8schemic !eart Disease8schemic !eart Disease

I h i ' t DiI h i ' t Di



Ischemic 'eart DiseaseIschemic 'eart Disease

Stale An4ina



AnginaAngina



Angina Angina

Angina is a t!"e Angina is a t!"eof chestof chest

discomfortdiscomfort

caused ! "oorcaused ! "oor

lood olood othrough the loodthrough the lood

vessels -coronar! vessels -coronar!

vessels of the vessels of the

heart muscleheart muscle

-m!ocardium.-m!ocardium.



T f A i



Types of AnginaTypes of Angina

&9 Stable "n!ina9

11(

BACK MAIN EXIT INDEX

)9 nstable "n!ina9

;9 5ariant "n!ina9

1.1. Stable Angina . Symptom



H?,

1.1. Stable Angina . Symptom

0etrosternal ain0etrosternal ain

0adiatin! to le+t arm <0adiatin! to le+t arm <

sho(ldersho(lder

+elieved ! rest$ 0TL

7he commonest ca(se is7he commonest ca(se is

"/5"NCE/"/5"NCE/

"7$E08SCELE08S4S"7$E08SCELE08S4S

Lastin! less than &= min9Lastin! less than &= min9

11-


Stable Angina



E"ertio# E"ertio# Emotio# Emotio#

$ea%& meal' $ea%& meal' E"(o'ure to cold E"(o'ure to cold

)eather )eather

Predisosin! +actors 0elie3in!

+actors

*e't *e't

'u+li#gual

#itrogl&ceri#

118


Stable Angina



E"erci'e EC, 'ho)i#g t&(ical 'e%ere do)# 'lo(i#g E"erci'e EC, 'ho)i#g t&(ical 'e%ere do)# 'lo(i#g ST ST

segment segment ::

"n!inal ain is o+ten associated ith /eression"n!inal ain is o+ten associated ith /eression

o+o+ S7S7 se!mentse!ment

Standin! & min9 ; min9 > min9 ? min9

-n et'een attacks-n et'een attacks ## ECG is entirelyECG is entirely NORMALNORMAL

119

B"C@ M"4N EX47 4N/EX NEX7



Mana!ement o+ Stable



!

"n!ina&-&- General meas(res9General meas(res9

)-)- /r(! 7reatment9/r(! 7reatment9

;-;- Coronary arteryCoronary arteryre3asc(lari2ation9re3asc(lari2ation9

121


General meas(res



Sto( 'moki#g Sto( 'moki#g *educe )eight *educe )eight

reat $&(erte#'io# reat $&(erte#'io#

$&(erchole'trolimia $&(erchole'trolimia

a#d /ia+ete'a#d /ia+ete'

AVOID AVOIDSe%ereSe%ere

e"ertio#e"ertio#

$ea%& meal $ea%& meal Emotio#' Emotio#' Cold eather Cold eather

122


Grad(ated exercise may oen ne

collaterals

Stale Angina %Stale Angina %TreatmentTreatment



TreatmentTreatment

+is3 factor modi&cation -'ML Co%A+is3 factor modi&cation -'ML Co%A

+eductase inhiitors Q Statins+eductase inhiitors Q Statins

As"irin% As"irin% Decrease thromotic riscDecrease thromotic risc Decrease M/(?Decrease M/(?

nitratesnitrates

eta%loc3erseta%loc3ers

calcium channel loc3erscalcium channel loc3ers

ACE%inhiitors ACE%inhiitors

Anti%o#idants -E$ C$ Folate$ 1>K Anti%o#idants -E$ C$ Folate$ 1>K

Ahat are the antian!inal dr(!s



8r!anic nitrates9

Calci(m channel bloc*ers9

β

- adrenocetor bloc*ers9

12)




NITRATES NITRATES

5eins5eins

"rteries"rteries

12@


*ela"atio# o1 'mooth *ela"atio# o1 'mooth

mu'cle' /ilatatio#mu'cle' /ilatatio#



Preparations :



Short actin!Short actin!

%or ac(te attac*s%or ac(te attac*s

Lon! actin!Lon! actin!

%or antian!inal rohylaxis%or antian!inal rohylaxis

Nitro!lycerinNitro!lycerin

s(blin!(al, b(ccals(blin!(al, b(ccal

sray.sray.

4sosorbide4sosorbide

dinitrates(blin!(al,dinitrates(blin!(al,

b(ccal sray.b(ccal sray.

Nitro!lycerinNitro!lycerin

oral S0 9)=-&)m!. )-Doral S0 9)=-&)m!. )-D

times#daytimes#day - ) ointment &-&9=- ) ointment &-&9=inch#Dhrs.inch#Dhrs.

- atches & atchF)=m!.#day- atches & atchF)=m!.#day

4sosorbide dinitrate oral. &4sosorbide dinitrate oral. &-Dm! t9d9s9Dm! t9d9s9

4sosorbide mononitrate oral.4sosorbide mononitrate oral.

12-


/(ration o+ "ction o+ 5ario(s Prearations o+



8r!anic Nitrates

PreparationDuration of

action

H Short-actin!H

&-Nitro!lycerin

)- 4sosorbide dinitrate

a. S(blin!(alb. Sray

a. S(blin!(alb. Sray

&-; min&-; min

to min9&9= ho(rs

H Lon!-actin!H&-Nitro!lycerin

)- 4sosorbide dinitrate;-4sosorbide mononitrate

a. 8ralI s(stained releaseb. 8intmentc. 7ransdermal atches 8ral8ral

D-J ho(rs;- ho(rsJ-&) ho(rs

D- ho(rs-& ho(rs

A!erse Reactions : A!erse Reactions :

& P t l $ t i <& P t l $ t i < ) 7 h di) 7 h di



&- Post(ral $yotension <&- Post(ral $yotension <

SyncoeSyncoe

)- 7achycardia)- 7achycardia

@B roin4 Hea"ace@B roin4 Hea"ace

D- %acial %l(shin!D- %acial %l(shin!

;- /r(! 0ash;- /r(! 0ash

- Prolon!ed hi!h dose- Prolon!ed hi!h dose

Methaemo!lobinaemiaMethaemo!lobinaemia

129




β

-bloc*ers are e++ecti3e in S7"BLE < NS7"BLEan!ina

4n contrast they are not (se+(l +or

3asosastic an!ina 5ariant. KPrin2metal<

may orsen the condition9 7his deleterio(s

e++ect is li*ely d(e to an increase in coronary

resistance ca(sed by the (noosed e++ects o+catecholamines actin! at -adrenocetors9

"ontrainications :"ontrainications :



C$%C$% "-5 bloc* "-5 bloc*

PeriheralPeriheral

5asc(lar5asc(lar

diseasedisease

$yotension$yotension

BronchialBronchial

asthmaasthma

131




5eraamil 780B1(0 $4 /8 r 780B1(0 $4 /8 r

/iltia2em 7(0B120 $4 /8 r 7(0B120 $4 /8 r

/ihydroyridine !ro(

Ni+ediine &-Dm!. #J hr

"mlodiine =m!#day

sed in treatment o+ all tyes o+ an!ina9

132


#ec$anism of anti%anginal action : #ec$anism o

f anti%anginal action :



f g

& - Coronary artery dilatation and relie+o+ coronary sasm 3ariant an!ina.

5eraamil < /iltia2em.

/ecrease $09

/ecrease contractility

/ecrease "5 cond(cti3ity

"rteriolardilatation

5asc(lar

resistance"+terload

) -/ecrease myocardial 8) demand d(e to:

A!erse reactions : A!erse reactions :



/i22iness/i22inessAnkleAnkle

e"e$ae"e$a$yotension$yotension$eadache$eadache

+lusin4+lusin4ConstiationConstiation

"-5 bloc* < $%"-5 bloc* < $% onlyonly

ith 5eraamil <ith 5eraamil <

/iltia2em/iltia2em

0e+lex0e+lex

7achycardia7achycardia

ith Ni+ediineith Ni+ediine

"ontrainications of"ontrainications

of

V il & DiltiV

il & Dilti



; - Bradycardia9

Verapamil & Diltia'em:Verapamil & Diltia'em:

& - $%

) - Sin(s or "-5 node

disease9

7reatment o+ an ac(te attac* o+ an!ina



S(blin!(alS(blin!(al nitro!lycerin nitro!lycerin 9= m! . or isosorbide9= m! . or isosorbide

dinitrate = m! .dinitrate = m! . or8ral sray8ral sray nitro!lycerin nitro!lycerin 9D m!#metered9D m!#metereddose.,dose., isosorbide dinitrate&9)= m!#meteredisosorbide dinitrate&9)= m!#metered

dose.dose.

0elie+ ithin &-; min9 Persistence o+ ain

0eeat nitro!lycerin at = min90eeat nitro!lycerin at = min9

inter3al ; tab9 max9.inter3al ; tab9 max9.

0elie+ not relie3ed

n*arction$8SP47"L4"748N

13(




Coronary artery byass !ra+tin!Coronary artery byass !ra+tin!

C"BG.C"BG.

Perc(taneo(s 7ransl(minalPerc(taneo(s 7ransl(minalcoronary "n!iolasty P7C".coronary "n!iolasty P7C".

%or atients not resondin! to%or atients not resondin! to

ade1(ate medical therayade1(ate medical theray

13-




reat$ent o* Stale An4ina

BSNS



BSNS

Treatment (continued)



) !tentin" a stent is introd(ced into a blood 3essel on a balloon

catheter and ad3anced into the bloc*ed area o+ the artery

the balloon is then in+lated and ca(ses the stent to

exand (ntil it +its the inner all o+ the 3essel,con+ormin! to conto(rs as needed

the balloon is then de+lated and dran bac*

7he stent stays in lace ermanently, holdin! the 3essel

oen and imro3in! the +lo o+ blood9

Treatment(continued)



(continued)2) An"io#la$t%

a balloon catheter is assed thro(!h the !(idin! catheter tothe area near the narroin!9 " !(ide ire inside the balloon

catheter is then ad3anced thro(!h the artery (ntil the ti is

beyond the narroin!9

the an!iolasty catheter is mo3ed o3er the !(ide ire (ntilthe balloon is ithin the narroed se!ment9

balloon is in+lated, comressin! the la1(e a!ainst the artery

all

once la1(e has been comressed and the artery has beens(++iciently oened, the balloon catheter ill be de+lated and

remo3ed9

TEATEMENT'CAB



Stable Cngina / 5reatmentStable Cngina / 5reatment$oronary Crtery Fypass :rating Surgery$oronary Crtery Fypass :rating Surgery

7$CF:97$CF:9



Acute Coronar! Acute Coronar!S!ndromeS!ndrome

S!ndromes9S!ndromes9Terminolog!Terminolog!



Terminolog! Terminolog!

Patho"h!siolog! of all ; is the samePatho"h!siolog! of all ; is the same Unstale Angina -UAUnstale Angina -UA ST de"ression$ T 4ave inversion or normalST de"ression$ T 4ave inversion or normal 0o en7!me release0o en7!me release

0on%Transmural M!ocardial Infarction -0TMI or0on%Transmural M!ocardial Infarction -0TMI orSEMISEMI ST de"ression$ T 4ave inversion or normalST de"ression$ T 4ave inversion or normal 0o N aves0o N aves CP6$ ,D'CP6$ ,D' RR Tro"onin releaseTro"onin release

Transmural M!ocardial Infarction -AMITransmural M!ocardial Infarction -AMI ST elevationST elevation R N avesR N aves CP6$ ,D' R Tro"onin releaseCP6$ ,D' R Tro"onin release

7he (nderlyin! ca(se is7he (nderlyin! ca(se is

%iss(rin! o+ atheroscelerotic la1(es%iss(rin! o+ atheroscelerotic la1(es



"theroscelerotic chan!es"theroscelerotic chan!es

%iss(rin! o+ atheroscelerotic la1(es%iss(rin! o+ atheroscelerotic la1(es

Platelet a!!re!ationPlatelet a!!re!ation

7hrombosis7hrombosis

Coronary artery sasmCoronary artery sasm

1)-


Unstable Plaque:

More Detail



More Detail…….

#ross section o* a

co$%licate" %laCue



co$%licate" %laCue

Acute Coronar! Acute Coronar!

S!ndromeS!ndrome



S!ndromeS!ndrome

4schemic /iscom+ort

nstable Symtoms

No SBse4$entele6ation

SBse4$entele6ation

9nstale Non4@ @48aveangina *- *-

#D

Acute<e%er*usion

Histor&

=&sical Ea$

NSTEM is an acute process ofNSTEM is an acute process of

'efinition: N*/<

'efinition: N*/<



ACCA*A uideline$ACCA*A uideline$

myocardial ischemia withmyocardial ischemia with su!cientsu!cient

se"erity and duration to result inse"erity and duration to result inmyocardialmyocardial necrosisnecrosis..

The initial The initial E#$ in patients with NSTEME#$ in patients with NSTEM

does not show ST%se&mentdoes not show ST%se&ment ele"ation.ele"ation. NSTEM is distin&uished from 'A by theNSTEM is distin&uished from 'A by the

detection of cardiac mar(ers indicati"edetection of cardiac mar(ers indicati"e

of myocardialof myocardial necrosis in NSTEM andnecrosis in NSTEM and

the absence of abnormalthe absence of abnormal ele"ation ofele"ation ofsuch biomar(ers in patients withsuch biomar(ers in patients with 'A.'A.



M - &(e' M - &(e'



7ransm(ral7ransm(ralS7EM4.S7EM4.

+ull tickness+ull tickness

Su%eri$%ose"Su%eri$%ose"

tro$us intro$us in

aterosclerosisaterosclerosis

+ocal "a$a4e+ocal "a$a4e

S(b-endocardial NS7EM4.S(b-endocardial NS7EM4. 4nner &#; to hal+ o+ 3entric(lar4nner &#; to hal+ o+ 3entric(lar

allall

/ecreased circ(latin! blood/ecreased circ(latin! blood

3ol(me shoc*, $yotension,3ol(me shoc*, $yotension,

Lysed thromb(s.Lysed thromb(s.

Circ(m+erentialCirc(m+erential



ia4nosis o* ,: #ar"iac enF&$es

<ole o* tro%onin i



<ole o* tro%onin i

♥ roponin < is hi&hl)sensiti4e

♥ roponin < ma) eele4ated afterprolon&eds%endo(ardial

is(hemia♥ ee e0amples elo

#ar"iac enF&$es: o6er6iew



+egend# *6 Early CP24B isoforms after acute -

B6 Cardiac troponin after acute -

C6 CP24B after acute -

.6 Cardiac troponin after unstale angina

GD "ia4nosis o* ,



4

se&mentele4ation

se&mentdepression

a4e in4ersion

D a4e formation



ACUTE I0FE+I(+ MI ACUTE I0FE+I(+ MI



S5 ,L,VC58% 88& 888& CV-S5 ,L,VC58% 88& 888& CV-

ACUTE A0TE+I(+ MI ACUTE A0TE+I(+ MI



S5 S,:),5 ,L,VC58% V>/S5 S,:),5 ,L,VC58% V>/

(.(. Variant Angina .

)Prin'metal*



)Prin'metal*"$est pain at rest +e to"$est pain at rest +e to

coronary artery spasmcoronary artery spasm

EC, EC,

cha# ge'cha#ge'::

"c(te ele3ation o+"c(te ele3ation o+ S7S7

se!mentse!ment

7he baseline ECGAith chest ain ,

mar*ed S7 se!ment

ele3ation

0et(rn o+ the S7 se!ment to

the baseline a+ternitro!lycerin administration

1(1


,.,. -nstable Angina .



4ncreased +re1(ency4ncreased +re1(ency,, se3erity or d(rationse3erity or d(ration

o+ ain in a atient o+ Stable "n!inao+ ain in a atient o+ Stable "n!ina

#yocarial infarction may occ+r in 1%,/ of patients. #yocarial infarction may occ+r in 1%,/ of patients.

N9B9N9B9

Pain occ(rs ith less exertionPain occ(rs ith less exertion

or at restor at rest

1(2


Treatment of Acute M!ocardialTreatment of Acute M!ocardialInfarctionInfarction



as"irin$ he"arin$ analgesia$ o#!genas"irin$ he"arin$ analgesia$ o#!gen re"erfusion thera"! re"erfusion thera"!

thromol!tic thera"! -t%PA$ S6$ n%PA$ r% PAthromol!tic thera"! -t%PA$ S6$ n%PA$ r% PA ne cominations - t%PA$ r%PA R ? ;a inhine cominations - t%PA$ r%PA R ? ;a inhi cath la -PTCA$ stentcath la -PTCA$ stent

decrease M/(?decrease M/(? nitrates$ eta loc3ers and ACE inhiitorsnitrates$ eta loc3ers and ACE inhiitors

for high PC4P % diureticsfor high PC4P % diuretics for lo Cardiac (ut"ut % "ressors -do"amine$for lo Cardiac (ut"ut % "ressors -do"amine$

levo"hed$ doutamine) IA1P) earl!levo"hed$ doutamine) IA1P) earl!catheteri7ationcatheteri7ation



Firinol!ticFirinol!ticThera"! inThera"! in

STEMISTEMI



Coagulation andCoagulation and

Firinol!sisFirinol!sisTissue Plasminogen



Firinol!sisFirinol!sis

0irinolysis0irinolysis

0irin

Coagulation 0actors

0irinogen

Plasmin

Plasminogen

*ctivator

0irinolysis0irinolysis



Aside9 other Anti%thromotic Aside9 other Anti%thromotic

drug t!"esdrug t!"es



Anti%"latelet agents Anti%"latelet agents includeinclude As"irin -acet!lsalic!lic acid As"irin -acet!lsalic!lic acid clo"idogrelclo"idogrel di"!ridamoledi"!ridamole ticlo"idineticlo"idine

gl!co"rotein IIIIIa inhiitorsgl!co"rotein IIIIIa inhiitors Thromol!tic -&rinol!tic drugsThromol!tic -&rinol!tic drugs includeinclude

tissue "lasminogen activator % t%PA % alte"lasetissue "lasminogen activator % t%PA % alte"lase-Activase-Activase

rete"lase -+etavaserete"lase -+etavase

tenecte"lase -T06asetenecte"lase -T06ase anistre"lase -Eminaseanistre"lase -Eminase stre"to3inase -6ai3inase$ Stre"tasestre"to3inase -6ai3inase$ Stre"tase uro3inase -Ao3inaseuro3inase -Ao3inase

Thromolytic .rugsThromolytic .rugs

!tre#tokina$e!tre#tokina$e



##

8t is a bacterial protein produced by group $8t is a bacterial protein produced by group $ (beta)(beta)//hemolytic streptococcihemolytic streptococci

Mechanism:Mechanism: 8t binds to plasminogen producing an8t binds to plasminogen producing an

activator com"le# activator com"le# that lyses ree plasminogen tothat lyses ree plasminogen to

the proteolytic enzyme plasminthe proteolytic enzyme plasmin "lasmin degrades"lasmin degrades fbrinfbrin clots as well asclots as well as fbrinogenfbrinogen

and other plasma proteins 7non/fbrin specifc9and other plasma proteins 7non/fbrin specifc9

"harmacoinetics"harmacoinetics

5he t5he tTT o the acti#ator comple' is about >I minuteso the acti#ator comple' is about >I minutes 5he comple' is inacti#ated by anti/streptococcal5he comple' is inacti#ated by anti/streptococcal

antibodies . by hepatic clearanceantibodies . by hepatic clearance


*lteplase (rt6P*)*lteplase (rt6P*)



p ( )( ) 8t is8t is a tissue plasminogen acti%ator (t.PA&a tissue plasminogen acti%ator (t.PA&

produced by recombinant DC technology o =>Oproduced by recombinant DC technology o =>O

amino acidsamino acids

$ost per day is around >>22 U$ost per day is around >>22 U

Mechanism9Mechanism9 8t is8t is an en'ymean en' yme which has the property o fbrin/which has the property o fbrin/

enhanced con#ersion o plasminogen to plasminenhanced con#ersion o plasminogen to plasmin

8t produces limited con#ersion o ree plasminogen in8t produces limited con#ersion o ree plasminogen in

the absence o fbrinthe absence o fbrin

Ehen introduced into the systemic circulation it bindsEhen introduced into the systemic circulation it bindsto fbrin in a thrombus and con#erts the entrappedto fbrin in a thrombus and con#erts the entrapped

plasminogen to plasmin ollowed by acti#ated localplasminogen to plasmin ollowed by acti#ated local

fbrinolysis with limited systemic proteolysisfbrinolysis with limited systemic proteolysis


Alteplase Alteplase



p

Thera"eutic UsesThera"eutic Uses Acute M!ocardial Infarction Acute M!ocardial Infarction in adults or thein adults or the

impro#ement o #entricular unction ollowing C)8 theimpro#ement o #entricular unction ollowing C)8 the

reduction o the incidence o congesti#e heart ailure&reduction o the incidence o congesti#e heart ailure&

and the reduction o mortality associated with C)8and the reduction o mortality associated with C)8

Acute Ischemic Stro3e Acute Ischemic Stro3e or impro#ing neurologicalor impro#ing neurological

reco#ery and reducing the incidence o disability+reco#ery and reducing the incidence o disability+

5reatment should only be initiated within I hours ater5reatment should only be initiated within I hours ater

the onset o stroe symptoms& and ater e'clusion othe onset o stroe symptoms& and ater e'clusion o

intracranial hemorrhageintracranial hemorrhage Pulmonar! EmolismPulmonar! Emolism99 5reatment o acute massi#e5reatment o acute massi#e

pulmonary embolismpulmonary embolism

Reteplase & TenectaplaseReteplase & Tenectaplase



+ete"lase+ete"lase is another human t/"C preparedis another human t/"C preparedby recombinant mutation technologyby recombinant mutation technology

8t is fbrin/specifc8t is fbrin/specifc

8t has longer duration than alteplase8t has longer duration than alteplase

Tenecta"laseTenecta"lase is another geneticallyis another genetically

modifed human t/"C prepared bymodifed human t/"C prepared by

recombinant technologyrecombinant technology

8t is more fbrin/specifc . longer duration8t is more fbrin/specifc . longer durationthan alteplasethan alteplase

hromol)ti( 'r%&shromol)ti( 'r%&s 9rokinase9rokinase



8t is an8t is an enzymeenzyme produced by theproduced by the idneyidney&&and ound in the urineand ound in the urine

8t is mainly used in the low molecular8t is mainly used in the low molecular

weight orm o uroinase obtained romweight orm o uroinase obtained rom

human neonatal idney cells grown inhuman neonatal idney cells grown intissue culturetissue culture

)echanism)echanism 8t acts on the endogenous8t acts on the endogenous

fbrinolytic system con#erting plasminogenfbrinolytic system con#erting plasminogen

to the enzyme plasmin that degrades fbrinto the enzyme plasmin that degrades fbrinclots as well as fbrinogen and some otherclots as well as fbrinogen and some other

plasma proteins 7plasma proteins 7on/fbrin selecti#eon/fbrin selecti#e99


9rokinase9rokinase



4roinase administered by4roinase administered byintra#enous inusion is rapidly clearedintra#enous inusion is rapidly cleared

by the li#er with an elimination hal/by the li#er with an elimination hal/

lie or biologic acti#ity o 1>/>2lie or biologic acti#ity o 1>/>2minutesminutes

$linical 4ses$linical 4ses

-or the lyses o acute massi#e-or the lyses o acute massi#epulmonary embolipulmonary emboli

Contraindications toContraindications to

Thromolytic TherapyThromolytic Therapy



Asolute contraindications include9 Asolute contraindications include9 +ecent head trauma or caranial tumor +ecent head trauma or caranial tumor

Previous hemorrhagic shoc3 Previous hemorrhagic shoc3

Stro3e or cerero%vascular events 8 !earStro3e or cerero%vascular events 8 !ear

oldold

Active internal leeding Active internal leeding

Ma:or surger! ithin to ee3sMa:or surger! ithin to ee3s

+elative contraindications include9+elative contraindications include9 Active "e"tic ulcer$ diaetic retino"ath!$ Active "e"tic ulcer$ diaetic retino"ath!$

"regnanc!$ uncontrolled 'T0"regnanc!$ uncontrolled 'T0

Firinolitic Thera"! inFirinolitic Thera"! inSTEMISTEMI



N23 o patients wR acute S5,)8 ha#e completeN23 o patients wR acute S5,)8 ha#e completeocclusion o culprit arteryocclusion o culprit artery

PCI "referred if "erformed in G minutesPCI "referred if "erformed in G minutes

of "resentation or if transfer toof "resentation or if transfer to

neighoring institution for PCI can occurneighoring institution for PCI can occur in ;G%>G min. in ;G%>G min.

5hombolytic therapy is the alternati#e5hombolytic therapy is the alternati#e

treatmenttreatment

ot as e(ecti#e in non/S5,)8 as the inarct/ot as e(ecti#e in non/S5,)8 as the inarct/related artery is not totally occluded in <2/?=3related artery is not totally occluded in <2/?=3

o caseso cases

PCI after PCI afterthrombolytics thrombolytics



yy

5his issue remains unresol#ed5his issue remains unresol#edI possible scenariosI possible scenarios

P-acilitated "$8Alytic drug gi#en prior toP-acilitated "$8Alytic drug gi#en prior to

planned "$8 in attempt to achie#e an openplanned "$8 in attempt to achie#e an open

inarct/related artery beore arri#al o cathinarct/related artery beore arri#al o cathlablab

PCd6uncti#e "$8A"$8 perormed within hoursPCd6uncti#e "$8A"$8 perormed within hours

ater thrombolysisater thrombolysis

P,arly electi#e "$8A"$8 perormed within aP,arly electi#e "$8A"$8 perormed within a

ew days ater thrombolysisew days ater thrombolysis

An4io4ra$ in unstale an4ina:

eccentric' ulcerate" %laCue



' % C

An4io4ra$ in unstale an4ina:

a*ter stent "e%lo&$ent



% &

PCI after PCI afterthrombolytics thrombolytics



y


P-acilitated "$8Alytic drug gi#en prior toP-acilitated "$8Alytic drug gi#en prior to

planned "$8 in attempt to achie#e an openplanned "$8 in attempt to achie#e an open

inarct/related artery beore arri#al o cathinarct/related artery beore arri#al o cathlablab

PCd6uncti#e "$8A"$8 perormed within hoursPCd6uncti#e "$8A"$8 perormed within hours

ater thrombolysisater thrombolysis

P,arly electi#e "$8A"$8 perormed within aP,arly electi#e "$8A"$8 perormed within a

ew days ater thrombolysisew days ater thrombolysis

Prehos"ital



Prehos"italPrehos"ital

Thromol!sisThromol!sis

Prehos"ital Thromol!sisPrehos"ital Thromol!sisPro:ect9Pro:ect9

Acute inferolateral infarctAcute inferolateral infarct



Acute inferolateral infarct Acute inferolateral infarct



!eparin!eparin

Cnd other current "arenteral Cnd other current "arenteral

Cnticoagulants Cnticoagulants

Unstale AnginaUnstale Angina Anti%coagulant Thera"! Anti%coagulant Thera"!



'e"arin'e"arin recommendation is ased onrecommendation is ased on

documented e5icac! in man! trials ofdocumented e5icac! in man! trials of

moderate si7emoderate si7e

meta%anal!sesmeta%anal!ses -8$?-8$? of si# trials shoed aof si# trials shoed a

;;< ris3 reduction in MI and death$ ut;;< ris3 reduction in MI and death$ ut

ith a to fold increase in ma:or ith a to fold increase in ma:or

leedingleeding

titrate PTT to ?# the u""er limits oftitrate PTT to ?# the u""er limits of

normalnormal1. #irculation 199);89:81B88

2. >A,A 199(;2-(:811B81@

Unstale AnginaUnstale Angina Anti%coagulant Thera"! Anti%coagulant Thera"!



,o%molecular%eight he"arin,o%molecular%eight he"arinad#antages o#er heparinad#antages o#er heparin etter io%availailit! etter io%availailit!

higher ratio -;98 of anti%a to anti%IIahigher ratio -;98 of anti%a to anti%IIaactivit! activit!

longer anti%a activit!$ avoid reoundlonger anti%a activit!$ avoid reound

induces less "latelet activationinduces less "latelet activation

ease of use -sucutaneous % d or idease of use -sucutaneous % d or id no need for monitoringno need for monitoring

PCI after thrombolytics??? PCI after thrombolytics???




PPFacilitated PCIBl!tic drug given "rior toFacilitated PCIBl!tic drug given "rior to

"lanned PCI in attem"t to achieve an"lanned PCI in attem"t to achieve an

o"en infarct%related arter! eforeo"en infarct%related arter! eforearrival of cath laarrival of cath la

PP Ad:unctive PCIBPCI "erformed ithin Ad:unctive PCIBPCI "erformed ithin

hours after thromol!sishours after thromol!sis

PPEarl! elective PCIBPCI "erformed ithinEarl! elective PCIBPCI "erformed ithin

a fe da!s after thromol!sisa fe da!s after thromol!sis



Coronary ArteryCoronary Artery

Bypass GraftBypass Graft



CardiogenicCardiogenic



Shoc3 Shoc3

De&nitionDe&nition



? mm$!

)9) li#min9m)

O&= mm$!



ES748NS



yosplint



Chan&e in radi%s

1



Infarct in ventricular all ith loss ofmuscle and scarring



ES748NS

A $ t h = %ympathetic activity#

P i i

Treatment of heartfailure



A6 $ypertrophy

.ilatation

∀↑ E6.6"

=6 ↑%ympathetic activity#

'.+.• /.C

*ngiotensine

*ldosterone

PositiveInotro"i

cs

Diuretics

ACEinhiito

rs

vasodilator s

Pharmacological $reatment

iuretics



(loop diuretics) thia'ide diureticsand potassium sparing diuretics&

5hese act by promoting the renal e'cretion

o salt and water by blocing tubularreabsorption o sodium and chloride+ 5heresulting loss o Buid reduces #entricularflling pressures 7preload9& producesconsistent haemodynamic and symptomaticbenefts and rapidly impro#es dyspnoea andperipheral oedema+



ca*TPase

caRR

Na

<n therape%ti( dose leads to partial inhiition of Na@?E@ Aase enz)me

NaNa

Na

Na

Na

Na

intracellular Na resulting in#

0a ca

e#change

caRR

Na6 R

caRRcaRR

caRR

sar(oplasmi( reti(%l%m

caRRcaRR

caRRcaRR

caRRcaRRcaRRcaRR

troponin

*ctin yosin

0orce &f Contractility



Ccute heart ailure 7C!-9 occurs withthe rapid onset o symptoms andsigns o heart ailure secondary toabnormal cardiac unction& causing

ele#ated cardiac flling pressures+ 5his causes se#ere dyspnoea and

Buid accumulates in the interstition

and al#eolar spaces o the lung7pulmonary oedema9+

S!%$W is a se#ere ailure o tissue perusion&characterized by hypotension& a low cardiac output ansigns o poor tissue perusion such as oliguria& colde tremities and poor cerebral nction $ardiogenic



e'tremities and poor cerebral unction+ $ardiogenicshoc is commonly due to myocardial inarction& acutemassi#e pulmonary embolus& pericardial tamponade .sudden/onset #al#ular regurgitation+

5*,,C5),5 "atients reXuire intensi#e care :eneral measures such as complete rest& continuous

<23 o'ygen administration and pain and an'iety relieare essential+ 5he inusion o Buid is necessary i the pulmonary

capillary wedge pressure is below 1? mm!g+ Short/acting #enous dilators such as glyceryl trinitrate

or sodium nitroprusside should be administered

intra#enously i the wedge pressure is >= mm!g ormore+ $ardiac inotropes to increase aortic diastolic pressure ,mergency re#ascularization o occluded arteries

Pathophysiology of chronic heart failure6



amani G " et al6 ayo Clin Proc6 =>A>DF#A>4AF

F !1! /a)o +o%ndation for /edi(al *d%(ation and esear(h

odified .or Procedureodified .or Procedure




HF

HF



Prof Univ Dr Ion C.Tintoiu FESCCentrul de Cardiologie al ArmateiUniversitatea Titu Maiorescu

Cardiac TransplantCardiac Transplant



8t has become more widely used since the8t has become more widely used since the

ad#ances in immunosuppressi#ead#ances in immunosuppressi#e

treatmenttreatment

Sur#i#al rateSur#i#al rate

1 year ?23 / N231 year ?23 / N23

= years O23= years O23

Christian 1arnardChristian 1arnard Born in South Africa in 1922Born in South Africa in 1922



Born in South Africa in 1922Born in South Africa in 1922

Studied heart surgery at theStudied heart surgery at the

University of Minnesota thenUniversity of Minnesota then

returned to set up a cardiac unitreturned to set up a cardiac unit

in Cape Town.in Cape Town.

December 1967: transplanted theDecember 1967: transplanted the

heart of a road accident victimheart of a road accident victim

into a 59 year old patientinto a 59 year old patient

Patient only survived 18 daysPatient only survived 18 days

due to infectious complicationsdue to infectious complications

(ut"atient Thera"! (ut"atient Thera"!



1!


HF

HF

6redi(tors of /ortalit) 2ased on



Anal)sis of A'-** 'ataaseClassifi(ation and e&ression ree CA anal)sis of

A'-** data shos:

hree 4ariales are the stron&est predi(tors of mortalit) in

hospitalized A'-+ patients:

2GN H 3 m&?dL

)stoli( lood press%re I 115 mm-&

er%m (reatinine H .5 m&?dL

2GN H 3 m&?dL

)stoli( lood press%re I 115 mm-&

er%m (reatinine H .5 m&?dL

+onaro KC et al. JA/A !!5;93:5=#!.



Starlings ,a



Future TechFuture Tech



Inotro"es in CardiacSurger!

1asics



1EF(+E I0(T+(PES

-luid



-luid Folus Legs up

*hythm ,$:& S*& slow& ast& paced on #entricle& S5Ys& ectopics

5amponade $V"& F,& 4%& temp& $;*& echo Fleeding

Drains& $;*& !b "neumothora'

$;*& e'amine& #ent alarms -ight Ventilator

"aralyse& sedate or e'tubate



+ece"tors



Atro"ine



Cntimuscurinic ie causes tachycardia Some pateints ha#e muscurinic

receptors on #entricle as well ie

inotropic

8ncreases !*

$%ZSV ' !*

Ca?R

8notrope and



8notrope and #asoconstrictor

Short acting

Feware radial arterypatients

Earn patient iawae

Do"amine

Ccts on dopamine



cts o dopa e

receptors on heart andidney

$auses a tachycardia7$%ZSV ' !*9

8ncreases urine output in

some patients Less metabolic side e(ects

compared with adrenaline

Feware patients withtachycardia 7gi#e [& )g>[9

Do"e#amine



5achycardia 8ncrease splanchnic and renal blood

Bow

VCS%D8LC5%*

Feware Vasodilated patients

Doutamine



Lie dopamine !as less e(ect on

pulmonary arterypressure good or

mitral #al#epatients

Adrenaline



,'cellent inotrope but dirty

8ncreased heart rate andinotropy 7\1/adrenoceptormediated9

Vasoconstriction in mostsystemic arteries and #eins7post6unctional a 1 and a >adrenoceptors9

Vasodilation in muscle and li#er #asculatures at low

concentrations 7b>/adrenoceptor9@ #asoconstrictionat high concentrations 7a1/adrenoceptor mediated9



0oradrenaline



Vasoconstrictor

8ncreased heart rate andincreased inotropy 7\1/adrenoceptor mediated9

Vasoconstriction occurs inmost systemic arteries and #eins 7post6unctional a 1 anda > adrenoceptors9

Cs can 8 wae patient up toa#oid orad

)ust ha#e a good cardiacoutput

0oradrenaline



Iso"renaline

$auses tachycardia



$auses tachycardiaand #asodilatation

:ood in patients

with high "Cpressures

Feware #asodilatedpatients

Eno#imone



hosphodiesterase <nhiitor

Kood in patients ith hi&h A press%re

nd line hen adrenaline ha4in& no

effe(t re(eptor disso(iationM



/asso"resin

nd



> line #asoconstrictor

)ost powerul

a#ailable

Cssociated with

organ ischaemia

0itric (#ide



MedicationMedication



Drug treatments should e initiatedDrug treatments should e initiatedin the folloing order9in the folloing order9 C$, inhibitor / with diuretic i needed / C$, inhibitor / with diuretic i needed /

or H!C :rades 8/8V+or H!C :rades 8/8V+

Cngiotensin/88 receptor antagonist / i Cngiotensin/88 receptor antagonist / iintolerant o C$, inhibitor+intolerant o C$, inhibitor+

Feta/blocer / or H!C :rades 8/8V+Feta/blocer / or H!C :rades 8/8V+

Spironolactone / or H!C :rades 888/8V+Spironolactone / or H!C :rades 888/8V+

Digo'in / or H!C :rades 88/8V+Digo'in / or H!C :rades 88/8V+


HF

HF

*ntiarrhythmics



/ost (ommon (a%se of C' in these patients is/ost (ommon (a%se of C' in these patients is4entri(%lar ta(h)arrh)thmia4entri(%lar ta(h)arrh)thmia

atients ith h?o s%stained V or C' <C' implantatients ith h?o s%stained V or C' <C' implant

atients ith C-+ ith an eOe(tion fra(tion of less thanatients ith C-+ ith an eOe(tion fra(tion of less than3!P ma) re(ei4e <C' implant3!P ma) re(ei4e <C' implant

Amiodarone for patients ith freQ%ent VCs and at fi Amiodarone for patients ith freQ%ent VCs and at fi

'ranedone for patients ith re(%rrent paro0)smal at fi.'ranedone for patients ith re(%rrent paro0)smal at fi.


HF

HF

"asodilators$ydrala5ine and Nitrates



$+eduction of afterload+eduction of afterload by arteriolarby arteriolar

#asodilatation 7hydralazin9 #asodilatation 7hydralazin9 →→ reducereduce

LV,D"& %LV,D"& %>> consumption&impro#e myocardialconsumption&impro#e myocardial

perusion&perusion& ↑↑ stroe #olume and $%"stroe #olume and $%"$+eduction of "reload+eduction of "reload FyFy #enous #enous

dilationdilation

7 itrate97 itrate9 →

J the #enous returnJ the #enous return →→J theJ the

load on both #entricles+load on both #entricles+

$4sually the ma'imum beneft is achie#ed4sually the ma'imum beneft is achie#ed

by using agents with both action+by using agents with both action+


HF

HF

*nticoagulation



Ctrial fbrillation Ctrial fbrillation

!Ro embolic episodes!Ro embolic episodesLet #entricular apical thrombusLet #entricular apical thrombus

Low LV e6ection ractionLow LV e6ection raction




HF

HF

Ne' Treatment Choices



Im"lantale ventricular assist devicesIm"lantale ventricular assist devices

1iventricular "acing1iventricular "acing 7only in patient7only in patient

with LFFF . $!-9with LFFF . $!-9

Arti&cial 'eart Arti&cial 'eart




PacingPacing




1>4er4ie of 'e4i(e herap)

Cbnormal #entricular conduction Cbnormal #entricular conductionresulting in a mechanical delay andresulting in a mechanical delay and

dysynchronous contractiondysynchronous contraction

1i/ Pacing1i/ Pacing



Thera"! Thera"! 6e! Points6e! Points IndicationsIndications

)oderate to se#ere $!- who ha#e ailed)oderate to se#ere $!- who ha#e ailed



optimaloptimal medical therapymedical therapy ,-0I23,-0I23 ,#idence o electrical conduction delay,#idence o electrical conduction delay


Ventricular remodelling Ventricular remodelling



E/citation4contraction

coupling↓

.ysrhythmias H

Electrical dyssynchrony

echanical dyssynchrony

& ill& ill



De&rillatorsDe&rillators-ICD’s-ICD’s

0eer Leneration Arti&cial0eer Leneration Arti&cial'earts'earts




'eart Failure9 Thera"! 'eart Failure9 Thera"!

Stage A9Stage A9

C t l i 3 f t t t d l i h i diC t l i 3 f t t t d l i h i di



Control ris3 factors$ treat underl!ing chronic diseaseControl ris3 factors$ treat underl!ing chronic diseasecontriutorscontriutors

Stage 19Stage 19 ACEA+111 if a""ro"riate ACEA+111 if a""ro"riate

Stage C9Stage C9 ACEKA+1$ 11$ diuretics ACEKA+1$ 11$ diuretics (ther vasodilators as a""ro"riate(ther vasodilators as a""ro"riate Devices -i%/ "acing$ Im"lantale de&rillatorsDevices -i%/ "acing$ Im"lantale de&rillators

Stage D9Stage D9 Mechanical assist devicesMechanical assist devices Continuous infusion of inotro"icsContinuous infusion of inotro"ics

'eart trans"lant'eart trans"lant 'os"ice'os"ice E#"erimental surger! or drugsE#"erimental surger! or drugs

De#ices and SurgicalDe#ices and Surgical)anagement)anagement

-irst option i the cause o heart ailure can be-irst option i the cause o heart ailure can be

t t d i llt t d i ll



treated surgicallytreated surgically

Se#eral therapeutic options pacing& an 8$D& aSe#eral therapeutic options pacing& an 8$D& a

#entricular assist de#ice& an artifcial heart& or a #entricular assist de#ice& an artifcial heart& or a

heart transplantheart transplant

"acing or resynchronization therapy is"acing or resynchronization therapy is

recommended or patients with H!C $lass 888recommended or patients with H!C $lass 888

or 8V with Q*S prolongation who areor 8V with Q*S prolongation who are

e'periencing symptoms despite medicationse'periencing symptoms despite medications

De#ices and SurgicalDe#ices and Surgical)anagement)anagement

Cn 8$D may be used in patients with arrhythmias Cn 8$D may be used in patients with arrhythmias

t t dd di d tht t dd di d th



to pre#ent sudden cardiac deathto pre#ent sudden cardiac death

C let #entricular assist de#ice may be used as a C let #entricular assist de#ice may be used as a

bridge to transplant or destination therapybridge to transplant or destination therapy

,nd/stage heart ailure patients may consider,nd/stage heart ailure patients may consider



,$: 1> l d,$: 1> l d



,$: 1> leads,$: 1> leads $hest ;/ray$hest ;/ray

Lab tests 7hyponatraemiaG9Lab tests 7hyponatraemiaG9

Fiomarers o !- F"& proF"& $*"&Fiomarers o !- F"& proF"& $*"&troponinstroponins

,chocardiography 7systolicRdiastolic,chocardiography 7systolicRdiastolic

dysunction& structural heart disease9dysunction& structural heart disease9 spiroergometryspiroergometry


Ph i l i ti



Physical examination

Medical history

Lab tests: BNP, …

X-ray, ECG,

Echo, Siro-Er!ometry…



FetablocersFetablocers

symptomssymptoms↓↓& prognosis& prognosis↑↑& mortality& mortality↓↓↓↓ ↓↓



remodellingremodelling↓↓& dyssynchrony& dyssynchrony↓↓ S$DS$D ↓↓& antiarrhythmic e(ect& antiarrhythmic e(ect starting dose& target dosestarting dose& target dose

!ypotension!ypotension -atigue-atigue

Fradycardia& bloc Fradycardia& bloc *educe dose in case o decompensation*educe dose in case o decompensation



DiureticsDiuretics

tt ↓↓ dd ↓↓ ii



symptomssymptoms↓↓& oedema& oedema↓↓& prognosis& prognosis→→ only in case o Buid retentiononly in case o Buid retention *CCS acti#ation*CCS acti#ation→→add C$,i or C*FGadd C$,i or C*FG

5itrate& combine5itrate& combine

!yonatraemia& hypoalemia& #olume!yonatraemia& hypoalemia& #olumedepletion& renal dysunctiondepletion& renal dysunction

Diuretic resistanceDiuretic resistance



Patients 'ith acute heart failure

freIuently develop chronic heart failure6

Patients 'ith chronic heart failure

freIuently decompensate acutely6

'EA+T FAI,U+E'EA+T FAI,U+E



Clinical Classi&cationsClinical Classi&cations

S!stolic9S!stolic9



2(1

S!stolic9S!stolic9 8mpaired ability o the heart to contract8mpaired ability o the heart to contract Eeaened muscle& enlarged heart sizeEeaened muscle& enlarged heart size 8nability o heart to empty8nability o heart to empty Let #entricular e6ection raction 7LV,-9 0 2_=3Let #entricular e6ection raction 7LV,-9 0 2_=3

DiastolicDiastolic inability o the heart to rela' is impairedinability o the heart to rela' is impaired Sti(& thicened myocardial wall but normal sizeSti(& thicened myocardial wall but normal size 8nability o heart to fll8nability o heart to fll

LV,-LV,- ≥≥ =3=3


AcuteAcute



2(2

Acute Acute sudden onset with associated signs andsudden onset with associated signs andsymptomssymptoms

ChronicChronic secondary to slow structural changessecondary to slow structural changes

occurring in the stressed myocardiumoccurring in the stressed myocardium

Acute Decom"ensated Acute Decom"ensated

sudden e'acerbation or onset osudden e'acerbation or onset osymptoms in chronic heart ailuresymptoms in chronic heart ailure


*eart +ailure is a Symptomatic isorder *eart +ailure is a S

ymptomatic isorder



2(3

*eart +ailure is a Symptomatic isorder 0e or3 'eart Association%Functional0e or3 'eart Association%Functional

Classi&cationClassi&cation

Class I9Class I9 o abnormal symptoms with acti#ityo abnormal symptoms with acti#ity

Class II9Class II9 Symptoms with normal acti#itySymptoms with normal acti#ityClass III9Class III9 )ared limitation due to symptoms)ared limitation due to symptoms

with less than ordinary acti#itywith less than ordinary acti#ity

Class I/9Class I/9 Symptoms at rest and se#ereSymptoms at rest and se#ere

limitations in unctional acti#itylimitations in unctional acti#ity


*eart +ailure is a Progressi%e isorder *eart +ailure is a Pro

gressi%e isorder

ACCA'A S f 'F



2()

ACCA'A Stages of 'F ACCA'A Stages of 'F

Stage A%Stage A%/"resence o ris actors or heart ailure/"resence o ris actors or heart ailure

Stage 1%Stage 1%/"resence o structural heart disease but/"resence o structural heart disease but

no Symptomsno SymptomsStage C%%Stage C%%"resence o structural heart disease"resence o structural heart disease

along with signs and symptomsalong with signs and symptoms

Stage D%%Stage D%%"resence o structural heart diseases"resence o structural heart diseases

and ad#anced signs and symptomsand ad#anced signs and symptoms

ACCA'A ?GGJ ACCA'A ?GGJLuidelinesLuidelines



2(@

#ar"iac <&t$ ,ana4e$ent



2((

S$all i$%ro6e$ents in

e$o"&na$ics si4ni*icant

i$%ro6e$ents in H+ s&$%to$s

s&$%to$s.?%ti$iFin4 e$o"&na$ics as

lon4 een a tar4et o*

tera%& in H+.

Cardiac +h!thm ManagementCardiac +h!thm Management

<isk <e"uction



2(-

<isk <e"uction#<ia4nostics

H< ren"sH< ariailit&=atient Acti6it&

ntratoracic $%e"anceArr&t$ias<e$ote ,onitorin4



e*t entricular Assist e6ice



T!"es of 'eart FailureT!"es of 'eart Failure

Systolic 7or sXueezing9 heart ailureSystolic 7or sXueezing9 heart ailure Decreased pumping unction o the heart whichDecreased pumping unction o the heart which



Decreased pumping unction o the heart& whichDecreased pumping unction o the heart& which

results in Buid bac up in the lungs and heartresults in Buid bac up in the lungs and heart

ailureailure

Diastolic 7or rela'ation9 heart ailureDiastolic 7or rela'ation9 heart ailure 8n#ol#es a thicened and sti( heart muscle8n#ol#es a thicened and sti( heart muscle

Cs a result& the heart does not fll with blood Cs a result& the heart does not fll with blood

properlyproperly

5his results in Buid bacup in the lungs and heart5his results in Buid bacup in the lungs and heart

ailureailure

+is3 Factors for 'eart+is3 Factors for 'eartFailureFailure

$oronary artery$oronary arterydidisease DiabetesDiabetes



#Acoronar& arter& "isease; Hle*t 6entricular &%ertro%&.

$oronary artery$oronary arterydiseasedisease

!ypertension 7LV!9!ypertension 7LV!9

Val#ular heart Val#ular heart

diseasedisease Clcoholism Clcoholism

8nection 7#iral98nection 7#iral9

DiabetesDiabetes$ongenital heart deect$ongenital heart deect

%ther%ther

%besity%besity Cge Cge

SmoingSmoing

!igh or low hematocrit!igh or low hematocritle#elle#el

%bstructi#e Sleep Cpnea%bstructi#e Sleep Cpnea



A 6e! Indicator for Diagnosing A 6e! Indicator for Diagnosing'eart Failure'eart Failure

,6ection -raction 7,-9,6ection -raction 7,-9 ,6ection -raction 7,-9 is the percentage,6ection -raction 7,-9 is the percentage



,6ection -raction 7,-9 is the percentage,6ection -raction 7,-9 is the percentageo blood that is pumped out o your hearto blood that is pumped out o your heartduring each beatduring each beat

Com"arison 1eteenCom"arison 1eteen ACCA'A 'F Stage and ACCA'A 'F Stage and

0'A Functional Class0'A Functional Class"CC#"$" $% Sta!e& N'$" %(nctional Class)

None



1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2 New York Heart Association/ittle !rown an" #o$%an&' 19(). A"a%te" *ro$: +arrell ,H et al. JAMA. 2002;28-:890–89-.

" "t hi!h ris* +or heart +ail(re b(t itho(t

str(ct(ral heart disease or symtomso+ heart +ail(re e!, atients ith

hyertension or coronary artery disease.

B Str(ct(ral heart disease b(t itho(tsymtoms o+ heart +ail(re

C Str(ct(ral heart disease ith rior orc(rrent symtoms o+ heart +ail(re

/ 0e+ractory heart +ail(re re1(irin!seciali2ed inter3entions

4 "symtomatic

44 Symtomatic ith moderate exertion

45 Symtomatic at rest

444 Symtomatic ith minimal exertion

None

'o 'eart Failure Is'o 'eart Failure IsDiagnosedDiagnosed

)edical history is taen to re#eal symptoms)edical history is taen to re#eal symptoms

"hysical e'am is done"hysical e'am is done



"hysical e'am is done"hysical e'am is done

5ests5ests $hest ;/ray$hest ;/ray

Flood testsFlood tests

,lectrical tracing o heart 7,lectrocardiogram or,lectrical tracing o heart 7,lectrocardiogram or

],$:^9],$:^9

4ltrasound o heart 7,chocardiogram or ],cho^94ltrasound o heart 7,chocardiogram or ],cho^9

;/ray o the inside o blood #essels 7Cngiogram9;/ray o the inside o blood #essels 7Cngiogram9



Patho"h!siolog! Patho"h!siolog!

Pathologicd li

+o' e1ectionf ti .eath

%udden

.eathCoronary arterydisease

$ypertension yocardiali 1

Pathologic Progression of C/Pathologic Progression of C/DiseaseDisease



Adapted from Cohn JN. N Engl J Med . 1996;335:9!"9#.

remodeling fraction .eath

%ymptoms#

.yspnea

0atigue

Edema

Chronic

heart

failure

$Neurohormonalstimulation

$yocardialto/icity

Pumpfailure

Cardiomyopathy

"alvular disease

in1ury.iaetes

Com"ensator! Mechanisms9Com"ensator! Mechanisms9+enin%Angiotensin%Aldosterone+enin%Angiotensin%Aldosterone

S!stemS!stemenin *ngiotensinogen

*ngiotensin -

BetaBeta%timulation%timulation

$ C&C&$ NNa



g

*ngiotensin --

Peripheral"asoconstriction

↑ *fterload

↓ Cardiac &utput

$eart 0ailure$eart 0ailure

↑ Cardiac 8orkload

↑ Preload

↑ Plasma "olume

%alt 8ater etention

Edema

*ldosterone %ecretion

*CE

2aliuresis

C&C&$ NaNa

0irosis



Drug Thera"! Drug Thera"!

ear a ureTreatments9 MedicationTreatments9 Medication

T!"esT!"es)A#E inhibitor*an&iotensin%con"ertin&

Type 0hat it

does)E/pands blood "essels whichlowers blood pressure1



* & &enzyme+

)A,- *an&iotensinreceptor bloc(ers+

)-eta%bloc(er

)i&o/in

)iuretic

)Aldosteronebloc(ade

lowers blood pressure1neurohormonal bloc(ade

)Similar to A#E inhibitorlowers blood pressure

),educes the action of stresshormones and slows the heartrate)Slows the heart rate and impro"esthe heart3s pumpin& function *EF+

)Filters sodium and e/cess 4uid fromthe blood to reduce the heart3swor(load

)-loc(s neurohormal acti"ation and

+ational for Medications+ational for Medications

-4h! does m! doctor have-4h! does m! doctor have

me on so man! "illsKKme on so man! "illsKK

8mpro#e Symptoms8mpro#e Symptoms 8mpro#e Sur#i#al8mpro#e Sur#i#al



8mpro#e Symptoms8mpro#e Symptoms Diuretics 7waterDiuretics 7water

pills9pills9

digo'indigo'in

8mpro#e Sur#i#al8mpro#e Sur#i#al FetablocersFetablocers

C$,/inhibitors C$,/inhibitors

Cldosterone Cldosterone

blocersblocers Cngiotensin Cngiotensin

receptor blocersreceptor blocers

7C*FYs97C*FYs9

,ifest!le Changes,ifest!le Changes

)Eat a low%sodium1 low%fat diet

0hat 0hy

)Sodium is bad for hi&h bloodpressure1 causes 4uid retention



)5ose wei&ht

)Stay physically acti"e

),educe or eliminatealcohol and ca6eine

)7uit Smo(in&

p

)E/tra wei&ht can put astrain on the heart

)E/ercise can help reducestress and blood pressure

)Alcohol and ca6eine can wea(enan already dama&ed heart

)Smo(in& can dama&e blood "esselsand ma(e the heart beat faster

(ral Medications to(ral Medications toCounteract..Counteract..

*CCS 8nhibitors*CCS 8nhibitors C$, 8RC*FC$, 8RC*Fs



#3

*CCS 8nhibitors*CCS 8nhibitors C$, 8RC*Fs C$, 8RC*Fs Cldosterone Cntagonists Cldosterone Cntagonists Feta FlocersFeta Flocers

SS 8nhibitorsSS 8nhibitors Feta FlocersFeta Flocers

VasodilatorRitric %'ide Cgonists VasodilatorRitric %'ide Cgonists 8sorbide dinitrateRhydralzine8sorbide dinitrateRhydralzine

ACE Inhiitors ACE Inhiitors

8nhibit the enzyme responsible or8nhibit the enzyme responsible or



#

8nhibit the enzyme responsible or8nhibit the enzyme responsible orcon#erting Cngiotensin 8 to Cngiotensincon#erting Cngiotensin 8 to Cngiotensin

88@ counteracts *CCS88@ counteracts *CCS

Decrease Systemic Vascular *esistanceDecrease Systemic Vascular *esistance7SV*97SV*9

,nhance acti#ity o inins and inin/,nhance acti#ity o inins and inin/

mediated prostaglandin synthesismediated prostaglandin synthesis

)odiy cardiac remodeling)odiy cardiac remodeling *educe F"@ how low is too low`*educe F"@ how low is too low`

1eta 1loc3ers9 U" to ;J<1eta 1loc3ers9 U" to ;J<++ ++

$ounteract acti#ation o *CCS and SS$ounteract acti#ation o *CCS and SS



#5

SS acti#ation promotes catecholamineSS acti#ation promotes catecholamineto'icity on cardiomyocytes& increases LVto'icity on cardiomyocytes& increases LVaterload and wall stress& promotesaterload and wall stress& promotes

myocardial ischemia and o'idati#e stressmyocardial ischemia and o'idati#e stress egati#e inotrope . egati#e chronotropeegati#e inotrope . egati#e chronotrope *ate control with arrhythmias*ate control with arrhythmias

$ontrols !* and F"$ontrols !* and F"



'o to give 1eta'o to give 1eta1loc3ers1loc3ers

Start low@ go slowunless switchingStart low@ go slowunless switching



#

@ g g@ g g "atient should be"atient should be eu%olemiceu%olemic prior toprior to

starting@ neg+starting@ neg+ inotropicinotropic action& increasedaction& increasedpreload can e'acerbate Buid o#erload+preload can e'acerbate Buid o#erload+

5itrate X > wees@ can go by T dose5itrate X > wees@ can go by T dose 5itrate to highest tolerated doseRstudy dose@5itrate to highest tolerated doseRstudy dose@

!* in <2s signifes adeXuate b1 blocade!* in <2s signifes adeXuate b1 blocade -ew contraindications high degree blocs&-ew contraindications high degree blocs&

true bronchospastic Csthmatic diseasetrue bronchospastic Csthmatic disease -ew side e(ects@ can eel worse at frst-ew side e(ects@ can eel worse at frst

The Adverse Im"act ofThe Adverse Im"act of Aldosterone Aldosterone

yocardial

firosis

yocardial

firosis



## Adapted from /(/ahon. Curr Opin Pharmacol. !!1;1:19!=196.Eorantzopo%los et al. Med Sci Monit. !!3;9:A1!=A15.

Prothromotic

effects

Prothromotic

effects*dverse effects

of aldosterone

*dverse effects

of aldosterone

&/idative

stress

&/idative

stress

Endothelial

dysfunction

Endothelial

dysfunction

"ascular

inflammation

"ascular

inflammation

Aldosterone Aldosterone Antagonists Antagonists

Cldosterone release inBuenced by Cngiotension 88 Cldosterone release inBuenced by Cngiotension 88



#9

"romotes salt and water retention& W[ and )g loss@"romotes salt and water retention& W[ and )g loss@sympathetic stimulation and parasympatheticsympathetic stimulation and parasympatheticinhibition& baroreceptor dysunction& #ascularinhibition& baroreceptor dysunction& #asculardamage and impaired arterial compliance+damage and impaired arterial compliance+

+A,ES9+A,ES9 7Spironolactone97Spironolactone9 ;G<;G< ris reduction inris reduction inmortality andmortality and ;J<;J< reduction in !- admissions asreduction in !- admissions ascompared with placebo@ *eal world`` -ew on Fetacompared with placebo@ *eal world`` -ew on FetaFlocersFlocers

EP'ESUSEP'ESUS,plerenone 78nspra9 post )8@,plerenone 78nspra9 post )8@ 8J<8J< risris

reduction % current therapy !- meds@ morereduction % current therapy !- meds@ morespecifc@ less S+,+ 7gynecomastia9specifc@ less S+,+ 7gynecomastia9

Must carefull! monitor 6R levelsMust carefull! monitor 6R levels

0itric (#ide0itric (#ide

8sosorbide dinitrateRhydralazine8sosorbide dinitrateRhydralazine



9!


7FiDil97FiDil9

*egulates $V processes including*egulates $V processes including

myocardial hypertrophy&myocardial hypertrophy&

remodeling& substrate use& #ascularremodeling& substrate use& #ascular

unction& inBammation& andunction& inBammation& and

thrombosisthrombosis

IsosorideIsosorideDinitrate'!drala7ineDinitrate'!drala7ine

A%'eFT 8 A%'eFT 8 "rotecti#e role o nitric o'ide "rotecti#e role o nitric o'ideddi i l d i i li h dd dAddi i l H;< d i i li h dd d



91

Additional H;< reduction in mortalit! hen added Additional H;< reduction in mortalit! hen addedto current standard thera"! 9 -African Americansto current standard thera"! 9 -African Americans

Decreased 1Decreased 1stst hospitalization or !- by II3hospitalization or !- by II3 8mpro#ed Q%L scores8mpro#ed Q%L scores

!ow it wors Vasodilator Falance o arterio and!ow it wors Vasodilator Falance o arterio and #enodilation #enodilation

!ydralazine pre#ents degredation o n+o+ and prolongs!ydralazine pre#ents degredation o n+o+ and prolongs #asodilatory e(ects o isosorbide #asodilatory e(ects o isosorbide

Should be gi#en to CC with !-Should be gi#en to CC with !-

C reasonable alternati#e or any patient who cannot C reasonable alternati#e or any patient who cannottae C$,RC*Fstae C$,RC*Fs UUUUUUUUUUUUUUUUUU

S!m"tom +elief S!m"tom +elief

Digo'inDigo'in



9

Digo'ingo Very mild positi#e inotrope& some Very mild positi#e inotrope& some

sympathoinhibitory neurohormonalsympathoinhibitory neurohormonalmodulating e(ects+modulating e(ects+

0o mortalit! data0o mortalit! data@ data on decreased@ data on decreasedhospitalizationshospitalizations

*arely used or !- in ,urope*arely used or !- in ,urope !elpul or rate control with C/fb!elpul or rate control with C/fb 4se I4se Irdrd line or symptom relie line or symptom relie /er! ,o dose /er! ,o dose

Diuretics9 Fluid 0aRDiuretics9 Fluid 0aR+etention+etention o nown impact on mortalityo nown impact on mortality

4seul and necessary ad6unct to therapy or4seul and necessary ad6unct to therapy or



93

y 6 pyy 6 py

congesti#e !-congesti#e !- s!m"tomss!m"toms due to sodiumdue to sodium

and water retention+and water retention+

Do not maintain clinical stability asDo not maintain clinical stability asmonotherapymonotherapy

*eractoriness . *enal Dysunction*eractoriness . *enal Dysunction

Inotro"esInotro"es Still gi#en in %" setting@ or low Still gi#en in %" setting@ or low

c+o+ states@ or s' relie@ end stage !- onlyc+o+ states@ or s' relie@ end stage !- only

P/Cs$ 0onsustained /T Ma!P/Cs$ 0onsustained /T Ma!0ot 'el"0ot 'el"

> ma6or types o V5> ma6or types o V5



9

5ype 1 "remature5ype 1 "remature #entricular #entricularcontraction 7"V$9contraction 7"V$9initiates 7<+<39initiates 7<+<39

5ype > o "V$5ype > o "V$7N1+?397N1+?39

$annot predict which$annot predict whichpatients get 5ype 1 #spatients get 5ype 1 #s5ype >5ype >

*nderson 2P, et al6*nderson 2P, et al6 J Am Coll Cardiol J Am Coll Cardiol 6 AFD=J#K4KJ66 AFD=J#K4KJ6

'FSA ?G8G'FSA ?G8G

Com"rehensiveCom"rehensive' t F il' t F il



Com"rehensiveCom"rehensive'eart Failure'eart Failure

PracticePracticeLuidelineLuidelineWey *ecommendationsWey *ecommendations

Pharmacologic Thera"!9Pharmacologic Thera"!9'!drala7ine and (ral'!drala7ine and (ral

0itrates0itrates A comination of h!drala7ine and A comination of h!drala7ine and



!!isosoride dinitrateisosoride dinitrate isisrecommendedrecommended as "art of standardas "art of standardthera"!$ in addition to eta%thera"!$ in addition to eta%loc3ers and ACE%inhiitors$ forloc3ers and ACE%inhiitors$ for African Americans ith 'F and African Americans ith 'F andreduced ,/EF9reduced ,/EF9

0'A III or I/ 'F0'A III or I/ 'F Strength of ,%idence - AStrength of ,%idence - A

0'A II 'F0'A II 'F Strength of ,%idence - Strength of ,%idence -

'FSA ?G8G Practice Luideline -=.?;'FSA ?G8G Practice Luideline -=.?;

Pharmacologic Thera"!9Pharmacologic Thera"!9

DiureticsDiuretics

Diuretic thera"!Diuretic thera"! is recommendedis recommended totorestore and maintain normal volumerestore and maintain normal volume



restore and maintain normal volumerestore and maintain normal volumestatus in "atients ith clinical evidencestatus in "atients ith clinical evidenceof uid overload$ generall! manifestedof uid overload$ generall! manifested!9!9

Congestive s!m"tomsCongestive s!m"toms Signs of elevated &lling "ressuresSigns of elevated &lling "ressures

Strength of ,%idence - AStrength of ,%idence - A

,oo" diuretics,oo" diuretics rather than thia7ide%rather than thia7ide%t!"e diuretics are t!"icall! necessar! tot!"e diuretics are t!"icall! necessar! to

restore normal volume status inrestore normal volume status in"atients ith 'F."atients ith 'F. Strength ofStrength of

,%idence - ,%idence -




EliminatioElimination9 +enal n9 +enal Met.Met.




9# All a4ailale for oral or <V administration




H%> hrsH%> hrs

1umetanid1umetanid

ee

G.J%8.G mgG.J%8.G mg

d or idd or id

8G mg8G mg >?<+;@<>?<+;@<

MM

>%@ hrs>%@ hrs



8?%8> hrs8?%8> hrs



?GG mg?GG mg >=<+%>=<+%;;<M;;<M

> hrs> hrs

Potassium%S"aringPotassium%S"aringDiureticsDiuretics

Agent Agent InitialInitial

Dail!Dail!DoseDose

Ma# TotalMa# Total

Dail!Dail!DoseDose

EliminatioEliminatio

nn

DuratioDuratio

n ofn of Action Action




S"ironolactonS"ironolactonee

8?.J%?J8?.J%?Jmg dmg d

JG mgJG mg MetaolicMetaolic H@%=?H@%=?hrshrs

E"lerenoneE"lerenone ?J%JG mg?J%JG mg

dd

8GG mg8GG mg +enal$+enal$

MetaolicMetaolic

Un3no Un3no

nn Amiloride Amiloride J mg dJ mg d ?G mg?G mg +enal+enal ?H hrs?H hrs

TriamtereneTriamterene JG%=J mgJG%=J mgidid

?GG mg?GG mg MetaolicMetaolic =% hrs=% hrs

Device Thera"!9Device Thera"!9Pro"h!lactic ICDPro"h!lactic ICD

PlacementPlacementPro"h!lactic ICD "lacementPro"h!lactic ICD "lacement should eshould econsideredconsidered in "atients ith an ,/EF V;J< andin "atients ith an ,/EF V;J< and



""mild to moderate 'F s!m"toms9mild to moderate 'F s!m"toms9 Ischemic etiolog!Ischemic etiolog! Strength of ,%idence - AStrength of ,%idence - A 0on%ischemic etiolog!0on%ischemic etiolog! Strength of ,%idence - Strength of ,%idence -

In "atients ho are undergoing im"lantation of aIn "atients ho are undergoing im"lantation of aiventricular "acing device$ use of a device thativentricular "acing device$ use of a device that"rovides de&rillation"rovides de&rillation should e considered.should e considered. Strength of ,%idence - Strength of ,%idence -

Decisions should e made in light of functionalDecisions should e made in light of functional

status and "rognosis ased on severit! ofstatus and "rognosis ased on severit! ofunderl!ing 'F and comorid conditions$ ideall!underl!ing 'F and comorid conditions$ ideall!after ;%> mos. of o"timal medical thera"!.after ;%> mos. of o"timal medical thera"!.

Strength of ,%idence - CStrength of ,%idence - C

Adapted from:

'FSA ?G8G Practice Luideline -88.8%'FSA ?G8G Practice Luideline -88.8%

88.?88.?'F ith Preserved ,/EFB'F ith Preserved ,/EFB

DiagnosisDiagnosis

Careful attention to di5erential diagnosisCareful attention to di5erential diagnosis

isis

recommendedrecommended in "atients ith 'F andin "atients ith 'F and"reserved ,/EF"reserved ,/EF



"reserved ,/EF."reserved ,/EF. Treatments ma! di5er ased on cardiacTreatments ma! di5er ased on cardiac

disorder.disorder. Evaluation for ischemic disease and inducileEvaluation for ischemic disease and inducile

m!ocardial ischemia should e included.m!ocardial ischemia should e included. +ecommended diagnostic tools9+ecommended diagnostic tools9

Echocardiogra"h! Echocardiogra"h! Electrocardiogra"h! Electrocardiogra"h! Stress imaging -via e#ercise or "harmacologicStress imaging -via e#ercise or "harmacologic

means$ using m!ocardial "erfusion ormeans$ using m!ocardial "erfusion or

echocardiogra"hic imagingechocardiogra"hic imaging Cardiac catheteri7ationCardiac catheteri7ation

Adapted from:

Strength of Evidence = C

Diagnostic AlgorithmDiagnostic Algorithm

for 'F ith Preserved ,/EFfor 'F ith Preserved ,/EF$0 'ith

Preserved +"E0

.ilated +" Non4dilated +"



"alvular disease

*,

No valvular dis6

$igh output $0

-ncreased

thickness

Normal

Thickness

ight vent6

dysfunction

Pulmonary

hypertension

-solated pre4

dominant "-

No mitral

ostruction

itral ostruction

%, atrial my/oma

Pericardial dis6

Tamponade

Constriction

No pericardial

disease

-nducile ischemia

-ntermittent;active

ischemia

Normal or

increased @%

$ypertrophic dis6

+o' @% voltage

-nfiltrative

myopathy

No aortic

valve disease

*ortic valve dis6

*ortic stenosis

No hypertensive

history of PE

$C, 0ary dis6

$ypertensive

history of PE

$ypertensive4$C

%ome patients 'ith "

dysfunction have +"

dysfunction due to

ventricular interaction6

No inducile ischemia, firotic, collagen4"ascular, C, cardinoid, diaetes,

adiation or chemotherapy induced

heart disease, infiltrative disease, co4

morid conditions, reconsider diagnosis

of $0

!-SC >212 "ractice :uideline 71>+I& 5able 1>+I9!-SC >212 "ractice :uideline 71>+I& 5able 1>+I9 Acute Decom"ensated 'eart Acute Decom"ensated 'eart

Failure -AD'FBFailure -AD'FBTreatment LoalsTreatment Loals

for 'os"itali7ed Patientsfor 'os"itali7ed Patients

8mpro#e symptoms& especially congestion and low/8mpro#e symptoms& especially congestion and low/output symptomsoutput symptoms



%ptimize #olume status%ptimize #olume status 8dentiy etiology8dentiy etiology 8dentiy precipitating actors8dentiy precipitating actors

%ptimize chronic oral therapy@ minimize side e(ects%ptimize chronic oral therapy@ minimize side e(ects 8dentiy who might beneft rom re#ascularization8dentiy who might beneft rom re#ascularization ,ducation patients concerning medication and !- sel/,ducation patients concerning medication and !- sel/

assessmentassessment

$onsider enrollment in a disease management$onsider enrollment in a disease managementprogramprogram


!-SC >212 "ractice :uideline 71>+=/1>+>29!-SC >212 "ractice :uideline 71>+=/1>+>29 (vervie of Treatment ("tions for(vervie of Treatment ("tions for

Patients ith AcutePatients ith Acute

Decom"ensated 'FDecom"ensated 'F

-luid and sodium restriction-luid and sodium restrictionDiuretics especially loop diureticsDiuretics& especially loop diuretics



Diuretics& especially loop diureticsDiuretics& especially loop diuretics4ltrafltrationRrenal replacement therapy4ltrafltrationRrenal replacement therapy

7in selected patients only9 7in selected patients only9

"arenteral #asodilators"arenteral #asodilators PP 7nitroglycerin& nitroprusside& nesiritide97nitroglycerin& nitroprusside& nesiritide9

8notropes8notropes PP 7milrinone or dobutamine9 7milrinone or dobutamine9

R%ee recommendations for stipulations and restrictions6

Device Thera"!9Device Thera"!91i t i l1iventricular




PacingPacing

Im"lantale CardiacIm"lantale CardiacDefririllatorsDefririllators

E1M Thera"iesE1M Thera"ies +elative +is3 +elative +is3

+eduction+eduction

Mortalit! Mortalit!

? !ear ? !ear



ACE%I ACE%I >I3>I3 >O3>O3

WW%1loc3ers%1loc3ers I=3I=3 1>31>3

Aldosterone Aldosterone Antagonists Antagonists

I23I23 1N31N3

ICDICD I13I13 ?+=3?+=3


Cbnormal #entricular conduction Cbnormal #entricular conduction

resulting in a mechanical delay andresulting in a mechanical delay and



3!>4er4ie of 'e4i(e herap)

g ydysynchronous contractiondysynchronous contraction

1i/ Pacing1i/ Pacing



Thera"! Thera"! 6e! Points6e! Points IndicationsIndications

)oderate to se#ere $!- who ha#e ailed)oderate to se#ere $!- who ha#e ailed

optimaloptimal medical therapymedical therapy ,-0I23,-0I23



,#idence o electrical conduction delay,#idence o electrical conduction delay


De&rillatorsDe&rillators



De&rillatorsDe&rillators-ICD’s-ICD’s

'eart Failure and Sudden'eart Failure and SuddenCardiac DeathCardiac Death

Sudden $ardiac Death 7S$D9Sudden $ardiac Death 7S$D9 Hour heart Hour heart suddenlysuddenl

y goes into a #ery ast and chaoticgoes into a #ery ast and chaotich th d t i bl dh th d t i bl d



rhythm and stops pumping bloodrhythm and stops pumping blood

$aused by an ]electrical^ problem in your heart$aused by an ]electrical^ problem in your heart

S$D is one o the leading causes o death in the 4+S+ _S$D is one o the leading causes o death in the 4+S+ _appro'imately =2&222 deaths a yearappro'imately =2&222 deaths a year

"atients with heart ailure are </N times as liely to"atients with heart ailure are </N times as liely to

de#elop sudden cardiac death as the generalde#elop sudden cardiac death as the generalpopulationpopulation

'o oes a e r atoro oes a e r ator

for sudden cardiac deathfor sudden cardiac death

or3K or3K



DeviceShown:

#ombination

8acema(er9e:brillator

4ho should Consider an 4ho should Consider anICDKICDK "atients with weaend heart& ew Hor"atients with weaend heart& ew Hor

!eart Cssociation 7H!C9 $lass 88 and!eart Cssociation 7H!C9 $lass 88 and

888 heart ailure& and measured let888 heart ailure& and measured let



#entricular e6ection raction 7LV,-9 #entricular e6ection raction 7LV,-9 00 I=3I=3

"atients who meet all current"atients who meet all current

reXuirements or a cardiacreXuirements or a cardiac

resynchronization therapy 7$*59 de#iceresynchronization therapy 7$*59 de#iceand ha#e H!C $lass 8V heart ailure@and ha#e H!C $lass 8V heart ailure@

(ther Thera"iesK(ther Thera"iesK

5ransplant5ransplant

Crtifcial hearts Crtifcial hearts



ew ]gadgets^ to help doctorsew ]gadgets^ to help doctors

manage heart ailuremanage heart ailure

'eart Trans"lantation'eart Trans"lantation

C good solution to the ailing heart_ C good solution to the ailing heart_

get a new heartget a new heart



4nortunately we are limited by4nortunately we are limited by

supply& not demandsupply& not demand

Cppro'imately >>22 transplants are Cppro'imately >>22 transplants are

perormed yearly in the 4S& and thisperormed yearly in the 4S& and this

number has been stable or the pastnumber has been stable or the past

>2 years+>2 years+

0eer Leneration Arti&cial0eer Leneration Arti&cial'earts'earts




Intrathoracic Im"edanceIntrathoracic Im"edancefor 'eart Failurefor 'eart Failure



4hat have e4hat have e



4hat have e 4hat have elearnedKlearnedK

In Summar!.In Summar!.

!eart ailure is common and has high!eart ailure is common and has high

mortalitymortality Drug therapy impro#es sur#i#alDrug therapy impro#es sur#i#al



Drug therapy impro#es sur#i#alDrug therapy impro#es sur#i#al Fetablocers& C$,/8& aldosterone antagonistsFetablocers& C$,/8& aldosterone antagonists

ewer de#ice therapies are showing promiseewer de#ice therapies are showing promise

or symptom relie and impro#ed sur#i#alor symptom relie and impro#ed sur#i#al Fi#entricular pacing& 8$DYsFi#entricular pacing& 8$DYs

5ransplants remain rare& but technology or5ransplants remain rare& but technology or

mechanical assist de#ices continues tomechanical assist de#ices continues toimpro#e/ stay tunedGimpro#e/ stay tunedG



'eart Failure9'eart Failure9

CurrentCurrent



L=L

CurrentCurrent

Luidelines inLuidelines in

Thera"! Thera"!

S1A+91A+9 0av! 0uclear Sumarine0av! 0uclear SumarineCommunications ModelCommunications Model

SSituationituation EhatYs going on with theEhatYs going on with thepatientpatient



3

patientpatient

11acgroundacground "ertinent clinical"ertinent clinical

bacgroundbacground

A A ssessmentssessment EhatEhat II thin thin

+ + ecommendation Ehat is needed .ecommendation Ehat is needed .time rametime rame

,#idence/Fased,#idence/Fased

"$ronic Heart +ailure:,e"ications <ationale



35

Symptomatic *elie Symptomatic *elie

Evidence%1ased MedicationsEvidence%1ased Medications

Counteract 'F Com"ensator!Counteract 'F Com"ensator!MechanismsMechanisms

:oals:oals "re#ent *emodeling and "rogressi#e"re#ent *emodeling and "rogressi#e



36

g gg g

Eorsening o LV unctionEorsening o LV unction

Decrease morbidity and mortalityDecrease morbidity and mortality

(ral Medications to(ral Medications toCounteract..Counteract..

*CCS 8nhibitors*CCS 8nhibitors C$, 8RC*Fs C$, 8RC*Fs



3

Cldosterone Cntagonists Cldosterone Cntagonists Feta FlocersFeta Flocers

SS 8nhibitorsSS 8nhibitors Feta FlocersFeta Flocers

VasodilatorRitric %'ide Cgonists VasodilatorRitric %'ide Cgonists

8sorbide dinitrateRhydralzine8sorbide dinitrateRhydralzine

ACE Inhiitors ACE Inhiitors

8nhibit the enzyme responsible or8nhibit the enzyme responsible orcon#erting Cngiotensin 8 to Cngiotensincon#erting Cngiotensin 8 to Cngiotensin



3#

con#erting Cngiotensin 8 to Cngiotensing g g

88@ counteracts *CCS88@ counteracts *CCS

Decrease Systemic Vascular *esistanceDecrease Systemic Vascular *esistance

7SV*97SV*9

,nhance acti#ity o inins and inin/,nhance acti#ity o inins and inin/

mediated prostaglandin synthesismediated prostaglandin synthesis

)odiy cardiac remodeling)odiy cardiac remodeling *educe F"@ how low is too low`*educe F"@ how low is too low`

1eta 1loc3ers9 U" to ;J<1eta 1loc3ers9 U" to ;J<

++ ++

$ounteract acti#ation o *CCS and SS$ounteract acti#ation o *CCS and SS SS acti#ation promotes catecholamineSS acti#ation promotes catecholamine



39

SS acti#ation promotes catecholamineSS acti#ation promotes catecholamineto'icity on cardiomyocytes& increases LVto'icity on cardiomyocytes& increases LVaterload and wall stress& promotesaterload and wall stress& promotes

myocardial ischemia and o'idati#e stressmyocardial ischemia and o'idati#e stress egati#e inotrope . egati#e chronotropeegati#e inotrope . egati#e chronotrope *ate control with arrhythmias*ate control with arrhythmias $ontrols !* and F"$ontrols !* and F"

1eta 1loc3ers9 ;1eta 1loc3ers9 ;

IndicatedIndicated

Meto"rolol ,Meto"rolol , 7 beta 1 selecti#e9 ),*85 !-7 beta 1 selecti#e9 ),*85 !-

CarvedilolCarvedilol 7beta 1& beta >& alpha blocade97beta 1& beta >& alpha blocade9 $%",*8$4S& $%),5$%",*8$4S& $%),5



33!

1iso"rolol1iso"rolol 7$8F8S 8897$8F8S 889 (0, (0,

C Feta blocer is not a beta blocer is not+ C Feta blocer is not a beta blocer is not+ :i#en to all post )8 andRor with LV:i#en to all post )8 andRor with LV

dysunctiondysunction Superiority with non/selecti#e beta blocersSuperiority with non/selecti#e beta blocers

with some alpha blocade`with some alpha blocade` $omet trial$omet trial



The Adverse Im"act ofThe Adverse Im"act of

Aldosterone Aldosterone

yocardial

firosis

yocardial

firosis



33 Adapted from /(/ahon. Curr Opin Pharmacol. !!1;1:19!=196.Eorantzopo%los et al. Med Sci Monit. !!3;9:A1!=A15.

Prothromotic

effects

Prothromotic

effects*dverse effects

of aldosterone

*dverse effects

of aldosterone

&/idative

stress

&/idative

stress

Endothelial

dysfunction

Endothelial

dysfunction

"ascular

inflammation

"ascular

inflammation

Aldosterone Aldosterone

Antagonists Antagonists

Cldosterone release inBuenced by Cngiotension 88 Cldosterone release inBuenced by Cngiotension 88 "romotes salt and water retention& W[ and )g loss@"romotes salt and water retention& W[ and )g loss@

sympathetic stimulation and parasympatheticsympathetic stimulation and parasympathetic



333

sympathetic stimulation and parasympatheticsympathetic stimulation and parasympatheticinhibition& baroreceptor dysunction& #ascularinhibition& baroreceptor dysunction& #asculardamage and impaired arterial compliance+damage and impaired arterial compliance+

+A,ES9+A,ES9 7Spironolactone97Spironolactone9 ;G<;G< ris reduction inris reduction inmortality andmortality and ;J<;J< reduction in !- admissions asreduction in !- admissions ascompared with placebo@ *eal world`` -ew on Fetacompared with placebo@ *eal world`` -ew on FetaFlocersFlocers

EP'ESUSEP'ESUS,plerenone 78nspra9 post )8@,plerenone 78nspra9 post )8@ 8J<8J< risris

reduction % current therapy !- meds@ morereduction % current therapy !- meds@ morespecifc@ less S+,+ 7gynecomastia9specifc@ less S+,+ 7gynecomastia9

Must carefull! monitor 6R levelsMust carefull! monitor 6R levels

0itric (#ide0itric (#ide


7FiDil97FiDil9



33

7FiDil97FiDil9

*egulates $V processes including*egulates $V processes including

myocardial hypertrophy&myocardial hypertrophy&remodeling& substrate use& #ascularremodeling& substrate use& #ascular

unction& inBammation& andunction& inBammation& and

thrombosisthrombosis

IsosorideIsosoride

Dinitrate'!drala7ineDinitrate'!drala7ine

A%'eFT 8 A%'eFT 8 "rotecti#e role o nitric o'ide "rotecti#e role o nitric o'ide Additional H;< reduction in mortalit! hen added Additional H;< reduction in mortalit! hen added

to current standard thera"! 9 -African Americansto current standard thera"! 9 -African Americans



335

to current standard thera"! 9 -African Americansto current standard thera"! 9 -African Americans Decreased 1Decreased 1stst hospitalization or !- by II3hospitalization or !- by II3 8mpro#ed Q%L scores8mpro#ed Q%L scores

!ow it wors Vasodilator Falance o arterio and!ow it wors Vasodilator Falance o arterio and #enodilation #enodilation !ydralazine pre#ents degredation o n+o+ and prolongs!ydralazine pre#ents degredation o n+o+ and prolongs

#asodilatory e(ects o isosorbide #asodilatory e(ects o isosorbide Should be gi#en to CC with !-Should be gi#en to CC with !- C reasonable alternati#e or any patient who cannot C reasonable alternati#e or any patient who cannot

tae C$,RC*Fstae C$,RC*Fs UUUUUUUUUUUUUUUUUU

S!m"tom +elief S!m"tom +elief

Digo'inDigo'in Very mild positi#e inotrope someVery mild positi#e inotrope some



336

Very mild positi#e inotrope& some Very mild positi#e inotrope& somesympathoinhibitory neurohormonalsympathoinhibitory neurohormonalmodulating e(ects+modulating e(ects+

0o mortalit! data0o mortalit! data@ data on decreased@ data on decreasedhospitalizationshospitalizations

*arely used or !- in ,urope*arely used or !- in ,urope !elpul or rate control with C/fb!elpul or rate control with C/fb 4se I4se Irdrd line or symptom relie line or symptom relie /er! ,o dose /er! ,o dose

Diuretics9 Fluid 0aRDiuretics9 Fluid 0aR+etention+etention o nown impact on mortalityo nown impact on mortality

4seul and necessary ad6unct to therapy or4seul and necessary ad6unct to therapy orcongesti#e !-congesti#e !- s!m"tomss!m"toms due to sodiumdue to sodium



33

co gest eg s! "to s! " due to sod uand water retention+and water retention+

Do not maintain clinical stability asDo not maintain clinical stability as

monotherapymonotherapy

*eractoriness . *enal Dysunction*eractoriness . *enal Dysunction

Inotro"esInotro"es Still gi#en in %" setting@ or low Still gi#en in %" setting@ or low

c+o+ states@ or s' relie@ end stage !- onlyc+o+ states@ or s' relie@ end stage !- only



4hat is ICD Thera"!K 4hat is ICD Thera"!K

$%lantale #ar"iac e*irillator

7# era%& consists o* %acin4'car"io6ersion' an" "e*irillation

t i t t t " " t



339

tera%ies to treat ra"& an" tac&

arr&t$ias.

An eEternal %ro4ra$$er is use" to

$onitor an" access te "e6ice

%ara$eters an" tera%ies *or eac

%atient.

+es!nchroni7ation+es!nchroni7ationThera"! Thera"!

Standard right atrial paceRsense leadStandard right atrial paceRsense lead

implanted to establish CV synchronyimplanted to establish CV synchrony Standard right #entricularStandard right #entricular



3!

Standard right #entricularStandard right #entricular

paceRsenseRdefbrillation lead and letpaceRsenseRdefbrillation lead and let

#entricular lead implanted to restore #entricular lead implanted to restore

#entricular synchrony with bi#entricular #entricular synchrony with bi#entricularpacingpacing

ight ventricular

lead

+eft ventricular

lead

*trial lead

u e nesu e nes

forforC+T Thera"! C+T Thera"!

Class I recommendationClass I recommendation )oderate to se#ere !- 7H!C $lass 888&)oderate to se#ere !- 7H!C $lass 888&



31

7 &or ambulatory $lass 8V9or ambulatory $lass 8V9

LV,- I=3LV,- I=3 Q*S duration M1>2 msQ*S duration M1>2 ms -or symptomatic patients despite optimal-or symptomatic patients despite optimal

medical therapymedical therapy

Group at high risk of SCD from ventricular arrhythmiaGroup at high risk of SCD from ventricular arrhythmia

$unt %*, et al6$unt %*, et al6 J Am Coll Cardiol J Am Coll Cardiol 6 =>>FDKJ#eA4e=66 =>>FDKJ#eA4e=6

agesages

+ecommended+ecommendedTreatmentsTreatments

StageStage TreatmentTreatment

'igh ris3 for develo"ing'igh ris3 for develo"ingheart failure -'Fheart failure -'F

0o structural heart0o structural heart

• Therapeutic lifestyle changesTherapeutic lifestyle changes• Optimize drug therapyOptimize drug therapy• Aspirin, AC inhi!itors, statins,Aspirin, AC inhi!itors, statins,

β""AA



3

0o structural heart0o structural heartdisease or 'F s!m"tomsdisease or 'F s!m"toms

Structural heart diseaseStructural heart disease

ith no signs or ith no signs ors!m"toms of 'Fs!m"toms of 'F

Structural heart diseaseStructural heart disease ith "rior or current ith "rior or currents!m"toms of 'Fs!m"toms of 'F

+efractor! end%stage 'F+efractor! end%stage 'F

BB

CC

DD

!lockers,!lockers,β

β"!lockers #carvedilol$,"!lockers #carvedilol$,dia!etic therapydia!etic therapy

• Optimize drug therapyOptimize drug therapy• %CD #!ridge to transplantation$%CD #!ridge to transplantation$• C&TC&T• Other devices #'(AD, pericardialOther devices #'(AD, pericardial

restraint) Class %%restraint) Class %%aa$$

• Optimize drug therapyOptimize drug therapy• %CD if '(* +-. and /01 days post"%CD if '(* +-. and /01 days post"

2% #Class %%2% #Class %%aa$$

• Optimize drug therapyOptimize drug therapy• %CD #if '(* +-., /01 days post"2%)%CD #if '(* +-., /01 days post"2%)

reduced '(* and 34 of SCA, (* or (T$reduced '(* and 34 of SCA, (* or (T$• C&T #if 5&S 6781 msec, '(* +-.$C&T #if 5&S 6781 msec, '(* +-.$

$unt %*, et al6$unt %*, et al6 J Am Coll CardiolJ Am Coll Cardiol =>>FDKJ#eA4e=6=>>FDKJ#eA4e=6

,atest ACCA'A,atest ACCA'ATreatment LuidelinesTreatment Luidelines

Cce 8nhibitors . Feta Flocers or all Systolic Cce 8nhibitors . Feta Flocers or all Systolicake Ho$e Su$$ar&:



33

Cce 8nhibitors . Feta Flocers or all Systolicy!- 7unless contraindicated9 5he writing!- 7unless contraindicated9 5he writingcommittee suggests that the benefts o betacommittee suggests that the benefts o beta

blocade are not a class e(ect and drugsblocade are not a class e(ect and drugse#aluated in clinical trials should be utilized+e#aluated in clinical trials should be utilized+ ew data supporting the use o Cce *eceptorew data supporting the use o Cce *eceptor

Flocers in the management o systolic heartFlocers in the management o systolic heartailure+ailure+

5he guidelines support the use o 8$D in5he guidelines support the use o 8$D inpatients with LV,- 2+I= regardless o etiology+patients with LV,- 2+I= regardless o etiology+

Ta3e 'ome continuedTa3e 'ome continued

Fi/#entricular pacers should be used inFi/#entricular pacers should be used inpatients with an ,- 2+I=& class 888/8Vpatients with an ,- 2+I=& class 888/8V

t d Q*S 1>2 St d Q*S 1>2 S



3

symptoms and a Q*S M 1>2 mSec+symptoms and a Q*S M 1>2 mSec+ Cldosterone antagonists should be started Cldosterone antagonists should be started

in patients with moderate/se#ere symptomsin patients with moderate/se#ere symptomsand reduced LV,- as long as the patientand reduced LV,- as long as the patientcan be monitored or hyperalemia+can be monitored or hyperalemia+

!ydralazine and nitrates can be added on!ydralazine and nitrates can be added onto standard medical therapy in Crican/to standard medical therapy in Crican/

Cmericans or others with residual Cmericans or others with residualsymptoms or used in patients withsymptoms or used in patients withintolerance to C$,/8 or C*Fs+intolerance to C$,/8 or C*Fs+

1ac3 to the Case1ac3 to the CaseStud!..Stud!..

Ehat H!C $lass o !-`Ehat H!C $lass o !-`

Ehat C$$ R C!C Stage``Ehat C$$ R C!C Stage``



35

PreventionPrevention

S!m"tomatic 'F % The Ti" ofS!m"tomatic 'F % The Ti" ofThe IceergThe Iceerg



36

$ypertension

+eft "entricular

$ypertrophy

.iastolic

.ysfunction

Post4-

emodeling

yocardial -schemia

*symptomatic

+eft "entricular.ysfunction

.iaetes

.yslipidemiaCoronary *rtery .isease

&ther C". isk 0actors

'FSA ?G8G'FSA ?G8GCom"rehensiveCom"rehensive





PracticePracticeLuidelineLuidelineWey *ecommendationsWey *ecommendations

Pharmacologic Thera"!9Pharmacologic Thera"!9'!drala7ine and (ral'!drala7ine and (ral

0itrates0itrates A comination of h!drala7ine and A comination of h!drala7ine and

isosoride dinitrateisosoride dinitrate isis



recommendedrecommended as "art of standardas "art of standardthera"!$ in addition to eta%thera"!$ in addition to eta%

loc3ers and ACE%inhiitors$ forloc3ers and ACE%inhiitors$ for African Americans ith 'F and African Americans ith 'F andreduced ,/EF9reduced ,/EF9 0'A III or I/ 'F0'A III or I/ 'F Strength of ,%idence - AStrength of ,%idence - A

0'A II 'F0'A II 'F Strength of ,%idence - Strength of ,%idence -

'FSA ?G8G Practice Luideline -=.?;'FSA ?G8G Practice Luideline -=.?;

Pharmacologic Thera"!9Pharmacologic Thera"!9DiureticsDiuretics

Diuretic thera"!Diuretic thera"! is recommendedis recommended totorestore and maintain normal volumerestore and maintain normal volumestatus in "atients ith clinical evidencestatus in "atients ith clinical evidencef id l d ll if t df id l d ll if t d



of uid overload$ generall! manifestedof uid overload$ generall! manifested!9!9

Congestive s!m"tomsCongestive s!m"toms Signs of elevated &lling "ressuresSigns of elevated &lling "ressures Strength of ,%idence - AStrength of ,%idence - A

,oo" diuretics,oo" diuretics rather than thia7ide%rather than thia7ide%t!"e diuretics are t!"icall! necessar! tot!"e diuretics are t!"icall! necessar! to

restore normal volume status inrestore normal volume status in"atients ith 'F."atients ith 'F. Strength ofStrength of ,%idence - ,%idence -




EliminatioElimination9 +enal n9 +enal

Met.Met.





H%> hrsH%> hrs



35! All a4ailale for oral or <V administration

ee d or idd or id ;J<M;J<M

1umetanid1umetanid

ee

G.J%8.G mgG.J%8.G mg

d or idd or id

8G mg8G mg >?<+;@<>?<+;@<

MM

>%@ hrs>%@ hrs



8?%8> hrs8?%8> hrs



?GG mg?GG mg >=<+%>=<+%;;<M;;<M

> hrs> hrs

Potassium%S"aringPotassium%S"aringDiureticsDiuretics

Agent Agent InitialInitial

Dail!Dail!DoseDose

Ma# TotalMa# Total

Dail!Dail!DoseDose

EliminatioEliminatio

nn

DuratioDuratio

n ofn of Action Action

S"ironolactonS"ironolacton 8?.J%?J8?.J%?Jdd

JG mgJG mg MetaolicMetaolic H@%=?H@%=?hh




ee mg dmg d hrshrs

E"lerenoneE"lerenone ?J%JG mg?J%JG mgdd

8GG mg8GG mg +enal$+enal$MetaolicMetaolic

Un3no Un3no nn

Amiloride Amiloride J mg dJ mg d ?G mg?G mg +enal+enal ?H hrs?H hrs

TriamtereneTriamterene JG%=J mgJG%=J mgidid

?GG mg?GG mg MetaolicMetaolic =% hrs=% hrs

Device Thera"!9Device Thera"!9Pro"h!lactic ICDPro"h!lactic ICD

PlacementPlacement

Pro"h!lactic ICD "lacementPro"h!lactic ICD "lacement should eshould econsideredconsidered in "atients ith an ,/EF V;J< andin "atients ith an ,/EF V;J< andmild to moderate 'F s!m"toms9mild to moderate 'F s!m"toms9 I h i ti lIschemic etiolog S h f , id ASt th f , id A



Ischemic etiolog!Ischemic etiolog! Strength of ,%idence - AStrength of ,%idence - A 0on%ischemic etiolog!0on%ischemic etiolog! Strength of ,%idence - Strength of ,%idence -

In "atients ho are undergoing im"lantation of aIn "atients ho are undergoing im"lantation of aiventricular "acing device$ use of a device thativentricular "acing device$ use of a device that"rovides de&rillation"rovides de&rillation should e considered.should e considered. Strength of ,%idence - Strength of ,%idence -

Decisions should e made in light of functionalDecisions should e made in light of functionalstatus and "rognosis ased on severit! ofstatus and "rognosis ased on severit! ofunderl!ing 'F and comorid conditions$ ideall!underl!ing 'F and comorid conditions$ ideall!after ;%> mos. of o"timal medical thera"!.after ;%> mos. of o"timal medical thera"!.


Adapted from:

'FSA ?G8G Practice Luideline -.='FSA ?G8G Practice Luideline -.=

Device Thera"!9Device Thera"!91iventricular Pacing1iventricular Pacing

1iventricular "acing thera"!1iventricular "acing thera"! isis

recommendedrecommended for "atients ithfor "atients ith all of theall of the

follo/ing follo/ing99



Sinus rh!thmSinus rh!thm

A idened N+S interval -X8?G ms A idened N+S interval -X8?G ms

Severe ,/ s!stolic d!sfunction -,/EFSevere ,/ s!stolic d!sfunction -,/EF YY ;J<;J<

Persistent$ moderate%to%severe 'FPersistent$ moderate%to%severe 'F

-0'A III des"ite o"timal medical-0'A III des"ite o"timal medical

thera"!.thera"!. Strength of ,%idence - AStrength of ,%idence - A

'FSA ?G8G Practice Luideline -88.8%'FSA ?G8G Practice Luideline -88.8%

88.?88.?'F ith Preserved ,/EFB'F ith Preserved ,/EFB

DiagnosisDiagnosis Careful attention to di5erential diagnosisCareful attention to di5erential diagnosis isis

recommendedrecommended in "atients ith 'F andin "atients ith 'F and"reserved ,/EF."reserved ,/EF.

Treatments ma! di5er ased on cardiacTreatments ma! di5er ased on cardiacdi d



!disorder.disorder.

Evaluation for ischemic disease and inducileEvaluation for ischemic disease and inducilem!ocardial ischemia should e included.m!ocardial ischemia should e included.

+ecommended diagnostic tools9+ecommended diagnostic tools9 Echocardiogra"h! Echocardiogra"h! Electrocardiogra"h! Electrocardiogra"h! Stress imaging -via e#ercise or "harmacologicStress imaging -via e#ercise or "harmacologic

means$ using m!ocardial "erfusion ormeans$ using m!ocardial "erfusion orechocardiogra"hic imagingechocardiogra"hic imaging

Cardiac catheteri7ationCardiac catheteri7ation

Adapted from:


Diagnostic AlgorithmDiagnostic Algorithm

for 'F ith Preserved ,/EFfor 'F ith Preserved ,/EF$0 'ith

Preserved +"E0

.ilated +" Non4dilated +"

"alvular disease

*

No valvular dis6

$igh output $0

-ncreased

thickness

Normal

Thickness

ight vent6

dysfunction



*, $igh output $0 thickness Thickness dysfunction

Pulmonary

hypertension

-solated pre4

dominant "-

No mitral

ostruction

itral ostruction

%, atrial my/oma

Pericardial dis6

Tamponade

Constriction

No pericardial

disease

-nducile ischemia

-ntermittent;active

ischemia

Normal or

increased @%

$ypertrophic dis6

+o' @% voltage

-nfiltrative

myopathy

No aortic

valve disease

*ortic valve dis6

*ortic stenosis

No hypertensive

history of PE

$C, 0ary dis6

$ypertensive

history of PE

$ypertensive4$C

%ome patients 'ith "

dysfunction have +"

dysfunction due to

ventricular interaction6

No inducile ischemia, firotic, collagen4"ascular, C, cardinoid, diaetes,

adiation or chemotherapy induced

heart disease, infiltrative disease, co4

morid conditions, reconsider diagnosis

of $0

!-SC >212 "ractice :uideline 71>+I& 5able 1>+I9!-SC >212 "ractice :uideline 71>+I& 5able 1>+I9

Acute Decom"ensated 'eart Acute Decom"ensated 'eartFailure -AD'FBFailure -AD'FBTreatment LoalsTreatment Loals

for 'os"itali7ed Patientsfor 'os"itali7ed Patients 8mpro#e symptoms& especially congestion and low/8mpro#e symptoms& especially congestion and low/

output symptomsoutput symptoms %ptimize #olume status%ptimize #olume status 8d ti ti l8d ti ti l



8dentiy etiology8dentiy etiology 8dentiy precipitating actors8dentiy precipitating actors

%ptimize chronic oral therapy@ minimize side e(ects%ptimize chronic oral therapy@ minimize side e(ects 8dentiy who might beneft rom re#ascularization8dentiy who might beneft rom re#ascularization ,ducation patients concerning medication and !- sel/,ducation patients concerning medication and !- sel/

assessmentassessment $onsider enrollment in a disease management$onsider enrollment in a disease management

programprogram


!-SC >212 "ractice :uideline 71>+=/1>+>29!-SC >212 "ractice :uideline 71>+=/1>+>29

(vervie of Treatment ("tions for(vervie of Treatment ("tions forPatients ith AcutePatients ith Acute

Decom"ensated 'FDecom"ensated 'F -luid and sodium restriction-luid and sodium restrictionDiuretics& especially loop diureticsDiuretics& especially loop diuretics4ltrafltrationRrenal replacement therapy4ltrafltrationRrenal replacement therapy



4ltrafltrationRrenal replacement therapy4ltrafltrationRrenal replacement therapy7in selected patients only9 7in selected patients only9

"arenteral #asodilators"arenteral #asodilators PP 7nitroglycerin& nitroprusside& nesiritide97nitroglycerin& nitroprusside& nesiritide9

8notropes8notropes PP 7milrinone or dobutamine9 7milrinone or dobutamine9

R%ee recommendations for stipulations and restrictions6

Predictors of Mortalit!Predictors of Mortalit!

1ased on Anal!sis of1ased on Anal!sis of AD'E+E Dataase AD'E+E Dataase

$lassifcation and *egression 5ree 7$C*59$lassifcation and *egression 5ree 7$C*59

analysis o CD!,*, data showsanalysis o CD!,*, data shows 5hree #ariables are the strongest predictors o5hree #ariables are the strongest predictors o

mortality in hospitalized CD!- patientsmortality in hospitalized CD!- patients



mortality in hospitalized CD!- patientsmortality in hospitalized CD!- patients

B9N M KL mg;d+

%ystolic lood pressure AAF mm$g

%erum creatinine M =6OF mg;d+

0onaro' GC et al6 <** =>>FD=L#FO=4>

Evi ence%1ase Treatment v ence% ase reatment

Across the Continuum of Across the Continuum ofS!stolic ,/D and 'FS!stolic ,/D and 'F

Control "olume -mprove Clinical &utcomes

.iureticsenal eplacement

Therapy

β

4Blocker *CE-

or *B

*ldosterone

*ntagonistor *B



.igo/in

Treat esidual %ymptoms

CT ±

an -C.

$.QN;-%.N-n selected patients

eart a ureear a ure

)anagement)anagement

Cpplying the Cpplying theC$$RC!C $hronicC$$RC!C $hronic



C$$RC!C $hronic C$$RC!C $hronic

!eart -ailure!eart -ailure:uidelines:uidelines

The CoreThe Core



Basic management

Stage C

Beta blockers

ACE inhibitors

ARB

Re#ractory H$

Stage D

%rans"lantation

Subgrou"s

H$ &ith normal '(E$



Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Deices

!notro"ic agents

The CoreThe Core



Congestive 'eartCongestive 'eartFailureFailure



FailureFailure

(:ectives(:ectives

Defnition and ,pidemiologyDefnition and ,pidemiology

"athophysiology"athophysiology

Diagnosis and $lassifcationDiagnosis and $lassifcation



Diagnosis and $lassifcationDiagnosis and $lassifcation

5reatment o Systolic Dysunction5reatment o Systolic Dysunction )edical 5herapy)edical 5herapy

De#ice 5herapyDe#ice 5herapy

4hat is C'FK 4hat is C'FK

Denition Denition

Cbnormality o cardiac unction that leads Cbnormality o cardiac unction that leadsto the inability o the heart to pump bloodto the inability o the heart to pump blood

t t th b d Y b i t b lit t th b d Y b i t b li



to meet the bodyYs basic metabolicto meet the bodyYs basic metabolic

demands or when it can do so only withdemands or when it can do so only with

an ele#ated flling pressurean ele#ated flling pressure

E"idemiolog! E"idemiolog! PrevalencePrevalence

C(ects nearly = million Cmericans currently& M=22&222 new cases C(ects nearly = million Cmericans currently& M=22&222 new cases

diagnosed each yeardiagnosed each year CostCost Cnnual direct cost in M12 billion dollars Cnnual direct cost in M12 billion dollars

Incidence increased ith ageIncidence increased ith age



gg ,(ects 1/>3 o patient rom =2/=N/years/old and 123 o patient o#er,(ects 1/>3 o patient rom =2/=N/years/old and 123 o patient o#er

the age o O=the age o O= Freuenc!Freuenc!

8t is the most common inpatient diagnosis in the 4S or patients o#er8t is the most common inpatient diagnosis in the 4S or patients o#er<= years o age<= years o age

Visits to their amily practitioner on a#erage >/I times per year Visits to their amily practitioner on a#erage >/I times per year LenderLender

)enM women in those between 2 and O= years o age)enM women in those between 2 and O= years o age 5he se'es are eXual o#er O= years o age5he se'es are eXual o#er O= years o age

Patho"h!siolog! of 'eartPatho"h!siolog! of 'eartFailureFailure !emodynamic )odel!emodynamic )odel

eurohumoral Cdaptationseurohumoral Cdaptations ]]double/edged swords^double/edged swords^



g *enin/Cngiotensin/Cldosterone System*enin/Cngiotensin/Cldosterone System

Sympathetic er#ous SystemSympathetic er#ous System Cntidiuretic !ormone Cntidiuretic !ormone Ctrial and F/type atriuretic "eptides Ctrial and F/type atriuretic "eptides ,ndothelin,ndothelin

'el" initiall! 'el" initiall!

Vasoconstriction Vasoconstriction *edistributes blood to #ital organs*edistributes blood to #ital organs

*estoration o $ardiac %utput*estoration o $ardiac %utput



*estoration o $ardiac %utputp 8ncreased myocardial contractility and8ncreased myocardial contractility and

heart rateheart rate ,'pansion o the e'tracellular Buid,'pansion o the e'tracellular Buid

#olume #olume



0eurohumoral%+AAS0eurohumoral%+AAS



'urt long%term'urt long%term



Preci"itating CausesPreci"itating Causes

CommonCommon

$CD 7O239$CD 7O239 SystemicSystemic

!ypertension!ypertension

+are+are Cnemia Cnemia

$onnecti#e 5issue Disease$onnecti#e 5issue Disease Viral )yocarditis Viral )yocarditis !emochromatosis!emochromatosis !8V !8V ! perR! poth roidism!yperR!ypothyroidism



!ypertensionyp

8diopathic8diopathic

,ess Common,ess Common Diabetes )ellitusDiabetes )ellitus

Val#ular Disease Val#ular Disease

!yperR!ypothyroidism!yperR!ypothyroidism !ypertrophic!ypertrophic

$ardiomyopathy$ardiomyopathy

8nfltrati#e Disease including8nfltrati#e Disease includingamyloidosis and sarcoidosisamyloidosis and sarcoidosis )ediastinal radiation)ediastinal radiation "eripartum cardiomyopathy"eripartum cardiomyopathy *estricti#e pericardial*estricti#e pericardial

diseasedisease 5achyarrhythmias5achyarrhythmias

5o'ins5o'ins 5rypanosomiasis 7$hagasY5rypanosomiasis 7$hagasY

disease9disease9

S!stolic vs. DiastolicS!stolic vs. Diastolic

Diastolic dysunctionDiastolic dysunction ,- normal or increased,- normal or increased ! t i! t i



!ypertension!ypertension Due to chronic replacementDue to chronic replacement

fbrosis . ischemia/inducedfbrosis . ischemia/induceddecrease in distensibilitydecrease in distensibility

Systolic dysunctionSystolic dysunction ,- 0 23,- 0 23 4sually rom coronary disease4sually rom coronary disease Due to ischemia/induced decreaseDue to ischemia/induced decrease

in contractilityin contractility

)ost common is a combination o)ost common is a combination obothboth

Sut!"es of S!stolicSut!"es of S!stolic'eart Failure'eart Failure

!igh output!igh output Se#ere anemiaSe#ere anemia

CV malormationsCV malormations

*ight !eart -ailure*ight !eart -ailure "eripheral edema"eripheral edema

Let !eart -ailureLet !eart -ailure



CV malormations CV malormations

hyperthyroidismhyperthyroidism

Low cardiacLow cardiacoutputoutput

Let !eart -ailureLet !eart -ailure "ulmonary"ulmonary

congestioncongestion Fi#entricularFi#entricular

-ailure-ailure Systemic andSystemic and

pulmonarypulmonary

congestioncongestion

EvaluationEvaluation

!istory ris actors or ischemic!istory ris actors or ischemic

heart disease& amily historyheart disease& amily history "hysical e'am SI& VD more specifc"hysical e'am SI& VD more specifc



ysigns o !- than rales& peripheralsigns o !- than rales& peripheral

edemaedema

E#amE#am

)a6or $riteria)a6or $riteria

"aro'ysmal"aro'ysmalnocturnal dyspneanocturnal dyspnea

ec Vein Distentionec Vein Distention

)inor $riteria)inor $riteria

Cnle edema Cnle edema octurnal $oughocturnal $ough

Dyspnea onDyspnea on



*ales*ales

$ardiomegaly$ardiomegaly "ulmonary ,dema"ulmonary ,dema

SI :allopSI :allop

!epato6ugular!epato6ugular

*eBe'*eBe'

Dyspnea onDyspnea on

ordinary e'ertionordinary e'ertion

!epatomegaly!epatomegaly "leural ,(usion"leural ,(usion


M1>2bpmM1>2bpm

Con&rming the PresenceCon&rming the Presenceof 'eart Failureof 'eart Failure$;*/cardiomegaly and pulmonary$;*/cardiomegaly and pulmonary

edema@ WerleyYs F Linesedema@ WerleyYs F Lines Laboratory ValuesLaboratory Values



F"F"

)aybe inc by age& emale gender& $*8&)aybe inc by age& emale gender& $*8&pulm disease& hyperthyroid& obesity&pulm disease& hyperthyroid& obesity&

steroid usesteroid use

,lectrocardiogramR,$!%,lectrocardiogramR,$!% Cnterior Q wa#es& LFFF& LV! Cnterior Q wa#es& LFFF& LV!

0egative Prognostic0egative PrognosticFactorsFactors $linical$linical

8ncreased Cge& Diabetes& Smoing8ncreased Cge& Diabetes& Smoing LaboratoryLaboratory

! ponatremia ,le ated ne rohormones!yponatremia ,le#ated neurohormones



!yponatremia& ,le#ated neurohormones!yponatremia& ,le#ated neurohormones

!emodynamic!emodynamic *educed ,-& 8ncreased "ulm $ap Eedge*educed ,-& 8ncreased "ulm $ap Eedge

"ressure"ressure

,lectrophysiological,lectrophysiological

C/fb& C/Butter& Ventricular ectopy& V/tach C/fb& C/Butter& Ventricular ectopy& V/tach

Classi&cation of 'eart Failure9 ACCA'A Stage vs 0'A ClassClassi&cation of 'eart Failure9 ACCA'A Stage vs 0'A Class



Princi"les of TreatmentPrinci"les of Treatment

Systolic !-

Systolic !-

↓↓ "reload"reload ↓↓ Cterload Cterload

↑↑

C$,/8& Feta/ C$,/8& Feta/

blocers& andblocers& andaldosteronealdosterone

antagonist are theantagonist are the



↑↑ Ionotropy Ionotropy

↓↓ eurohumoraleurohumoralacti#ityacti#ity

antagonist are theantagonist are the

mainstay omainstay o

treatmenttreatment

Treatment of S!stolicTreatment of S!stolic'eart Failure'eart Failure C$, 8nhibitors/ C$, 8nhibitors/

Eors to inhibit the o#er stimulation o theEors to inhibit the o#er stimulation o the*CS that leads to myocardial hypertrophy and*CS that leads to myocardial hypertrophy and

fbrosisfbrosis



$auses balanced #asodilation$auses balanced #asodilation

Decrease the rate o morbidity . mortality inDecrease the rate o morbidity . mortality inall pts with systolic heart ailureall pts with systolic heart ailure

/8 treating acute !-& can start ater F" tolerates/8 treating acute !-& can start ater F" tolerates

and pulmonary edema is relie#edand pulmonary edema is relie#ed

ACE%I ACE%I

S%LVD/,nalaprilS%LVD/,nalapril>2mgRday 71 mo9>2mgRday 71 mo9 >=<N "atients with>=<N "atients with

and ,- 0I=3and ,- 0I=3

$%S,S4S/$%S,S4S/

,nalapril >+=/2mg,nalapril >+=/2mg71?? days9 #s placebo71?? days9 #s placebo

"ts were already"ts were already



and ,- 0I=3and ,- 0I=3 ,arlier stages o !-,arlier stages o !-

e#en asymptomatice#en asymptomatic H!C $lass 88/888H!C $lass 88/888

Cll cause mortality Cll cause mortalitydec by 1<3dec by 1<3

)orality rate rom)orality rate rom!- dec by 1<3!- dec by 1<3

yytaing digo'in andtaing digo'in anddiureticsdiuretics

>=I "atient with>=I "atient withH!C $lass 8V H!C $lass 8V

Dec mortality atDec mortality at < months /23< months /23

1 Hear _ >O31 Hear _ >O3



1eta%eta%

loc3er thera"!%hich toloc3er thera"!%hich to"ic3K"ic3K

5hree beta/blocers 5hree beta/blocers Fisoprolol 7ebeta9 /5rial $8F8S/88Fisoprolol 7ebeta9 /5rial $8F8S/88

)etoprolol 75oprol ;L9 _5rial ),*85/!- 7sustained release9)etoprolol 75oprol ;L9 _5rial ),*85/!- 7sustained release9 $ar#edilol 7$oreg9 5rial/$%",*8$4S$ar#edilol 7$oreg9 5rial/$%",*8$4S

< *$5Ys with M N&222 pts already taing C$,/8 showed a< *$5Ys with M N&222 pts already taing C$,/8 showed ai if d i i l li d dd d h 75i if t d ti i t t l t lit d dd d th 75



signifcant reduction in total mortality and sudden death 75signifcant reduction in total mortality and sudden death 75>& and I= o#er 1/> years9 regardless o se#erity>& and I= o#er 1/> years9 regardless o se#erity

Carvedilol vs. Meto"rolol -C(MET ?GG;Carvedilol vs. Meto"rolol -C(MET ?GG; ;G? "ts) carvedilol ?Jmg id vs. meto"rolol JG;G? "ts) carvedilol ?Jmg id vs. meto"rolol JG mg idmg id "atient with H!C $lasses 88/8V"atient with H!C $lasses 88/8V $ar#edilol _greater reduction in mortality 75& 1? o#er =$ar#edilol _greater reduction in mortality 75& 1? o#er =

years9 and cardio#ascular mortality 75& 1< o#er = years9 years9 and cardio#ascular mortality 75& 1< o#er = years9than metoprolol but hypotension was greater in car#edilol 71than metoprolol but hypotension was greater in car#edilol 71

#s 11 percent9 #s 11 percent9

Aldosterone Antagonists Aldosterone Antagonists

Spironolactone 7Cldactone@Spironolactone 7Cldactone@ *CL,S*CL,S 1NNN91NNN9

"ts 1&<<I $lass 888R8V& C$,& Loop&Dig& ,- 0 I=3"ts 1&<<I $lass 888R8V& C$,& Loop&Dig& ,- 0 I=3 Decreased all cause mortality o I23& 5Z12Decreased all cause mortality o I23& 5Z12

!yperalemia& gynecomastia!yperalemia& gynecomastia



yp & gyyp gy

,plerenone 78nspra@,plerenone 78nspra@ ,"!,S4S >22I,"!,S4S >22I99 "ts <&<> asym LV dysunction& D)& or ater )8"ts <&<> asym LV dysunction& D)& or ater )8

Dec $V mortality o 1I3& 5ZIDec $V mortality o 1I3& 5ZI

ewer more selecti#e inhibitor@ ewer sideewer more selecti#e inhibitor@ ewer side

e(ectse(ects

)ore pts on beta/blocers)ore pts on beta/blocers

'!drala7ine -A"resoline'!drala7ine -A"resoline

and isosoride dinitrateand isosoride dinitrate-Soritrate-Soritrate

!ydralazine!ydralazine

*educes systemic #ascular resistance by*educes systemic #ascular resistance bypreerentially dilating arteriolespreerentially dilating arterioles

8sosorbide Dinitrate8sosorbide Dinitrate

"reerential Venodilator reduces #entricular"reerential Venodilator reduces #entricular



"reerential Venodilator/reduces #entricular"reerential Venodilator/reduces #entricularflling pressure and treat pulmonary congestionflling pressure and treat pulmonary congestion

*educes mortality _ upto >?3*educes mortality _ upto >?3

"oor tolerability/MI23 drop out o study"oor tolerability/MI23 drop out o study

Bushing& headaches& gi upset& less reXuently canBushing& headaches& gi upset& less reXuently can

cause positi#e CC titers and lupus/liecause positi#e CC titers and lupus/liesyndromesyndrome



Digo#inDigo#in

)ay relie#e symptoms& does not)ay relie#e symptoms& does not

reduce mortalityreduce mortality "ts taing digo'in are less liely to"ts taing digo'in are less liely to

b h i li d 7>=3 d i 9b h it li d 7>=3 d ti 9



be hospitalized 7>=3 reduction9be hospitalized 7>=3 reduction9

)ore admissions or suspected)ore admissions or suspecteddigo'in to'icitydigo'in to'icity


)ainstay o symptomatic treatment)ainstay o symptomatic treatment

8mpro#e Buid retention8mpro#e Buid retention 8ncrease e'ercise tolerance8ncrease e'ercise tolerance

( bidi li ( bidi li



o e(ects on morbidity or mortalityo e(ects on morbidity or mortality

Anti"latelet Thera"! and Anti"latelet Thera"! and Anticoagulation Anticoagulation 8ncreased ris o 5hromboembolic8ncreased ris o 5hromboembolic

e#ents& 1+</I+>3 per yeare#ents& 1+</I+>3 per year Cntiplatelet therapy 7aspirin9 in not Cntiplatelet therapy 7aspirin9 in not

l i ti t i i h th l i ti t i i h th



useul in patient in sinus rhythmuseul in patient in sinus rhythm

$oumadin or patient with atrial$oumadin or patient with atrialfbrillation or a pre#iousfbrillation or a pre#ious

thromboembolic e#entthromboembolic e#ent



0on"harmacological0on"harmacologicalManagementManagement Sodium *estriction to >gRdaySodium *estriction to >gRday

*is -actor )anagement*is -actor )anagement ,'ercise,'ercise Decreases mortality 75Z9Decreases mortality 75Z9 Decreases hospitalizations 75Z=9Decreases hospitalizations 75Z=9



Decreases hospitalizations 75Z=9Decreases hospitalizations 75Z=9

)ultidisciplinary& Disease/)anagement Cpproach)ultidisciplinary& Disease/)anagement Cpproach $!C)" _ $ardio#ascular !ospital Ctherosclerosis$!C)" _ $ardio#ascular !ospital Ctherosclerosis

)anagement "rogram)anagement "rogram CSC& beta/blocer& itrates& C$,/8& Statin& ,'ercise& CSC& beta/blocer& itrates& C$,/8& Statin& ,'ercise&

Smoing $essation& Dietary counseling 7use increasedSmoing $essation& Dietary counseling 7use increasedby ?239by ?239

Device Thera"! Device Thera"!

8mplantable $ardio#erter/8mplantable $ardio#erter/

Defbrillators 78$D9Defbrillators 78$D9 $ardiac *esynchronization 5herapy$ardiac *esynchronization 5herapy

7$*597$*59



7$*597$*59

Let Ventricular Cssist De#icesLet Ventricular Cssist De#ices7LVCD97LVCD9

ICDICD

S$D/!e-5 7sudden cardiac death9S$D/!e-5 7sudden cardiac death9

>=>1 patients with depressed LV systolic>=>1 patients with depressed LV systolicunction and $lass 88/888 !-unction and $lass 88/888 !- *andomized to standard therapy #s+*andomized to standard therapy #s+

d d h l 8$D d dt d d th l 8$D t d d



standard therapy plus 8$D #s+ standardstandard therapy plus 8$D #s+ standard

therapy plus amiodaronetherapy plus amiodarone >I3 reduction in mortality with 8$D>I3 reduction in mortality with 8$D o di(erence in mortality with amiodaroneo di(erence in mortality with amiodarone *esults did not #ary based on etiology o LV*esults did not #ary based on etiology o LV

dysunctiondysunction

ICDICD

*ecommended in pts with ,-0I23*ecommended in pts with ,-0I23

and mild to moderate symptoms oand mild to moderate symptoms o!-!-

S i l ith d ti lSur#i#al with good unctional



Sur#i#al with good unctionalSur#i#al with good unctional

capacity is anticipated or M 1 yearcapacity is anticipated or M 1 year

,eft /entricular Assist,eft /entricular AssistDevices -,/ADDevices -,/AD *,)C5$! 5rial/*,)C5$! 5rial/

1 yr sur#i#al =>31 yr sur#i#al =>37LVCD9 #s >3 7r'97LVCD9 #s >3 7r'9 > yr sur#i#al >I3 #s> yr sur#i#al >I3 #s

?3?3



?3 ,nd/Stage 7$lass 8V9,nd/Stage 7$lass 8V9 !- pts ineligible or!- pts ineligible or

transplant due totransplant due to M<=yoM<=yo D) with ,%DD) with ,%D

$*8$*8



Diastolic D!sfunctionDiastolic D!sfunction

Ccute )anagement is the SC), Ccute )anagement is the SC),

$hronic )anagement is$hronic )anagement is$%5*%V,*S8CL$%5*%V,*S8CL Diuretics/dec Buid #olumeDiuretics/dec Buid #olume



$$F/promote let #entricular rela'ation$$F/promote let #entricular rela'ation

C$,/8/promote regression o let #entricular C$,/8/promote regression o let #entricular

hypertrophyhypertrophy

Feta/blocersRantiarrhytmic agents/controlFeta/blocersRantiarrhytmic agents/control

heart rate or maintain atrial contractionheart rate or maintain atrial contraction

Pathophysiology of chronic heart failure6



amani G " et al6 ayo Clin Proc6 =>A>DF#A>4AF

F !1! /a)o +o%ndation for /edi(al *d%(ation and esear(h


Treatment.Treatment.



loc!ing the "##$ and $ympathetic loc!ing the "##$ and $ympathetic

%er&o's system %er&o's system

Flocing se#eral neurohormonal RFlocing se#eral neurohormonal Rcytoine systemscytoine systems

,nhancing compensatory mechanisms in,nhancing compensatory mechanisms in

acute heart ailure F"acute heart ailure@ F"

.irections in $eart 0ailure.irections in $eart 0ailure

TherapyTherapy



acute heart ailure@ F"acute heart ailure@ F"

Flocing metabolic pathwaysFlocing metabolic pathways 5reating concomitant problems5reating concomitant problems De#ices and mechanical supportDe#ices and mechanical support

Surgical reconstructionSurgical reconstruction

"harmacogenomics"harmacogenomics



Does inhibition of BNP degradation (when coupled to ACE

inhibition) with omapatrilat improve survival?

&"ET9E# *CE;NEP -nhiitors&"ET9E# *CE;NEP -nhiitors

in $eart 0ailurein $eart 0ailure% Event Free Survival% Event Free Survival

1.01.0

0.80.8



Packer et al, Circulation 2002

&mapatrilat&mapatrilat

EnalaprilEnalapril

P=0.187P=0.187

0.60.6

0.40.4

0.20.2

0.00.000 33 66 99 1212 1515 1818 2121 2424

MonthsMonths

Etanercept %urvival %tudy (ENE8*+)Etanercept %urvival %tudy (ENE8*+)

EventEvent44free survival Rfree survival R

Primary EndPrimary End--Point (Death or CHF Hospitalization)Point (Death or CHF Hospitalization)

A>>A>>

>>

J>J>

A>>A>>

>>

J>J>



(n=1500)

Mann et al, HFSA 2002

> K A= AJ => =K =J L= LJ K> KK K F=> K A= AJ => =K =J L= LJ K> KK K F= FJ J> JK J O= OJ > K G= GJFJ J> JK J O= OJ > K G= GJ

8eeks8eeks

Place(oPlace(o

EtanerceptEtanercept (i'(i' ti' ti' S A6A> S A6A>

GFR C-# >6GAGFR C-# >6GA44A6LLA6LL

P S >6LLP S >6LL

K>K>

=>=>

>>

K>K>

=>=>

>>

(n=1500)

EN*B+E - --# osentan (ETEN*B+E - --# osentan (ET** ET ET

BB *ntagonist) -*ntagonist) -

n $eart 0ailure (nSA,JAL)n $eart 0ailure (nSA,JAL)

A>>A>>

>>>>

O>O>

J>J>

R of Patients (Event40ree from death;$0 hosp)R of Patients (Event40ree from death;$0 hosp)



Packer et al, ACC Late-Breaking Trials 2002

>K>K J>J> JAFJAF FOLFOL FK=FK= F>=F>= LLLL =L=L A=LA=L AJAJ

>>

>O>O O=LO=L JFFJFF JALJAL FOOFOO FA=FA= LL ==== AALAAL AA

>>

No6 at isk#No6 at isk#

F>F>

K>K>L>L>

=>=>

A>A>

>>

>> ALAL =J=J LL F=F= JFJF OO AA A>KA>K AAOAAO AL>AL>

BosentanBosentan

PlaceoPlaceo+og rank p4value# >6J+og rank p4value# >6J

Weeks fromWeeks from

an!omi"ationan!omi"ation

Flocing the *CCS and SympatheticFlocing the *CCS and Sympathetic

er#ous systemer#ous system


nhancing compensatory mechanisms in nhancing compensatory mechanisms in

ac'te heart fail're* %Pac'te heart fail're* %P


TherapyTherapy



ac'te heart fail're* %P ac'te heart fail're* %P

Flocing metabolic pathwaysFlocing metabolic pathways 5reating concomitant problems5reating concomitant problems De#ices and mechanical supportDe#ices and mechanical support



*trial;ventricular stretch*trial;ventricular stretchreceptors link lood volumereceptors link lood volume

to renal functionto renal function

$ .istension of a alloon catheter in.istension of a alloon catheter inatria of dogs resulted in diuresisatria of dogs resulted in diuresis

The 'eart as a Secretor!The 'eart as a Secretor!(rgan(rgan



<amieson and Palade < Cell Biol AJKD=L#AFA<amieson and Palade < Cell Biol AJKD=L#AFA

" $enry, et al6 (AFJ)$enry, et al6 (AFJ)

$ %ecretory granules discovered in%ecretory granules discovered inthe atriathe atria

" 2isch (AFJ)2isch (AFJ)

" <amieson and Palade (AJK)<amieson and Palade (AJK)

$ de Bold, et al (AA) reportde Bold, et al (AA) reportnatriuresisnatriuresis

in rats after in1ection of atrialin rats after in1ection of atriale/tractse/tracts

$ BNP 'as characteri5ed y aminoBNP 'as characteri5ed y aminoacid seIuence and .N* clonesacid seIuence and .N* clones

" (%udoh, et al6 A and(%udoh, et al6 A and



30

28

26

-1

-4#*

#*

#*#*

#

Mean Observed Value (mmHg) Mean Change (mmHg)30

28

26

24

-1

-4

Mean Observed Value (mmHg) Mean Change (mmHg)

Nesiritide in $eart 0ailure# "*CNesiritide in $eart 0ailure# "*CPP

UU

LL

MM

Pulmonary Capillary Wedge Pressure (absolute and change)Pulmonary Capillary Wedge Pressure (absolute and change)



#oung et al, $AMA 2002

BLBL %&m%&m '0m'0mBLBL%&m%&m'0m'0m

24

22

20

181hr 2hr 3hr 1hr 2hr 3hr

-7

-10

#*

#*

#

# #

#* #*#

PlaceboNitroglycerinNesiritide

# p < .05 versus placebo*p < .05 versus nitroglycerin

24

22

20

181hr 2hr 3hr 1hr 2hr 3hr

-7

-10

# p < .05 versus placebo*p < .05 versus nitroglycerin

Primary End Point: PCWP through 3 HoursPrimary End Point: PCWP through 3 Hours

Heart Fail're Heart Fail're



Prof Univ Dr Ion C.Tintoiu Centrul de Cardiologie al Armatei Universitatea Titu

Maiorescu

Ne' .iuretics4 *denosine eceptorNe' .iuretics4 *denosine eceptor

odulatorsodulators

Adenosine Adenosine11 re(eptor anta&onists =re(eptor anta&onists = ↑↑ afferent arteriole floafferent arteriole flo

2K919 CV=12K919 CV=1

=F>=F>

=>>=>>

e t i o n

e t i o n



Furosemi!eFurosemi!e Place(oPlace(o B)*+%*B)*+%*

AF>AF>

A>>A>>

F>F>

>>

% o d i u m E

/ c r e

% o d i u m E

/ c r e

( m E

I )

( m E

I )

)ottlie( et al, Circulation 2002

Coniva"tan andTolva"tan9Coniva"tan andTolva"tan90e Auaretic Agents0e Auaretic Agents

$ ConivaptanConivaptan 4 an *"P4A and *"P4= receptor4 an *"P4A and *"P4= receptor

lockerD promotes an aIuaresis, correctslockerD promotes an aIuaresis, correctshyponatremia, and has vasodilator activityhyponatremia, and has vasodilator activity(reduces pulmonary capillary 'edge(reduces pulmonary capillary 'edgepressure and raises cardiac output)6pressure and raises cardiac output)6



Francis and Tang, JAMA 2004

p p )p p )$

TolvaptanTolvaptan an *"P4A receptor locker that an *"P4A receptor locker thatcorrects hyponatremia in edematous patientscorrects hyponatremia in edematous patients'ith hyponatremia via an aIuaresis'ith hyponatremia via an aIuaresissurvival study under'ay (E"EE%T)survival study under'ay (E"EE%T)







TherapyTherapy




loc!ing metabolic path+ays loc!ing metabolic path+ays 5reating concomitant problems5reating concomitant problems De#ices and mechanical supportDe#ices and mechanical support



Partial 0atty *cid &/idation (p0&3) -nhiitionPartial 0atty *cid &/idation (p0&3) -nhiition

<nhiit fatt) a(id o0idation onl)<nhiit fatt) a(id o0idation onl)at hi&h fatt) a(id (on(entrationsat hi&h fatt) a(id (on(entrations

ermit normal fatt) a(id o0idation ratesermit normal fatt) a(id o0idation rates

at ph)siolo&i( fatt) a(id (on(entrationsat ph)siolo&i( fatt) a(id (on(entrations reser4e hi&h=ener&) phosphatesreser4e hi&h=ener&) phosphates

and (ontra(tile f%n(tionand (ontra(tile f%n(tion ed%(e a((%m%lation of la(ti(ed%(e a((%m%lation of la(ti(

id d i t i ti -id d i t i ti -

FattyFattyAcidsAcids

GlucoseGlucose

PyruvatePyruvate

pFOXpFOXInhibitionInhibition

LacticLactic

acid (acid ())

HH++ (())

Ranolazine, Trimetazidine, and EtomoxirRanolazine, Trimetazidine, and Etomoxir



a(id and maintains tiss%e p-a(id and maintains tiss%e p-

'ela) or pre4ent onset of'ela) or pre4ent onset ofio(hemi(alM m)o(ardial is(hemiaio(hemi(alM m)o(ardial is(hemia Allo more ener&) to e Allo more ener&) to e prod%(ed fromprod%(ed from

ea(h >ea(h > mole(%le (ons%medmole(%le (ons%med

KrebsKrebs

CycleCycle

Oxidative PhosphorylationOxidative Phosphorylation

Energy ATPEnergy ATP







TherapyTherapy



acute heart ailure@ F"@

Flocing metabolic pathwaysFlocing metabolic pathways Treating concomitant problemsTreating concomitant problems De#ices and mechanical supportDe#ices and mechanical support



*nemia in *mulatory $eart*nemia in *mulatory $eart

0ailure0ailure



Tang et al ACC Presentation 200'

Double blind& randomized& placebo/Double blind& randomized& placebo/

controlled study e#aluating the saetycontrolled study e#aluating the saetyand e(icacy o erythropoietin in theand e(icacy o erythropoietin in the

treatment o patients with hearttreatment o patients with heart

Erythropoietin in $eart 0ailureErythropoietin in $eart 0ailure



ailure and anemiaailure and anemia• Darbepoetin 7Cmgen9Darbepoetin 7Cmgen9 S5C)8C/!e-5/ S5C)8C/!e-5/

e'ercise study@ !8"%$*C5,S /sur#i#ale'ercise study@ !8"%$*C5,S /sur#i#al

studystudy

• $oncerns about$oncerns about ↑↑ thrombosisthrombosis







TherapyTherapy



@@

Flocing metabolic pathwaysFlocing metabolic pathways

5reating concomitant problems5reating concomitant problems De&ices and mechanical s'pport De&ices and mechanical s'pport

$'rgical reconstr'ction$'rgical reconstr'ction


pe ne rug e#e opment n eartpe ne rug e#e opmen n ear-ailure-ailure

some winners and loserssome winners and losersele(ti4e Aldosterone Anta&onistsele(ti4e Aldosterone Anta&onists *plerenone *, *-*G*plerenone *, *-*G

*ndothelin e(eptor Anta&inst *A*ndothelin e(eptor Anta&inst *A 2osentan *AC-=1, *NA2L*=1 S =2osentan *AC-=1, *NA2L*=1 S = esozantan <T=1 to =5esozantan <T=1 to =5

'ar%sentan *A-'ar%sentan *A- *nrasentan *NC>*nrasentan *NC>

Vasopeptidase <nhiitors V<Vasopeptidase <nhiitors V< >mapatrilat >V*G*, >CAV*,>mapatrilat >V*G*, >CAV*,

>*A>*A

hosphodiesterase=3hosphodiesterase=3<nhiitor <nhiitor *no0imone *no0imone EMPO"E,EMPO"E,

ESSEN#I$%, EMO#E ESSEN#I$%, EMO#E

<mm%ne /od%lators<mm%ne /od%lators

*taner(ept *NA<ANC*,*taner(ept *NA<ANC*,*C>V**C>V*

<nfli0ima AAC-<nfli0ima AAC- <mm%ne mod%lator, VA=991<mm%ne mod%lator, VA=991

$CC%$IM $CC%$IM



Natri%reti( eptidesNatri%reti( eptides

Nesiritide *C*'*N, V/AC,Nesiritide *C*'*N, V/AC,FUSION1,2 FUSION1,2

<midazoline=1 e(e(ptor Anta&onist<midazoline=1 e(e(ptor Anta&onist /o0onidine />UC>N, />U*/o0onidine />UC>N, />U*

Cal(i%m ensitizersCal(i%m ensitizers Le4osimendan L<'>, GLAN,Le4osimendan L<'>, GLAN, E!I!E E!I!E

/is(ellaneo%s/is(ellaneo%s AK* (ross=lin reaer, AL= AK* (ross=lin reaer, AL=

11 '<A/>N',11 '<A/>N', S$PP&IE,S$PP&IE,SI%!E SI%!E

Nei4olol Nei4olol SENIOSSENIOS 2i'il 2i'il $'&eF# $'&eF# darepoetin darepoetin S#$MIN$'&eF# S#$MIN$'&eF# ,,

-<>CA*-<>CA*

Slide courte'& o1 ,. 3ra#ci'

0on"harmacologicon" armaco og c

ManagementManagementand 'ealth Careand 'ealth Care

MaintenanceMaintenance

in Patients ithin Patients ith



in Patients ithin Patients ith

Chronic 'eartChronic 'eart

FailureFailure

!-SC >212!-SC >212*ecommendations*ecommendations

'FSA ?G8G Practice'FSA ?G8G Practice

LuidelineLuideline0on"harmacologicBDiet and 0utrition0on"harmacologicBDiet and 0utrition #ecommendation 0.1 #ecommendation 0.1

Dietar! instruction regarding sodiumDietar! instruction regarding sodiuminta3einta3e is recommendedis recommended in allin all

"atients ith 'F."atients ith 'F.

Patients ith 'F and diaetesPatients ith 'F and diaetes



Patients ith 'F and diaetes$Patients ith 'F and diaetes$

d!sli"idemia or severe oesit! shouldd!sli"idemia or severe oesit! shoulde given s"eci&c dietar! instructions.e given s"eci&c dietar! instructions.

Strength of ,%idence - Strength of ,%idence -


LuidelineLuideline0on"harmacologicBDietar! Sodium0on"harmacologicBDietar! Sodium

#ecommendation 0.2 #ecommendation 0.2

Dietar! sodium restriction -?%; gDietar! sodium restriction -?%; gdail!dail! is recommendedis recommended for "atientsfor "atients

ith the clinical s!ndrome of 'F ith the clinical s!ndrome of 'F

d dd d d d ,/EFd d ,/EF



and "reservedand "reserved or or de"ressed ,/EF.de"ressed ,/EF. Further restriction -Y ? g dail!Further restriction -Y ? g dail!

ma! e consideredma! e considered inin

moderate to severe 'F.moderate to severe 'F. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline0on"harmacologicBFluid Inta3e0on"harmacologicBFluid Inta3e

#ecommendation 0. #ecommendation 0.

+estriction of dail! uid inta3e to Y ?+estriction of dail! uid inta3e to Y ?liters9liters9 Is recommendedIs recommended in "atients ithin "atients ith

severe h!"onatremia -serum sodiumsevere h!"onatremia -serum sodium8;G



Y 8;G mE,Y 8;G mE, Should e consideredShould e considered for all "atientsfor all "atients

demonstrating uid retention that isdemonstrating uid retention that isdi5icult to control des"ite high dosesdi5icult to control des"ite high dosesof diuretic and sodium restriction.of diuretic and sodium restriction.


rac cerac ce

LuidelineLuideline0on"harmacologicB0utrition in0on"harmacologicB0utrition in

Advanced 'F Advanced 'F #ecommendation 0.3 #ecommendation 0.3 ItIt is recommendedis recommended that s"eci&c attention ethat s"eci&c attention e

"aid to nutritional management of "atients"aid to nutritional management of "atients ith advanced 'F and unintentional eight ith advanced 'F and unintentional eightloss or muscle asting -cardiac cache#ia.loss or muscle asting -cardiac cache#ia. Measurement of nitrogen alance$ caloricMeasurement of nitrogen alance$ caloric

inta3e and "realumin ma! e useful ininta3e and "realumin ma! e useful in



inta3e$ and "realumin ma! e useful ininta3e$ and "realumin ma! e useful in

determining a""ro"riate nutritionaldetermining a""ro"riate nutritionalsu""lementation.su""lementation. Caloric su""lementationCaloric su""lementation is recommendedis recommended.. Anaolic steroids are Anaolic steroids are not recommendednot recommended forfor

cache#ic "atients.cache#ic "atients.





LuidelineLuideline0on"harmacologicB0utraceuticals0on"harmacologicB0utraceuticals

#ecommendation 0.0 #ecommendation 0.0 Documentation of the t!"e and dose of naturoceuticalDocumentation of the t!"e and dose of naturoceutical

"roducts utili7ed ! "atients ith 'F"roducts utili7ed ! "atients ith 'F

isis

recommendedrecommended.. Strength of ,%idence - CStrength of ,%idence - C 0aturoceutical use is0aturoceutical use is not recommendednot recommended for relief offor relief of

s!m"tomatic 'F or for the secondar! "revention ofs!m"tomatic 'F or for the secondar! "revention ofcardiovascular events.cardiovascular events. Patients should e instructed to avoid usingPatients should e instructed to avoid using



Patients should e instructed to avoid usingPatients should e instructed to avoid usingnatural or s!nthetic "roducts containing e"hedranatural or s!nthetic "roducts containing e"hedra-ma huang$ e"hedrine or its metaolites ecause-ma huang$ e"hedrine or its metaolites ecauseof an increased ris3 of mortalit! and moridit!.of an increased ris3 of mortalit! and moridit!.

Products should e avoided that ma! haveProducts should e avoided that ma! havesigni&cant drug interactions ith digo#in$signi&cant drug interactions ith digo#in$ vasodilators$ eta loc3ers$ antiarrh!thmic drugs vasodilators$ eta loc3ers$ antiarrh!thmic drugsand anticoagulants.and anticoagulants. Strength ofStrength of



LuidelineLuideline0on"harmacologicBCPAP0on"harmacologicBCPAP


Continuous "ositive aira!Continuous "ositive aira!"ressure to im"rove dail!"ressure to im"rove dail!

functional ca"acit! and ualit! offunctional ca"acit! and ualit! of



lifelife is recommendedis recommended in "atientsin "atients ith 'F and ostructive slee" ith 'F and ostructive slee"

a"nea documented ! a""roveda"nea documented ! a""roved

methods of "ol!somnogra"h!.methods of "ol!somnogra"h!. Strength of ,%idence - Strength of ,%idence -


LuidelineLuideline0on"harmacologicB(#!gen0on"harmacologicB(#!gen


Su""lemental o#!gen$ either at nightSu""lemental o#!gen$ either at nightor during e#ertion$ isor during e#ertion$ is notnotrecommendedrecommended for "atients ith 'F infor "atients ith 'F inthe asence of an indication due tothe asence of an indication due tounderl!ing "ulmonar! disease.underl!ing "ulmonar! disease.



underl!ing "ulmonar! disease.underl!ing "ulmonar! disease.

Patients ith resting h!"o#emia orPatients ith resting h!"o#emia oro#!gen desaturation during e#erciseo#!gen desaturation during e#erciseshould e evaluated for residual uidshould e evaluated for residual uidoverload or concomitant "ulmonar!overload or concomitant "ulmonar!disease.disease.



LuidelineLuideline0on"harmacologicBInsomnia0on"harmacologicBInsomnia


The identi&cation of treataleThe identi&cation of treataleconditions$ such as slee"%disorderedconditions$ such as slee"%disordered

reathing$ urologic anormalities$reathing$ urologic anormalities$

restless leg s!ndrome and de"ressionrestless leg s!ndrome and de"ression



should e consideredshould e considered in "atients ithin "atients ith'F and chronic insomnia.'F and chronic insomnia. Pharmacologic aids to slee" induction ma!Pharmacologic aids to slee" induction ma!

e necessar!.e necessar!. Agents that do not ris3 "h!sical de"endence Agents that do not ris3 "h!sical de"endence

are "referred.are "referred. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline0on"harmacologicBDe"ression0on"harmacologicBDe"ression


ItIt is recommendedis recommended that screening forthat screening for

endogenous or "rolonged reactiveendogenous or "rolonged reactivede"ression in "atients ith 'F e conductedde"ression in "atients ith 'F e conductedfolloing diagnosis and at "eriodic intervalsfolloing diagnosis and at "eriodic intervalsas clinicall! indicated.as clinicall! indicated.



For "harmacologic treatment$ selectiveFor "harmacologic treatment$ selectiveserotonin rece"tor u"ta3e inhiitors -SS+Isserotonin rece"tor u"ta3e inhiitors -SS+Isare "referred over tric!clic antide"ressants$are "referred over tric!clic antide"ressants$ecause the latter have the "otential toecause the latter have the "otential tocause ventricular arrh!thmias$ ut thecause ventricular arrh!thmias$ ut the

"otential for drug interactions should e"otential for drug interactions should econsidered.considered. Strength of ,%idence - Strength of ,%idence -


LuidelineLuideline0on"harmacologicBStress0on"harmacologicBStress

#ecommendation 0.11 #ecommendation 0.11 0on"harmacologic techniues0on"harmacologic techniues

for stress reductionfor stress reduction ma! ema! e



!!

consideredconsidered as a useful ad:unctas a useful ad:unctfor reducing an#iet! in "atientsfor reducing an#iet! in "atients

ith 'F. ith 'F.



LuidelineLuideline0on"harmacologicBSe#ual D!sfunction0on"harmacologicBSe#ual D!sfunction


ItIt is recommendedis recommended that treatmentthat treatmento"tions for se#ual d!sfunction eo"tions for se#ual d!sfunction ediscussed o"enl! ith oth male anddiscussed o"enl! ith oth male andfemale "atients ith 'F.female "atients ith 'F.

The use of "hos"hodiasterase%J -PDEJThe use of "hos"hodiasterase%J -PDEJ



The use of "hos"hodiasterase J -PDEJThe use of "hos"hodiasterase J -PDEJ

inhiitors such as sildena&linhiitors such as sildena&l ma! ema! econsideredconsidered for use for se#ual d!sfunctionfor use for se#ual d!sfunctionin "atients ith chronic stale 'F.in "atients ith chronic stale 'F. These agents areThese agents are not recommendednot recommended inin

"atients ta3ing nitrate "re"arations."atients ta3ing nitrate "re"arations. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline0on"harmacologicBSmo3ing Alcohol0on"harmacologicBSmo3ing Alcohol


ItIt is recommendedis recommended that "atients ith 'Fthat "atients ith 'Fe advised to sto" smo3ing and to limite advised to sto" smo3ing and to limitalcohol consum"tion to V ? standardalcohol consum"tion to V ? standarddrin3s "er da! in men or V 8 standarddrin3s "er da! in men or V 8 standarddrin3 "er da! in omen.drin3 "er da! in omen.



" !!

Patients sus"ected of having an alcohol%Patients sus"ected of having an alcohol%induced cardiom!o"ath! should e advisedinduced cardiom!o"ath! should e advisedto astain from alcohol consum"tion.to astain from alcohol consum"tion.

Patients sus"ected of using illicit drugsPatients sus"ected of using illicit drugsshould e counseled to discontinue suchshould e counseled to discontinue suchuse.use. Strength of ,%idenceStrength of ,%idence

- -

Diagnosis of heart failureDiagnosis of heart failure ,$: 1> leads,$: 1> leads

$hest ;/ray$hest ;/ray Lab tests 7hyponatraemiaG9Lab tests 7hyponatraemiaG9

Fiomarers o !-Fiomarers o !- 10P$ "ro10P$10P$ "ro10P$

Phisical e#amination



Fiomarers o !-Fiomarers o !- 10P$ "ro10P$10P$ "ro10P$

C+P$ tro"oninsC+P$ tro"onins ,chocardiography 7systolicRdiastolic,chocardiography 7systolicRdiastolic

dysunction& structural heart disease9dysunction& structural heart disease9

spiroergometryspiroergometry


LuidelineLuideline0on"harmacologicB/accinations0on"harmacologicB/accinations


Pneumococcal vaccine and annualPneumococcal vaccine and annual

inuen7a vaccinationinuen7a vaccination areare

recommendedrecommended in all "atients ithin all "atients ith



"

'F in the asence of 3non'F in the asence of 3noncontraindications.contraindications. Strength of ,%idence - Strength of ,%idence -

rac cerac ce

LuidelineLuideline0on"harmacologicBEndocarditis0on"harmacologicBEndocarditis

Pro"h!la#isPro"h!la#is #ecommendation 0.14 #ecommendation 0.14 Endocarditis "ro"h!la#isEndocarditis "ro"h!la#is is not recommendedis not recommended ased onased on

the diagnosis of 'F alone. Consistent ith the A'Athe diagnosis of 'F alone. Consistent ith the A'Arecommendation$ Z"ro"h!la#is should e given for onl!recommendation$ Z"ro"h!la#is should e given for onl!s"eci&c cardiac conditions$ associated ith the highests"eci&c cardiac conditions$ associated ith the highestris3 of adverse outcome from endocarditis9’ris3 of adverse outcome from endocarditis9’

ZZ"rosthetic cardiac valves"rosthetic cardiac valves "revious infective endocarditis"revious infective endocarditis congenital heart disease -C'D’ such as Zunre"aired c!anoticcongenital heart disease -C'D’ such as9 Zunre"aired c!anotic



congenital heart disease -C'D’ such as9 Zunre"aired c!anoticcongenital heart disease -C'D’ such as9 Zunre"aired c!anotic

C'D$ including "alliative shunts and conduitsC'D$ including "alliative shunts and conduits com"letel! re"aired congenital heart defect ith "rostheticcom"letel! re"aired congenital heart defect ith "rostheticmaterial or device$ hether "laced ! surger! or ! cathetermaterial or device$ hether "laced ! surger! or ! catheterintervention$ during the &rst si# months after the "rocedureintervention$ during the &rst si# months after the "rocedure

re"aired C'D ith residual defects at the site or ad:acent tore"aired C'D ith residual defects at the site or ad:acent tothe site of a "rosthetic "atch or "rosthetic device -hichthe site of a "rosthetic "atch or "rosthetic device -hichinhiit endotheliali7ationinhiit endotheliali7ation

cardiac trans"lantation reci"ients ho develo" cardiaccardiac trans"lantation reci"ients ho develo" cardiac

valvulo"ath!.’ valvulo"ath!.’



LuidelineLuideline0on"harmacologicB0SAIDs0on"harmacologicB0SAIDs


0SAIDs$ including C(%?0SAIDs$ including C(%?inhiitors$ areinhiitors$ are not recommendednot recommended in "atients ith chronic 'F.in "atients ith chronic 'F.



The ris3 of renal failure and uidThe ris3 of renal failure and uidretention is mar3edl! increased inretention is mar3edl! increased in

the setting of reduced renal functionthe setting of reduced renal function

or ACE inhiitor thera"!.or ACE inhiitor thera"!. Strength of ,%idence - Strength of ,%idence -


LuidelineLuideline0on"harmacologicBEm"lo!ailit! 0on"harmacologicBEm"lo!ailit!


ItIt is recommendedis recommended that "atients iththat "atients ith

ne or recent%onset 'F e assessed forne or recent%onset 'F e assessed for

em"lo!ailit! folloing a reasonaleem"lo!ailit! folloing a reasonale

i d f li i l t ili ti"eriod of clinical staili7ation



"eriod of clinical staili7ation."eriod of clinical staili7ation. An o:ective assessment of functional An o:ective assessment of functional

e#ercise ca"acit! is useful in thise#ercise ca"acit! is useful in this

determination.determination. Strength ofStrength of



LuidelineLuideline0on"harmacologicBEm"lo!ailit! 0on"harmacologicBEm"lo!ailit!


ItIt is recommendedis recommended that "atients ith chronicthat "atients ith chronic'F ho currentl! are em"lo!ed and hose :o'F ho currentl! are em"lo!ed and hose :odescri"tion is com"atile ith theirdescri"tion is com"atile ith their"rescried activit! level e encouraged to"rescried activit! level e encouraged toremain em"lo!ed$ even if a tem"orar!remain em"lo!ed$ even if a tem"orar!



remain em"lo!ed$ even if a tem"orar!e a e " o!ed$ e e a te "o a !

reduction in hours or3ed or tas3 "erformedreduction in hours or3ed or tas3 "erformedis reuired.is reuired. +etraining+etraining should e consideredshould e considered andand

su""orted for "atients ith a :o demanding asu""orted for "atients ith a :o demanding alevel of "h!sical e#ertion e#ceedinglevel of "h!sical e#ertion e#ceeding

recommended levels.recommended levels. Strength ofStrength of ,%idence - ,%idence -


LuidelineLuideline0on"harmacologicBE#ercise Training0on"harmacologicBE#ercise Training #ecommendation 0.17 #ecommendation 0.17 (9, in 2818&(9, in 2818&

It is recommendedIt is recommended that "atients ith 'Fthat "atients ith 'Fundergo e#ercise testing to determine suitailit!undergo e#ercise testing to determine suitailit!for e#ercise training -"atient does not develo"for e#ercise training -"atient does not develo"signi&cant ischemia or arrh!thmias. If deemedsigni&cant ischemia or arrh!thmias. If deemedsafe$ e#ercise training should e considered forsafe$ e#ercise training should e considered for"atients ith 'F in order to9"atients ith 'F in order to9

Facilitate understanding of e#erciseFacilitate understanding of e#erciset ti -h t t d i te#"ectations -heart rate ranges and a""ro"riate



e#"ectations -heart rate ranges and a""ro"riatee#"ectations -heart rate ranges and a""ro"riate

levels of e#ercise traininglevels of e#ercise training Increase e#ercise duration and intensit! in aIncrease e#ercise duration and intensit! in a

su"ervised settingsu"ervised setting Promote adherence to a general e#ercise goal ofPromote adherence to a general e#ercise goal of

;G minutes of moderate activit!e#ercise$ J da!s;G minutes of moderate activit!e#ercise$ J da!s"er ee3 ith arm u" and cool don e#ercises"er ee3 ith arm u" and cool don e#ercises

Strength of Evidence = !

Drill of theDrill of theMonthMonthDe#eloped by )ichael LindsayDe#eloped by )ichael Lindsay

n Overview of Ventricular



n Overview of Ventricular

ssist Devicesssist Devices

&

Pre Hospital Management

re Hospital Management

Student (:ectivesStudent (:ectivesAt the conclusion of this rillAt the conclusion of this rillStudents /ill be able to:Students /ill be able to: Defne !eart -ailureDefne !eart -ailure

Defne Ventricular Cssist De#ice 7VCD9 and their use inDefne Ventricular Cssist De#ice 7VCD9 and their use intreating !eart -ailuretreating !eart -ailure

8dentiy types o Ventricular Cssist De#ices8dentiy types o Ventricular Cssist De#ices

,'plain the di(erence between "ulsatile and,'plain the di(erence between "ulsatile and



pp

onpulsatile Bowonpulsatile Bow 8dentiy hemodynamic di(erences in patients with a VCD8dentiy hemodynamic di(erences in patients with a VCD

List VCD related complicationsList VCD related complications

Demonstrate how to assess a patient with a VCDDemonstrate how to assess a patient with a VCD

Describe how to treat VCD complicationsDescribe how to treat VCD complications 8dentiy VCD resources that can be utilized when caring8dentiy VCD resources that can be utilized when caring

or these patients+or these patients+

'eart Failure'eart FailurePP !eart ailure is a condition where the heart!eart ailure is a condition where the heart

cannot pump enough blood throughout the body+cannot pump enough blood throughout the body+

PP 8t de#elops o#er time as the pumping action o8t de#elops o#er time as the pumping action o

the heart grows weaer+the heart grows weaer+PP )ost cases in#ol#e the let side where the heart)ost cases in#ol#e the let side where the heart

cannot pump enough o'ygen/rich blood to thecannot pump enough o'ygen/rich blood to the

rest o the body+rest o the body+



PP Eith right sided ailure& the heart cannotEith right sided ailure& the heart cannote(ecti#ely pump blood to the lungs where thee(ecti#ely pump blood to the lungs where the

blood pics up o'ygen+blood pics up o'ygen+

/entricular Assist Device /entricular Assist Device

-/AD-/AD C mechanical pump that is surgically attached C mechanical pump that is surgically attached

to one o the heartYs #entricles to augment orto one o the heartYs #entricles to augment or

replace nati#e #entricular unctionreplace nati#e #entricular unction

$an be used or the let 7L VCD9& right 7* VCD9&$an be used or the let 7L VCD9& right 7* VCD9&

or both #entricles 7Fi VCD9or both #entricles 7Fi VCD9

Cre powered by e'ternal power sources that Cre powered by e'ternal power sources that



p y pp y p

connect to the implanted pump #ia aconnect to the implanted pump #ia apercutaneous lead 7dri#eline9 that e'its thepercutaneous lead 7dri#eline9 that e'its the

body on the right abdomenbody on the right abdomen

"ump output Bow can be pulsatile or"ump output Bow can be pulsatile or

nonpulsatilenonpulsatile

8hy .o 8e Need "*.sU8hy .o 8e Need "*.sU

!eart disease is the leading cause o death in!eart disease is the leading cause o death in

the Eestern worldthe Eestern world

= million people in the 4S ha#e congesti#e= million people in the 4S ha#e congesti#e

heart ailure 7$!-9heart ailure 7$!-9

>=2&222 are in the most ad#anced stage o>=2&222 are in the most ad#anced stage o



$!-$!- =22&222 new cases each year=22&222 new cases each year

=2&222 deaths each year=2&222 deaths each year

only e(ecti#e treatment or end stage $!- isonly e(ecti#e treatment or end stage $!- is


8hy .o 8e Need "*.sU8hy .o 8e Need "*.sU

Fut& in >22?Fut& in >22?

OI1? people were waiting or a heartOI1? people were waiting or a heart

>>12 recei#ed one>>12 recei#ed one

<>I died waiting<>I died waiting



<>I died waiting<>I died waiting

1>22/1=22 VCD implanted in >22?1>22/1=22 VCD implanted in >22?

-ndications for "*.-ndications for "*.

Fridge to transplantFridge to transplant

7F5597F559

most commonmost common

allow rehab romallow rehab romse#ere $!- whilese#ere $!- while

awaiting donorawaiting donor

]]Destination^ therapy 7D59Destination^ therapy 7D59

permanent de#ice&permanent de#ice&

instead o transplantinstead o transplant

currently only incurrently only intransplant/ineligibletransplant/ineligible

patientspatients

Fridge to candidacyFridge to candidacy

7F5$9R7F5$9R



Fridge to reco#eryFridge to reco#ery7F5*97F5*9

unload heart& allowunload heart& allow

]re#erse remodeling^]re#erse remodeling^

can be short/ or long/can be short/ or long/termterm

7F5$9R7F5$9R

Fridge to decision 7F5D9Fridge to decision 7F5D9 when eligibility unclearwhen eligibility unclear

at implantat implant

not true ]indication^not true ]indication^

but true or many ptsbut true or many pts

T!"es of /ADsT!"es of /ADs

"ulsatile"ulsatile



andand

on "ulsatileon "ulsatile

PulsatilePulsatile Ventricle/lie pumping sac de#ice+ Ventricle/lie pumping sac de#ice+

Flood enters #ia the inBow cannula and flls a Be'ibleFlood enters #ia the inBow cannula and flls a Be'ible

pumping chamber+pumping chamber+

,lectric motor or pneumatic 7air9 pressure collapses,lectric motor or pneumatic 7air9 pressure collapsesthe chamber and orces blood into systemicthe chamber and orces blood into systemic

circulation #ia the outBow cannula+circulation #ia the outBow cannula+



$an be LVCD& *VCD& or FiVCD$an be LVCD& *VCD& or FiVCD

-irst/generation de#ices 7in use since early 1N?2s9-irst/generation de#ices 7in use since early 1N?2s9

"atients will ha#e a palpable pulse and a measurable"atients will ha#e a palpable pulse and a measurable

blood pressure+ Foth are generated rom the VCDblood pressure+ Foth are generated rom the VCD

output Bow+output Bow+

Pulsatile /AD 6e!Pulsatile /AD 6e!

ParametersParameters "ump *ate"ump *ate

!ow ast the VCD is pumping 7flling .!ow ast the VCD is pumping 7flling .emptying9emptying9

$an be set at a f'ed rate or can automatically$an be set at a f'ed rate or can automaticallyad6ustad6ust

"ulsatile VCDs are loud and the rate can be"ulsatile VCDs are loud and the rate can be



assessed by listeningassessed by listening

%utput%utput 5he amount o blood e6ected rom the VCD5he amount o blood e6ected rom the VCD

)easured is liters per minute)easured is liters per minute 8s dependent upon preload& aterload& and8s dependent upon preload& aterload& and

pump ratepump rate

0on%Pulsatile0on%Pulsatile $ontinuous/Bow de#ices$ontinuous/Bow de#ices

8mpeller 7spinning turbine/lie rotor blade9 propels blood8mpeller 7spinning turbine/lie rotor blade9 propels bloodcontinuousl! continuousl

! orward into systemic circulation+orward into systemic circulation+ C'ial Bow blood lea#es impeller blades in the same direction as C'ial Bow blood lea#es impeller blades in the same direction as

it enters 7thin an or boat motor propeller9+it enters 7thin an or boat motor propeller9+

)ost implanted de#ices are LVCDs only)ost implanted de#ices are LVCDs only

Cre Xuite and cannot be heard outside o the patientYs body+ Cre Xuite and cannot be heard outside o the patientYs body+ Cssess VCD status by auscultation o#er the ape' o the LV+ 5he Cssess VCD status by auscultation o#er the ape' o the LV+ 5heVCD should ha#e a continuous& smooth humming sound+VCD should ha#e a continuous& smooth humming sound+



VCD should ha#e a continuous& smooth humming sound+ VCD should ha#e a continuous& smooth humming sound+

5he "atient may ha#e a wea& irregular& or non/palpable pulse5he "atient may ha#e a wea& irregular& or non/palpable pulse

5he "atient may ha#e a narrow pulse pressure and may not be5he "atient may ha#e a narrow pulse pressure and may not bemeasurable with automated blood pressure monitors+ 5his is duemeasurable with automated blood pressure monitors+ 5his is due

to the continuous orward outBow rom the VCD+to the continuous orward outBow rom the VCD+

5he )ean Crterial "ressure is the ey in monitoring5he )ean Crterial "ressure is the ey in monitoringhemodynamics+ 8deal range is <=/N2 mm!g+hemodynamics+ 8deal range is <=/N2 mm!g+



0on Pulsatile /AD 6e!0on Pulsatile /AD 6e!

ParametersParameters "ower"ower

5he amount o power the VCD consumes to5he amount o power the VCD consumes tocontinually run at a set speedcontinually run at a set speed

Sudden or gradual sustained increases in theSudden or gradual sustained increases in thepower can indicate thrombus inside the VCDpower can indicate thrombus inside the VCD



"ulsatility 8nde' 7"89"ulsatility 8nde' 7"89 C measure o the pressure di(erential inside C measure o the pressure di(erential inside

the internal VCD pump during the nati#ethe internal VCD pump during the nati#eheartYs cardiac cycleheartYs cardiac cycle

Varies by patient Varies by patient 8ndicates #olume status& right #entricle8ndicates #olume status& right #entricle

unction& and nati#e heart contractilityunction& and nati#e heart contractility

0on Pulsatile /AD 6e!0on Pulsatile /AD 6e!

ParametersParameters 5he de#ice parameters are displayed5he de#ice parameters are displayed

numerically on the VCD console or $ontrollernumerically on the VCD console or $ontroller

Eill #ary with each indi#idual patient and VCDEill #ary with each indi#idual patient and VCD

de#icede#ice



Basic "*. anagementBasic "*. anagement

CLL VCDs are CLL VCDs are "reload/dependent"reload/dependent

,W:/independent,W:/independent

Cterload/sensiti#e Cterload/sensiti#e Cnticoagulated Cnticoagulated

"rone to"rone to



inectioninectionbleedingbleeding

thrombosisRstroethrombosisRstroe

mechanical malunctionmechanical malunction Wey di(erences depend on pulsatile #s+ non/Wey di(erences depend on pulsatile #s+ non/

pulsatile de#icepulsatile de#ice

"*.s commonly seen in the"*.s commonly seen in the

communitycommunity



Thoratec "*. (p"*.;i"*.)Thoratec "*. (p"*.;i"*.)

"neumatic& e'ternal7pVCD9 or internal 7iVCD9&"neumatic& e'ternal7pVCD9 or internal 7iVCD9&"ulsatile

"ulsatile pump7s9pump7s9

right/& let/& or bi/#entricular supportright/& let/& or bi/#entricular support

7*VCDRLVCDRFiVCD97*VCDRLVCDRFiVCD9

up to O+> lpm Bowup to O+> lpm Bow

Short/ to medium/term use 7up to 1/> years9Short/ to medium/term use 7up to 1/> years9

bridge to reco#erybridge to reco#ery



bridge to reco#erybridge to reco#ery

bridge to transplantbridge to transplant

hospital discharge possiblehospital discharge possible

iVA'pVA'




$eartate 3"E +"*%$eartate 3"E +"*%

8nternally implanted& electric8nternally implanted& electric "ulsatile

"ulsatile pumppump let heart support onlylet heart support only

up to 12 lpm Bowup to 12 lpm Bow

)edium/ to long/term therapy 7months to)edium/ to long/term therapy 7months to years9 years9


destination therapy 7only -DC/appro#ed D5



destination therapy 7only -DC/appro#ed D5destination therapy 7only -DC appro#ed D5

de#ice9de#ice9

$eartate -- +"*%$eartate -- +"*%

8nternally implanted& a'ial/Bow 78nternally implanted& a'ial/Bow 7

non%"ulsatilenon%

"ulsatile9 de#ice9 de#ice

let heart support onlylet heart support only

speed ?222/1=222 rpmspeed ?222/1=222 rpm

Bow I/? lpmBow I/? lpm

)edium/ to long/term therapy 7months to years9)edium/ to long/term therapy 7months to years9

bridge to transplant 7-DC/appro#ed9bridge to transplant 7-DC/appro#ed9

destination therapy 7in#estigational9destination therapy 7in#estigational9



<arvik =>>> +"*.<arvik =>>> +"*. C'ial/Bow 7 C'ial/Bow 7non%"ulsatilenon%

"ulsatile99

pumppump

electric& intra/electric& intra/

#entricular #entricular

let heart support onlylet heart support only



Speed ?222/1>222 rpmSpeed ?222/1>222 rpm Bow I/= lpmBow I/= lpm )edium/ to long/term therapy)edium/ to long/term therapy

7months to years97months to years9


7in#estigational97in#estigational9

<arvik =>>> +"*.<arvik =>>> +"*.



VCD 8ssues VCD 8ssues



Prolems;ComplicationsProlems;Complications )a6or VCD $omplications)a6or VCD $omplications

FleedingFleeding

5hrombosis5hrombosis

8nection8nection sepsis is leading cause o death in long/term VCDsepsis is leading cause o death in long/term VCD

supportsupport



*V dysunctionRailure*V dysunctionRailure

Sucdown 7low preload causes a nonpulsatle VCD toSucdown 7low preload causes a nonpulsatle VCD to

collapse the #entricle9collapse the #entricle9

De#ice ailureRmalunction 7highly #ariable by de#iceDe#ice ailureRmalunction 7highly #ariable by de#ice

type9type9

Prolems;ComplicationsProlems;Complications %ther $ommon 8ssues%ther $ommon 8ssues

Crrhythmias Crrhythmias

C patient can be in a lethal arrhythmia and be C patient can be in a lethal arrhythmia and be

asymptomatic+ 5reat the patient not the monitor+asymptomatic+ 5reat the patient not the monitor+ Do not cardio#ertR defb+ unless the patient isDo not cardio#ertR defb+ unless the patient is

unstable with the arrhythmia+unstable with the arrhythmia+



Do not initiate chest compressions unlessDo not initiate chest compressions unlessinstructed by a physician or VCD coordinator+instructed by a physician or VCD coordinator+

$hest compressions can disrupt the implanted$hest compressions can disrupt the implanted

eXuipment causing bleeding and deatheXuipment causing bleeding and death

,lectrical shoc rom cardio#ertR defb+ will not,lectrical shoc rom cardio#ertR defb+ will not

damage any o the VCD eXuipmentdamage any o the VCD eXuipment


!ypertension!ypertension

!igh aterload can limit VCD BowR output!igh aterload can limit VCD BowR output

Do not administer antihypertensi#e medicationsDo not administer antihypertensi#e medications

or nitrates unless instructed by a physician oror nitrates unless instructed by a physician or

VCD $oordinator VCD $oordinator



!ypotensionR loss o "reload!ypotensionR loss o "reload Cll VCDs are preload dependent+ C loss or Cll VCDs are preload dependent+ C loss or

reduction in preload will compromise VCDreduction in preload will compromise VCD

unction and limit BowR outputunction and limit BowR output


DepressionR Cd6ustment DisordersDepressionR Cd6ustment Disorders

Li#ing with a VCD is di(icult to management or aLi#ing with a VCD is di(icult to management or a

lot o patients+lot o patients+ C large percentage o patients e'perience C large percentage o patients e'perience

symptoms o depressionsymptoms o depression



"ortabilityR ,rgonomics"ortabilityR ,rgonomics 5he e'ternal VCD eXuipment is hea#y and5he e'ternal VCD eXuipment is hea#y and

cumbersome limiting a patientYs mobility andcumbersome limiting a patientYs mobility and

greatly impacting their Xuality o lie+greatly impacting their Xuality o lie+

Prolems;ComplicationsProlems;Complications

Fleeding . 5hrombosisFleeding . 5hrombosis

$areul control o anticoagulation is$areul control o anticoagulation is

imperati#eimperati#e"atients are oten on both anticoagulants"atients are oten on both anticoagulants

and platelet inhibitorsand platelet inhibitors

De#ice thrombosisDe#ice thrombosis



rare in pulsatile de#icesrare in pulsatile de#ices

typically re#ealed by increased power andtypically re#ealed by increased power and

signs and symptoms o hemolysissigns and symptoms o hemolysis

Alarms Alarms Cll VCD de#ices typically ha#e two Cll VCD de#ices typically ha#e two

distingue alarms to indicate adistingue alarms to indicate aproblem and itYs se#erityproblem and itYs se#erity Cd#isory Clarms Cd#isory Clarms

$riticalR !azardous Clarms



$riticalR !azardous ClarmsR

Alarms Alarms Cd#isory Clarms are intermittent Cd#isory Clarms are intermittent

beeping sounds that ha#e abeeping sounds that ha#e acorrespondingcorresponding H,LL%E H,LL%E light thatlight that

illuminates on the system controllerilluminates on the system controller ot critical but the de#ice reXuiresot critical but the de#ice reXuires



XX

attentionattention

Liely due to low battery& cableLiely due to low battery& cable

disconnected& or de#ice not unctioningdisconnected& or de#ice not unctioning

properly+properly+

Alarms Alarms !azardous!azardous oror $ritical$ritical alarms are a loud&alarms are a loud&

continuous& shrill sound that ha#e acontinuous& shrill sound that ha#e a

correspondingcorresponding *,D*,D light that illuminateslight that illuminateson the system controlleron the system controller 8ndicating the de#ice needs immediate8ndicating the de#ice needs immediate

attentionattention



%ten because the pump has stopped or a%ten because the pump has stopped or a

problem is detected with the systemproblem is detected with the system

controllercontroller

)ost liely inter#ention reXuired is to)ost liely inter#ention reXuired is tochange out the system controllerchange out the system controller

Field ManagementField Management Cll VCDs are dependant on adeXuate Cll VCDs are dependant on adeXuate

preload in order to maintain properpreload in order to maintain properunctioningunctioning

Volume resuscitation in an unstable Volume resuscitation in an unstable VCD patient is the frst line o



VCD patient is the frst line op

therapy beore #asopressors but betherapy beore #asopressors but be

cautious with Buid as to not o#er loadcautious with Buid as to not o#er load

the right #entricle in L VCDs only+the right #entricle in L VCDs only+

Field ManagementField Management itrates can be detrimental to a VCDitrates can be detrimental to a VCD

patient because o the reduction inpatient because o the reduction inpreloadpreload *esults in decreased pump e(iciency*esults in decreased pump e(iciency

$onsult with medical control beore$onsult with medical control beore



administering nitrates per protocoladministering nitrates per protocol

Field ManagementField Management 8nitiate 8V therapy with all VCD8nitiate 8V therapy with all VCD

patients i possiblepatients i possible 4se aseptic techniXue due to the4se aseptic techniXue due to the

patientYs increased riss o inectionpatientYs increased riss o inection



Field ManagementField Management VCD patients are susceptible to VCD patients are susceptible to

other in6uries unrelated to the VCDother in6uries unrelated to the VCD $ontact the VCD $oordinator& they$ontact the VCD $oordinator& they

are your most #aluable resourceare your most #aluable resource



when encountering these patientswhen encountering these patients $onsult with medical control about$onsult with medical control about

transporttransport

A$ 1$ C$ D$ Es of A$ 1$ C$ D$ Es of

thethe

Management ofManagement ofanette Wass Eenger& )Danette Wass Eenger& )D



'eart Failure'eart FailureEmor! Universit! School ofEmor! Universit! School of

MedicineMedicine

Lrad! Memorial 'os"italLrad! Memorial 'os"ital

Atlanta$ Leorgia Atlanta$ Leorgia

(:ectives(:ectivesUnderstand the cornerstones ofUnderstand the cornerstones of

thera"! thera"! angiotensin%converting en7!meangiotensin%converting en7!me

inhiitors$ diuretics$ and digitalisinhiitors$ diuretics$ and digitalis



revie the role of other thera"ies9revie the role of other thera"ies9"harmacothera"eutic as ell as"harmacothera"eutic as ell as

non"harmacothera"euticnon"harmacothera"eutic

a""roachesa""roaches

E"idemiolog! E"idemiolog!

H.= million "atients in the UnitedH.= million "atients in the United

States are estimated to have heartStates are estimated to have heartfailurefailure

H=G$GGG ne cases recogni7ed annuall! H=G$GGG ne cases recogni7ed annuall!

Each !ear$ @=J$GGG hos"itali7edEach !ear$ @=J$GGG hos"itali7ed



"atients have a "rimar! diagnosis of"atients have a "rimar! diagnosis ofheart failure. It is the ma:or hos"italheart failure. It is the ma:or hos"ital

discharge diagnosis for "atients in thedischarge diagnosis for "atients in the

Medicare age grou".Medicare age grou".

E"idemiolog! E"idemiolog! heart failure increases ith ageheart failure increases ith age

half of all heart failurehalf of all heart failurehos"itali7ations occur inhos"itali7ations occur in

individuals \ age >J !ears.individuals \ age >J !ears.



In the United States$ the estimatedIn the United States$ the estimatedcosts for the management ofcosts for the management of

"atients ith heart failure e#ceed"atients ith heart failure e#ceed

]8G illion annuall!.]8G illion annuall!.

Treatment o:ectivesTreatment o:ectives Decrease s!m"tomsDecrease s!m"toms

Im"rove e#ercise ca"acit! Im"rove e#ercise ca"acit! Enhance ualit! of lifeEnhance ualit! of life

Decrease moridit! Decrease moridit!



+etard the "rogression of heart+etard the "rogression of heartfailurefailure

Im"rove survivalIm"rove survival

Cornerstones of Thera"! Cornerstones of Thera"! Angiotensin converting en7!me Angiotensin converting en7!me

-ACE inhiitors-ACE inhiitors diureticsdiuretics

digitalisdigitalis

id li f h i did li f h i d



guidelines for the severit!%asedguidelines for the severit!%asedthera"! of heart failure.thera"! of heart failure.

As!m"tomatic Patients As!m"tomatic PatientsFor as!m"tomatic "atients ithFor as!m"tomatic "atients ith

left ventricular d!sfunctionleft ventricular d!sfunction-0'A class I$ t!"icall! those-0'A class I$ t!"icall! those

ith an e:ection fraction elo ith an e:ection fraction elo

HG<$HG<$



ACE inhiitors are ACE inhiitors are

recommendedrecommended

S!m"tomatic PatientsS!m"tomatic Patients 0'A class II0'A class II

ACE inhiitors$ mild diuretics$ and ACE inhiitors$ mild diuretics$ anddigo#in$ ith or ithout the use of 1%digo#in$ ith or ithout the use of 1%

loc3er thera"! loc3er thera"!

0'A class III0'A class III

dd l di idd l di i



add loo" diureticsadd loo" diuretics 0'A class I/0'A class I/

consider "ositive inotro"ic agentsconsider "ositive inotro"ic agents

surgical thera"ies ma! also e a""liedsurgical thera"ies ma! also e a""lied

Angiotensin Converting Angiotensin Converting

Inhiitors "h!siologicInhiitors "h!siologicene&tsene&ts

Crterio#enous Vasodilatation Crterio#enous Vasodilatation

↓

"ulmonar! arterial diastolic"ulmonar! arterial diastolic"ressure"ressure

↓

"ulmonar! ca"illar! edge "ressure"ulmonar! ca"illar! edge "ressure

↓

left ventricular end%diastolicleft ventricular end%diastolic



"ressure"ressure↓

s!stemic vascular resistances!stemic vascular resistance

↓

s!stemic lood "ressures!stemic lood "ressure

↓

ma#imal o#!gen u"ta3e -M/(ma#imal o#!gen u"ta3e -M/(??


InhiitorsInhiitors "h!siologic ene&ts"h!siologic ene&ts

↑

,/ function and cardiac out"ut,/ function and cardiac out"ut

↑

renal$ coronar!$ cereral lood o renal$ coronar!$ cereral lood o

0o change in heart rate or m!ocardial0o change in heart rate or m!ocardial

contractilit! contractilit!

h l i i



no neurohormonal activationno neurohormonal activation

resultant diuresis and natriuresisresultant diuresis and natriuresis


InhiitorsInhiitors clinical ene&tsclinical ene&ts

Increases e#ercise ca"acit! Increases e#ercise ca"acit!

im"roves functional classim"roves functional class attenuation of ,/ remodeling "ost MIattenuation of ,/ remodeling "ost MI

decrease in the "rogression of chronicdecrease in the "rogression of chronic

'F'F

d d h i li i



decreased hos"itali7ationdecreased hos"itali7ation

enhanced ualit! of lifeenhanced ualit! of life

im"roved survivalim"roved survival

As!m"tomatic Patients As!m"tomatic Patients,nalopril,nalopril

S%LVD "re#ention 5rialS%LVD "re#ention 5rial

EFY;J<EFY;J<

↓

'F "rogression$'F "rogression$↓

hos"itali7ationhos"itali7ation

$aptopril$aptopril

SCV, :8SS8 I 8S8S SCV, :8SS8 I 8S8S



SCV,& :8SS8/I& 8S8S/SCV,& :8SS8/I& 8S8S/ Post MI$ EF YHG<Post MI$ EF YHG<

↓

overall mortalit!$overall mortalit!$↓

re%infarctionre%infarction

↓

hos"itali7ation$hos"itali7ation$↓

'F "rogression'F "rogression

S!m"tomatic PatientsS!m"tomatic Patients!ydralazine [ 8sosorbide dinitrate!ydralazine [ 8sosorbide dinitrate

V!e-5/8 V!e-5/8

↓

mortalit!$ im"roved functional classmortalit!$ im"roved functional class

as com"ared ith use of digo#in andas com"ared ith use of digo#in and

diureticsdiuretics

V! -5 88V! -5 88



V!e-5/88 V!e-5/88"roved less e5ective than enalo"ril"roved less e5ective than enalo"ril

S!m"tomatic PatientsS!m"tomatic Patients,nalopril,nalopril [ digo'in [ diuretics[ digo'in [ diuretics

S%LVD 5reatment 5rialS%LVD 5reatment 5rialEFY;J<$ FC III%I/EFY;J<$ FC III%I/

↓

mortalit!$mortalit!$↓


$%S,S4S/88$%S,S4S/88

FC I/FC I/



FC I/ FC I/ ↓

mortalit! -HG<$mortalit! -HG<$↓

s!m"toms$s!m"toms$↓


im"roved functional classim"roved functional class

S!m"tomatic PatientsS!m"tomatic PatientsLosartanLosartan -AT%II inhiitor-AT%II inhiitor

,L85, 5rial,L85, 5rial

losartan im"roved the survival of elderl!losartan im"roved the survival of elderl!

heart failure "atients treated com"ared ithheart failure "atients treated com"ared ith

t il tht il th



ca"to"ril thera"! ca"to"ril thera"!

Luidelines to ACE InhiitorLuidelines to ACE Inhiitor

Thera"! Thera"!

ContraindicationsContraindications

+enal arter! stenosis+enal arter! stenosis +enal insu5icienc! -relative+enal insu5icienc! -relative

'!"er3alemia'!"er3alemia

Arterial h!"otension Arterial h!"otension

Co ghCo gh



CoughCough Angioedema Angioedema

Alternatives Alternatives

'!drala7ine R ISD0$ AT%II inhiitor'!drala7ine R ISD0$ AT%II inhiitor

Luidelines to ACE InhiitorLuidelines to ACE Inhiitor

Thera"! Thera"!

It is im"ortant to titrate to theIt is im"ortant to titrate to the

dosage regimen used in the clinicaldosage regimen used in the clinicaltrials in the asence of s!m"tomstrials in the asence of s!m"toms

or adverse e5ects on end%organor adverse e5ects on end%organ

"erfusion"erfusion

i h t f ili h t f il



in ver! severe heart failure$in ver! severe heart failure$h!drala7ine and nitrates added toh!drala7ine and nitrates added to

ACE inhiitor thera"! can further ACE inhiitor thera"! can further

im"rove cardiac out"utim"rove cardiac out"ut

Anticoagulant Thera"! Anticoagulant Thera"!

+ecommended for +ecommended for

"atients ith 0'A III%I/ and EF Y;G< or"atients ith 0'A III%I/ and EF Y;G< or ventricular aneur!sm or ver! dilated ,/ ventricular aneur!sm or ver! dilated ,/

Indicated for Indicated for "atients ith heart failure ho have atrial"atients ith heart failure ho have atrial

&rillation a "rior emolic e"isode&rillation a "rior emolic e"isode



&rillation$ a "rior emolic e"isode$&rillation$ a "rior emolic e"isode$identi&ed intracardiac thromus$ leftidenti&ed intracardiac thromus$ left

ventricular aneur!sm$ thromo"hleitis$ ventricular aneur!sm$ thromo"hleitis$

or "rolonged ed restor "rolonged ed rest

titrate I0+ to ? to ;titrate I0+ to ? to ;

Arrh!thmias Arrh!thmias

Sudden death occurs inSudden death occurs in

aout JG< of "atients ithaout JG< of "atients ith

h t f ilheart failure



heart failure

Amiodarone Amiodarone

+andomi7ed clinical trials+andomi7ed clinical trials

$!-/S5C5$!-/S5C5 0'A II%III "atients ith ischemic0'A II%III "atients ith ischemic

cardiom!o"ath! % amiodarone had nocardiom!o"ath! % amiodarone had no

a5ect on survivala5ect on survival

:,S8$C:,S8$C



:,S8$C :,S8$C 0'A III%I/ "atients ith more non%0'A III%I/ "atients ith more non%

ischemic cardiom!o"ath! % o"enischemic cardiom!o"ath! % o"en

laeled amiodarone decreasedlaeled amiodarone decreased

mortalit! mortalit!

AICD AICD

+andomi7ed clinical trials+andomi7ed clinical trials

CV8D CV8D amiodarone vs im"lantale de&rillator amiodarone vs im"lantale de&rillator

shoed the AICD grou" had loer mortalit!shoed the AICD grou" had loer mortalit!

AICD should e considered for "atients AICD should e considered for "atients

ith ventricular &rillation or "rior ith ventricular &rillation or "rior

dd d thdd d th



sudden deathsudden death

1eta%loc3ers or amiodarone ma! e1eta%loc3ers or amiodarone ma! e

a""ro"riate for "atients ith sustaineda""ro"riate for "atients ith sustained

/T$ ith or ithout s!m"toms /T$ ith or ithout s!m"toms

Assist Devices Assist Devices

a bridge to cardiac transplantationa bridge to cardiac transplantation candidates must meet the inclusioncandidates must meet the inclusion

and e'clusion criteria or cardiacand e'clusion criteria or cardiac

transplantationtransplantation



transplantationtransplantation

β

%loc3ing Drugs%loc3ing Drugs "hysiologic benefts"hysiologic benefts

increase the densit! ofincrease the densit! of

β

%8 rece"tors%8 rece"tors

inhiit catecholamine to#icit! inhiit catecholamine to#icit!

decrease neurohormonal activationdecrease neurohormonal activation

decrease heart ratedecrease heart rate

id tih t i ti i l"ro ide antih "ertensi e antianginal



"rovide antih!"ertensive$ antianginal$"rovide antih!"ertensive$ antianginal$

and antiarrh!thmic e5ectsand antiarrh!thmic e5ects

antio#idant and anti"roliferativeantio#idant and anti"roliferative

e5ectse5ects

β

%loc3ing Drugs%loc3ing Drugs $linical benefts$linical benefts

decrease s!m"toms of 'Fdecrease s!m"toms of 'F im"rove left ventricular functionim"rove left ventricular function

im"rove e#ercise toleranceim"rove e#ercise tolerance



β

%loc3ing Drugs % Clinical%loc3ing Drugs % Clinical

TrialsTrials F!C5F!C5 --

β

%1loc3er 'eart Attac3 Trial%1loc3er 'eart Attac3 Trial

"ro"ranolol decreased"ro"ranolol decreasedcardiovascular mortalit!$ suddencardiovascular mortalit!$ sudden

death$ and reinfarction in "ost%MIdeath$ and reinfarction in "ost%MI

"atients"atients

ene&t is greatest in "atients hoene&t is greatest in "atients ho



ene&t is greatest in "atients hoene&t is greatest in "atients hoalso had left ventricular d!sfunctionalso had left ventricular d!sfunction

β


TrialsTrials SCV,SCV, 77Survival and /entricularSurvival and /entricular

EnlargementEnlargement99 "ost%MI "atients ith an EF YHG<"ost%MI "atients ith an EF YHG<

β

% loc3ers reduced mortalit! oth% loc3ers reduced mortalit! oth

in the ACE inhiitor and the "laceoin the ACE inhiitor and the "laceo

grou"grou"



grou"grou" loest mortalit! occurred inloest mortalit! occurred in

"atients receiving oth ACE and"atients receiving oth ACE andβ

%%

loc3ing thera"! loc3ing thera"!

β


TrialsTrials )D$)D$ 77Meto"rolol in DilatedMeto"rolol in Dilated

Cardiom!o"ath! Cardiom!o"ath! 99 0'A II%III ith dilated0'A II%III ith dilated

cardiom!o"ath! cardiom!o"ath!

no decrease in mortalit! no decrease in mortalit!

signi&cant decrease in s!m"tomssigni&cant decrease in s!m"toms



signi&cant decrease in s!m"tomssigni&cant decrease in s!m"toms

signi&cant increase in e#ercisesigni&cant increase in e#ercise

tolerance$ ,/ e:ection fraction$tolerance$ ,/ e:ection fraction$

ualit! of lifeualit! of life

β


TrialsTrials )%$!C)%$!C 77Multicenter (ral CarvedilolMulticenter (ral Carvedilol

'eart Failure Assessment Trial'eart Failure Assessment Trial99 0'A II%III heart failure0'A II%III heart failure

uadru"le thera"! -RACE$ diuretic$uadru"le thera"! -RACE$ diuretic$

digo#indigo#in

H< decrease in the cominedH< decrease in the comined



H< decrease in the cominedH< decrease in the cominedend"oints of mortalit! andend"oints of mortalit! and


no im"rovements in e#ercise toleranceno im"rovements in e#ercise tolerance

β


TrialsTrials "*,$8S,"*,$8S,

77Pros"ective +andomi7edPros"ective +andomi7ed

Evaluation of Carvedilol onEvaluation of Carvedilol on

S!m"toms and E#erciseS!m"toms and E#ercise99 decrease in mortalit! from @< to ;<decrease in mortalit! from @< to ;<

HG< decrease in hos"itali7ationHG< decrease in hos"itali7ation



HG< decrease in hos"itali7ationHG< decrease in hos"itali7ation decrease in s!m"tomsdecrease in s!m"toms

im"rovement in ,/ e:ection fractionim"rovement in ,/ e:ection fraction

no a5ect on e#ercise toleranceno a5ect on e#ercise tolerance

Calcium Channel 1loc3ingCalcium Channel 1loc3ing

DrugsDrugs "otential beneft"otential beneft

anti%ischemic and vasodilator!anti%ischemic and vasodilator!e5ectse5ects

Cd#erse e(ect Cd#erse e(ect negative inotro"ic "ro"ertiesnegative inotro"ic "ro"erties

)D"85 R S"*85 t i l)D"85 R S"*85 t i l



)D"85 R S"*85 trials)D"85 R S"*85 trials diltia7em$ vera"amil$ and nifedi"inediltia7em$ vera"amil$ and nifedi"ine

are not recommended for "atientsare not recommended for "atients

ith 'F ith 'F

Calcium Channel 1loc3ingCalcium Channel 1loc3ing

DrugsDrugs "*C8S,/1"*C8S,/1 -Pros"ective +andomi7ed-Pros"ective +andomi7ed

Amlodi"ine Survival Evaluation Amlodi"ine Survival Evaluation 0'A III%I/ heart failure0'A III%I/ heart failure

ACE$ digo#in$ diuretics ^ amlodi"ine ACE$ digo#in$ diuretics ^ amlodi"ine

no change in total mortalit! no change in total mortalit!

no survival ene&t in ischemicsno survival ene&t in ischemics



no survival ene&t in ischemicsno survival ene&t in ischemicsim"roved survival in non%ischemicsim"roved survival in non%ischemics

no change in e#ercise toleranceno change in e#ercise tolerance

Coronar! +evasculari7ationCoronar! +evasculari7ation @G< of "atients ith heart failure@G< of "atients ith heart failure

have coronar! diseasehave coronar! disease

Patients should e evaluated for thePatients should e evaluated for the

"resence of m!ocardial ischemia and"resence of m!ocardial ischemia and

the "otential ene&t ofthe "otential ene&t of

revaculari7ationrevaculari7ation



revaculari7ationrevaculari7ation Survival as im"roved !Survival as im"roved !

revasculari7ation com"ared ithrevasculari7ation com"ared ith

medical thera"!$ even in the asencemedical thera"!$ even in the asence

of angina "ectoris -Du3e dataaseof angina "ectoris -Du3e dataase

Cardiac Trans"lantationCardiac Trans"lantation Survival of >G<%G< at 8%!r$ =G< at J%!r Survival of >G<%G< at 8%!r$ =G< at J%!r

Inclusion Criteria9Inclusion Criteria9 must &rst e#clude remediale m!ocardialmust &rst e#clude remediale m!ocardial

ischemiaischemia

heart failure refractor! to o"timal medical +# heart failure refractor! to o"timal medical +#

left ventricular e:ection fraction Y?G<left ventricular e:ection fraction Y?G<

/(/(?? ma#ma# 8H m,3gmin8H m,3gmin



/( /(?? ma#ma#≤

8H m,3gmin8H m,3gmin

Prolems9Prolems9 re:ection$ graft atherosclerosis$ neo"lasia$re:ection$ graft atherosclerosis$ neo"lasia$

costavailailit! costavailailit!

Cardiom!o"last!Cardiom!o"last!

Cardiac +eduction Surger! Cardiac +eduction Surger!

currentl! consideredcurrentl! considerede#"erimentale#"erimental



DietDiet 5raditional approach non/5raditional approach non/

pharmacologic management ispharmacologic management is

sodium and water restrictionsodium and water restriction

Sodium e'cess is the main reasonSodium e'cess is the main reason

or heart ailure e'acerbationor heart ailure e'acerbation

* i di > I R d* t i t di t > t I R d



*estrict sodium to > to I grams R day*estrict sodium to > to I grams R day

DiureticsDiuretics ↓↓ sodium and water retentionsodium and water retention

↓↓ symptoms o #olume o#erloadsymptoms o #olume o#erload thiazide diuretics are not acti#e withthiazide diuretics are not acti#e with

:-* 0I2 mLRmin:-* 0I2 mLRmin

in resistant edema loop diureticsin resistant edema loop diuretics



in resistant edema& loop diuretics&in resistant edema& loop diuretics&W W [[/sparing diuretics& and metolazone/sparing diuretics& and metolazone

are indicatedare indicated

DigitalisDigitalis Fenefcial hemodynamic e(ectsFenefcial hemodynamic e(ects

↑↑ cardiac out"utcardiac out"ut ↑↑ left ventricular e:ection fractionleft ventricular e:ection fraction

↓↓ left ventricular diastolic "ressureleft ventricular diastolic "ressure

↑↑ e#ercise tolerancee#ercise tolerance

↑↑ t i inatriuresis



↑↑ natriuresisnatriuresis

↓↓ neurohormonal activationneurohormonal activation

Digitalis % Clinical TrialsDigitalis % Clinical Trials D8:D8: 7Digitalis 8n#estigation :roup97Digitalis 8n#estigation :roup9

0'A class I%I/ heart failure0'A class I%I/ heart failure no change in mortalit! com"aredno change in mortalit! com"ared

ith "laceo thera"! ith "laceo thera"!

↓↓ comined end"oint ofcomined end"oint of

hos"itali7ations and deathhos"itali7ations and death



hos"itali7ations and deathhos"itali7ations and death ↑↑ serious arrh!thmia and MIserious arrh!thmia and MI

Digitalis % Clinical TrialsDigitalis % Clinical Trials *CD8C$,*CD8C$, 77+andomi7ed Assessment of+andomi7ed Assessment of

the e5ect of Digo#in on Inhiitors ofthe e5ect of Digo#in on Inhiitors of

ACE ACE99 e:ection fraction Y;J<e:ection fraction Y;J<

ACE$ diuretics$ digo#in ACE$ diuretics$ digo#in

associated ithassociated ith ↓↓ e#ercise tolerance ine#ercise tolerance ini i h l i h hti t ith l i h th



associated ithassociated ith ↓↓ e#ercise tolerance ine#ercise tolerance in"atients ith normal sinus rh!thm"atients ith normal sinus rh!thm

ithdraal of digo#in resulted in ithdraal of digo#in resulted in ↓↓ e#ercise tolerance$ ande#ercise tolerance$ and ↑↑ inin


Digitalis % Clinical TrialsDigitalis % Clinical Trials

"*%V,D"*%V,D -Pros"ective +andomi7ed-Pros"ective +andomi7ed

Stud! of /entricular Function andStud! of /entricular Function andE5icac! of Digo#inE5icac! of Digo#in

mild%to%moderate 'F ith EF Y;J<mild%to%moderate 'F ith EF Y;J<

in 0S+ and not on ACE inhiitorin 0S+ and not on ACE inhiitorthera"!thera"!



in 0S+ and not on ACE inhiitorin 0S+ and not on ACE inhiitorthera"! thera"!

ithdraal of digo#in resulted in ithdraal of digo#in resulted in ↓↓ e#ercise tolerance ande#ercise tolerance and ↑↑ inin


DoutamineDoutamine _%8 rece"tor agonist_%8 rece"tor agonist

lo%dose doutamine -?%; ug3gminlo%dose doutamine -?%; ug3gmin

↑

m!ocardial contractilit! and cardiacm!ocardial contractilit! and cardiacout"ut$ arteriovenous dilatationout"ut$ arteriovenous dilatation

high%dose doutamine -J%8J ug3gminhigh%dose doutamine -J%8J ug3gmin

tach!cardia$ arrh!thmia$ s"lanchnictach!cardia$ arrh!thmia$ s"lanchnic

and renal vasoconstrictionand renal vasoconstriction



tach!cardia$ arrh!thmia$ s"lanchnicand renal vasoconstrictionand renal vasoconstriction

associated ith s!m"tomatic ene&tassociated ith s!m"tomatic ene&t

continuous home "um" infusioncontinuous home "um" infusion

E#ercise TrainingE#ercise Training C!$"* C!$"*

$ardiac *ehabilitation :uidelines $ardiac *ehabilitation :uidelines

,'ercise training in patients with !-,'ercise training in patients with !-

decrease s!m"tomsdecrease s!m"toms

im"roves e#ercise toleranceim"roves e#ercise tolerance

ene&t additive to that attainedene&t additive to that attained



ene&t additive to that attainedene&t additive to that attained

ith ACEI ith ACEI

no orsening of left ventricularno orsening of left ventricular

functionfunction

E#ercise TrainingE#ercise Training$linical 5rials on e'ercise ollowing$linical 5rials on e'ercise ollowing

)8)8 ,C)8,C)8 7,'ercise and Cnterior )897,'ercise and Cnterior )89

,LVD,LVD 7,'ercise in LV Dysunction97,'ercise in LV Dysunction9

both inter#entional groups showedboth inter#entional groups showed

impro#ement in unctional capacity andimpro#ement in unctional capacity and



impro#ement in unctional capacity andimpro#ement in unctional capacity anddecrease in symptomsdecrease in symptoms

,LVD also showed an impro#ement in,LVD also showed an impro#ement in

e6ection ractione6ection raction

ConclusionConclusion

E5ects of 'eart FailureE5ects of 'eart FailureThera"iesThera"ies Im"rove in survivalIm"rove in survival

ACE inhiitors ACE inhiitors _%loc3ing drugs -selective_%loc3ing drugs -selective

Increased mortalit! Increased mortalit!

"ositive inotro"ic agents"ositive inotro"ic agents l i h l l 3i d -Kl i h l l 3i d -K



"ositive inotro"ic agents"ositive inotro"ic agents calcium channel loc3ing drugs -Kcalcium channel loc3ing drugs -K

0eutral on survival0eutral on survival

digitalisdigitalis

ConclusionConclusion

E5ects of 'eart FailureE5ects of 'eart FailureThera"iesThera"ies Prevention of ischemiaPrevention of ischemia

_%loc3ing drugs -selective_%loc3ing drugs -selective coronar! revasculari7ationcoronar! revasculari7ation

anticoagulant thera"! anticoagulant thera"!

'emod!namic im"rovement'emod!namic im"rovement

ACEI$ digitalis$ diuretics$ ACEI$ digitalis$ diuretics$



C $ d g ta s$ d u et cs$$ g $ $

h!drala7ineISD0h!drala7ineISD0

Prevention of sudden deathPrevention of sudden death

amiodarone and AICDamiodarone and AICD

Evaluation andEvaluation andManagement ofManagement of

Acute AcuteDecom"ensatedDecom"ensated

'eart Failure'eart Failure>212 !-SC>212 !-SCd* d i



'eart Failure'eart Failure>212 !-SC>212 !-SC*ecommendations*ecommendations


LuidelineLuideline Acute 'FBDiagnosis Acute 'FBDiagnosis

#ecommendation 12.1 #ecommendation 12.1 The diagnosis of AD'F should e ased "rimaril! onThe diagnosis of AD'F should e ased "rimaril! on

signs and s!m"toms.signs and s!m"toms. Strength of ,%idence - CStrength of ,%idence - C

4hen the diagnosis is uncertain$ determination of 4hen the diagnosis is uncertain$ determination of10P or 0T%"ro10P concentration10P or 0T%"ro10P concentration is recommendedis recommended in "atients eing evaluated for d!s"nea ho havein "atients eing evaluated for d!s"nea ho havesigns and s!m"toms com"atile ith 'F.signs and s!m"toms com"atile ith 'F. StrengthStrengthof ,%idence - Aof ,%idence - A

The natriuretic "e"tide concentration should not eThe natriuretic "e"tide concentration should not einter"reted in isolation$ ut in the conte#t of allinter"reted in isolation$ ut in the conte#t of alla ailale clinical data earing on the diagnosis ofavailale clinical data earing on the diagnosis of



availale clinical data earing on the diagnosis ofavailale clinical data earing on the diagnosis of'F$ and ith the 3noledge of cardiac and non%'F$ and ith the 3noledge of cardiac and non%cardiac factors that can raise or loer natriureticcardiac factors that can raise or loer natriuretic"e"tide levels."e"tide levels.


LuidelineLuideline Acute 'FB'os"ital Admission Acute 'FB'os"ital Admission

#ecommendation 12.2 #ecommendation 12.2 'os"ital admission'os"ital admission is recommendedis recommended

for "atients "resenting ith AD'Ffor "atients "resenting ith AD'F hen the clinical circumstances listed hen the clinical circumstances listedin Tale 8?.8.a are "resent.in Tale 8?.8.a are "resent.

Patients "resenting ith AD'FPatients "resenting ith AD'F

should e consideredshould e considered

for hos"italfor hos"ital

admission hen the clinicaladmission hen the clinical



"circumstances listed in Tale 8?.8.circumstances listed in Tale 8?.8.are "resent.are "resent.

Strength ofStrength of

,%idence - C ,%idence - C

o



Tale 8?.8.-aTale 8?.8.

-a 'os"itali7ation'os"itali7ation recommendedrecommended ininthe "resence of9the "resence of9

Evidence of severel! decom"ensated 'F$ including9Evidence of severel! decom"ensated 'F$ including9 '!"otension'!"otension 4orsening renal failure 4orsening renal failure Altered mentation Altered mentation

D!s"nea at restD!s"nea at rest T!"icall! reected ! resting tach!"neaT!"icall! reected ! resting tach!"nea

,ess commonl! reected ! o#!gen saturation Y G<,ess commonl! reected ! o#!gen saturation Y G< 'emod!namicall! signi&cant arrh!thmia'emod!namicall! signi&cant arrh!thmia



! ! g !! ! g ! Including ne onset of ra"id atrial &rillationIncluding ne onset of ra"id atrial &rillation

Acute coronar! s!ndromes Acute coronar! s!ndromes Strength ofStrength of ,%idence - C ,%idence - C



Tale 8?.8.-Tale 8?.8.

- 'os"itali7ation'os"itali7ation should e consideredshould e considered ininthe "resence of9the "resence of9

4orsened congestion 4orsened congestion

Even ithout d!s"neaEven ithout d!s"nea Signs and s!m"toms of "ulmonar! or s!stemicSigns and s!m"toms of "ulmonar! or s!stemic

congestioncongestion Even in the asence of eight gainEven in the asence of eight gain

Ma:or electrol!te disturanceMa:or electrol!te disturance Associated comorid conditions Associated comorid conditions

Pneumonia$ "ulmonar! emolus$ diaetic 3etoacidosis$Pneumonia$ "ulmonar! emolus$ diaetic 3etoacidosis$s!m"toms suggestive of TIA or stro3es!m"toms suggestive of TIA or stro3e + t d ICD & i+ t d ICD & i



+e"eated ICD &rings+e"eated ICD &rings Previousl! undiagnosed 'F ith signs and s!m"toms ofPreviousl! undiagnosed 'F ith signs and s!m"toms of

s!stemic or "ulmonar! congestions!stemic or "ulmonar! congestion





LuidelineLuideline Acute 'FBTreatment Loals Acute 'FBTreatment Loals Tale 8?.;Tale 8?.; Treatment Loals for Patients AdmittedTreatment Loals for Patients Admitted

for AD'Ffor AD'F Im"rove s!m"toms$ es"eciall! congestion and lo out"utIm"rove s!m"toms$ es"eciall! congestion and lo out"ut

s!m"tomss!m"toms

+estore normal o#!genation+estore normal o#!genation ("timi7e volume status("timi7e volume status Identif! etiolog! Identif! etiolog! Identif! and address "reci"itating factorsIdentif! and address "reci"itating factors ("timi7e chronic oral thera"! ("timi7e chronic oral thera"! Minimi7e side e5ectsMinimi7e side e5ects

Identif! "atients ho might ene&t fromIdentif! "atients ho might ene&t fromrevasculari7ation or device thera"! revasculari7ation or device thera"!

Id tif i 3 f th li d d fIdentif! ris3 of thromoemolism and need for



Identif! ris3 of thromoemolism and need forIdentif! ris3 of thromoemolism and need foranticoagulant thera"! anticoagulant thera"!

Educate "atients concerning medications and selfEducate "atients concerning medications and selfassessment of 'Fassessment of 'F

Consider and$ here "ossile$ initiate a diseaseConsider and$ here "ossile$ initiate a disease

management "rogrammanagement "rogram


LuidelineLuideline Acute 'FBPatient Monitoring Acute 'FBPatient Monitoring #ecommendation 12.3 #ecommendation 12.3

Patients admitted ith AD'FPatients admitted ith AD'F

should e carefull! monitored.should e carefull! monitored. ItIt is recommendedis recommended that the itemsthat the items

listed in Tale 8?.H e assessedlisted in Tale 8?.H e assessed

at the stated freuencies.at the stated freuencies.




LuidelineLuideline

Acute 'FBTale 8?.H. Patient Acute 'FBTale 8?.H. PatientMonitoring`Monitoring`FreuencFreuenc

! !

/alue /alue S"eci&csS"eci&cs

At least At leastdail! dail!

4eight 4eight Determine after voiding in the morningDetermine after voiding in the morning

Account for "ossile increased food inta3e Account for "ossile increased food inta3e

due to im"roved a""etitedue to im"roved a""etite


FluidFluidinta3e andinta3e andout"utout"ut

More thanMore thandail! dail!

/ital signs /ital signs (rthostatic lood "ressure$ if indicated(rthostatic lood "ressure$ if indicated

(#!gen saturation dail! until stale(#!gen saturation dail! until stale

At least At leastdail!dail!

SignsSigns Edema$ ascites$ "ulmonar! rales$Edema$ ascites$ "ulmonar! rales$he"atomegal! increased :ugular venoushe"atomegal! increased :ugular venous



dail! dail! he"atomegal!$ increased :ugular venoushe"atomegal!$ increased :ugular venous"ressure$ he"ato:ugular reu#$ liver"ressure$ he"ato:ugular reu#$ livertendernesstenderness


S!m"tomsS!m"toms (rtho"nea$ "aro#!smal nocturnal d!s"nea or(rtho"nea$ "aro#!smal nocturnal d!s"nea orcough$ nocturnal cough$ d!s"nea$ fatigue$cough$ nocturnal cough$ d!s"nea$ fatigue$

lightheadednesslightheadedness At least At leastdail! dail!

Electrol!teElectrol!tess

Potassium$ sodiumPotassium$ sodium

At least At least +enal+enal 1U0$ serum creatinine1U0$ serum creatinine

rac cerac ce

LuidelineLuideline Acute 'FBFluid (verload and Acute 'FBFluid (verload and

DiureticsDiuretics #ecommendation 12.4 #ecommendation 12.4

It is recommendedIt is recommended that "atientsthat "atients

admitted ith AD'F andadmitted ith AD'F andevidence of uid overload eevidence of uid overload e

treated initiall! ith loo"treated initiall! ith loo"

diureticsBusuall! givendiureticsBusuall! givenintravenousl! rather than orall!intravenousl! rather than orall!



! g! gintravenousl! rather than orall!.intravenousl! rather than orall!.



LuidelineLuideline Acute 'FBDiuretic Dosing Acute 'FBDiuretic Dosing #ecommendation 12.0 #ecommendation 12.0

ItIt is recommendedis recommended that diuretics ethat diuretics e

administered9administered9 at doses needed to "roduce a rate of diuresis su5icientat doses needed to "roduce a rate of diuresis su5icient

to achieveto achieve o"timal volume status ith relief ofo"timal volume status ith relief of

signs and s!m"toms of congestionsigns and s!m"toms of congestion

7edema& ele#ated V"& dyspnea97edema& ele#ated V"& dyspnea9

ithout inducing an e#cessivel! ra"id reduction ithout inducing an e#cessivel! ra"id reductionin9in9



in9in9 intra#ascular #olume& which may result in symptomaticintra#ascular #olume& which may result in symptomatic

hypotension andRor worsening renal unctionhypotension andRor worsening renal unction

or serum electrolytes& which may precipitate arrhythmias oror serum electrolytes& which may precipitate arrhythmias or

muscle cramps+muscle cramps+



LuidelineLuideline Acute 'FBDiuretics Assessment Acute 'FBDiuretics Assessment #ecommendation 12.5 #ecommendation 12.5

Careful re"eated assessment ofCareful re"eated assessment of

signs and s!m"toms ofsigns and s!m"toms ofcongestion and changes in od!congestion and changes in od!

eight eight is recommendedis recommended$ ecause$ ecauseclinical e#"erience suggests it isclinical e#"erience suggests it isdi5icult to determine thatdi5icult to determine that



congestion has een adeuatel!congestion has een adeuatel!treated in man! "atients.treated in man! "atients.



LuidelineLuideline Acute 'FBDiuretics Monitoring Acute 'FBDiuretics Monitoring #ecommendation 12.6 #ecommendation 12.6

Monitoring of dail! eights$ inta3e$ andMonitoring of dail! eights$ inta3e$ and

out"utout"ut

is recommendedis recommended

to assessto assess

clinical e5icac! of diuretic thera"!.clinical e5icac! of diuretic thera"!. +outine use of a Fole! catheter+outine use of a Fole! catheter is notis not

recommendedrecommended for monitoring volume status.for monitoring volume status. 'oever$ "lacement of a catheter'oever$ "lacement of a catheter isis

recommendedrecommended hen close monitoring of hen close monitoring ofurine out"ut is needed or if a ladder outleturine out"ut is needed or if a ladder outlet



urine out"ut is needed or if a ladder outlet"ostruction is sus"ected of contriuting toostruction is sus"ected of contriuting to orsening renal function. orsening renal function.


o


LuidelineLuideline Acute 'FBDiuretic Side E5ects Acute 'FBDiuretic Side E5ects

#ecommendation 12.7 (1 of 2& #ecommendation 12.7 (1 of 2&

Careful oservation for develo"ment of aCareful oservation for develo"ment of a

variet! of side e5ects$ including renal variet! of side e5ects$ including renal

d!sfunction$ electrol!te anormalities$d!sfunction$ electrol!te anormalities$

s!m"tomatic h!"otension$ and gouts!m"tomatic h!"otension$ and gout

is recommendedis recommended in "atients treated ithin "atients treated ith

diuretics$ es"eciall! hen used at highdiuretics$ es"eciall! hen used at highdoses and in comination.doses and in comination.



doses and in comination.doses and in comination. Patients should undergo routine laorator!Patients should undergo routine laorator!

studies and clinical e#amination as dictatedstudies and clinical e#amination as dictated

! their clinical res"onse.! their clinical res"onse. Strength ofStrength of



LuidelineLuideline Acute 'FBDiuretic Side E5ects Acute 'FBDiuretic Side E5ects

#ecommendation 12.7 (2 of 2& #ecommendation 12.7 (2 of 2&

It is recommendedIt is recommended that serum "otassiumthat serum "otassium

and magnesium levels e monitored atand magnesium levels e monitored at

least dail! and maintained in the normalleast dail! and maintained in the normal

range. More freuent monitoring ma! erange. More freuent monitoring ma! e

necessar! hen diuresis is ra"id.necessar! hen diuresis is ra"id.Strength of ,%idence - CStrength of ,%idence - C

(verl! ra"id diuresis ma! e associated(verl! ra"id diuresis ma! e associatedith severe muscle cram"s If indicatedith severe muscle cram"s If indicated



ith severe muscle cram"s. If indicated$ ith severe muscle cram"s. If indicated$

treatment ith "otassium re"lacementtreatment ith "otassium re"lacement

should e consideredshould e considered.. Strength ofStrength of


rac cerac ce

LuidelineLuideline Acute 'FBDiuretics +enal Acute 'FBDiuretics +enal

D!sfunctionD!sfunction #ecommendation 12.18 #ecommendation 12.18

Careful oservation for theCareful oservation for the

develo"ment of renal d!sfunctiondevelo"ment of renal d!sfunction isisrecommendedrecommended in "atients treated ithin "atients treated ithdiuretics.diuretics.

Patients ith moderate to severe renalPatients ith moderate to severe renald!sfunction and evidence of uidd!sfunction and evidence of uid

retention should continue to e treatedretention should continue to e treatedith diureticsith diuretics.



ith diuretics. ith diuretics. In the "resence of severe uidIn the "resence of severe uid

overload$ renal d!sfunction ma!overload$ renal d!sfunction ma!im"rove ith diuresis.im"rove ith diuresis. Strength ofStrength of





LuidelineLuideline Acute 'FBSodium Acute 'FBSodium #ecommendation 12.12 #ecommendation 12.12

A lo sodium diet -? g dail! A lo sodium diet -? g dail! isis

recommendedrecommended for most hos"itali7edfor most hos"itali7ed"atients."atients. Strength of ,%idence - CStrength of ,%idence - C

In "atients ith recurrent orIn "atients ith recurrent or

refractor! volume overload$ stricterrefractor! volume overload$ strictersodium restrictionsodium restriction ma! ema! e



!!

consideredconsidered.. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline Acute 'FBFluid +estriction Acute 'FBFluid +estriction #ecommendation 12.1 #ecommendation 12.1

Fluid restriction -Y? litersda!9Fluid restriction -Y? litersda!9

Is recommendedIs recommended

in "atients ith moderatein "atients ith moderate

h!"onatremia -serum sodium Y 8;G mE,h!"onatremia -serum sodium Y 8;G mE, Should e consideredShould e considered to assist in treatment ofto assist in treatment of

uid overload in other "atients.uid overload in other "atients.Strength of ,%idence - CStrength of ,%idence - C

In "atients ith severe -serum sodiumIn "atients ith severe -serum sodium

Y 8?J mE, or orseningY 8?J mE, or orseningh!"onatremia stricter uid restrictionh!"onatremia stricter uid restriction



h!"onatremia$ stricter uid restrictionh!"onatremia$ stricter uid restrictionma! e consideredma! e considered..

Strength of ,%idence -Strength of ,%idence -CC


LuidelineLuideline Acute 'F%%(#!gen Acute 'F%%(#!gen #ecommendation 12.13 #ecommendation 12.13

+outine administration of+outine administration of

su""lemental o#!gen9su""lemental o#!gen9 Is recommendedIs recommended in the "resence ofin the "resence of

h!"o#ia.h!"o#ia.

Is not recommendedIs not recommended in thein the f h i f h i



asence of h!"o#ia.asence of h!"o#ia.

$trength of &idence$trength of &idence

, C, C


LuidelineLuideline Acute 'F%%0I/ Acute 'F%%0I/ #ecommendation 12.14 #ecommendation 12.14 (9, in 2818&(9, in 2818&

Use of non%invasive "ositiveUse of non%invasive "ositive

"ressure ventilation"ressure ventilation ma! ema! e

consideredconsidered for severel!for severel!

d!s"neic "atients ith clinicald!s"neic "atients ith clinical

evidence of "ulmonar! edema.evidence of "ulmonar! edema.



" !" ! $trength of &idence$trength of &idence

, C, C


LuidelineLuideline Acute 'FB/T Pro"h!la#is Acute 'FB/T Pro"h!la#is #ecommendation 12.10 #ecommendation 12.10 (9, in 2818&(9, in 2818& 8 of ?8 of ?

/enous thromoemolism "ro"h!la#is /enous thromoemolism "ro"h!la#is

ith lo dose unfractionated he"arin$ ith lo dose unfractionated he"arin$lo molecular eight he"arin$ orlo molecular eight he"arin$ orfonda"arinu# to "revent "ro#imalfonda"arinu# to "revent "ro#imaldee" venous thromosis anddee" venous thromosis and

"ulmonar! emolism"ulmonar! emolism is recommendedis recommended for "atients ho are admitted to thefor "atients ho are admitted to the



""hos"ital ith AD'F and ho are nothos"ital ith AD'F and ho are notalread! anticoagulated and have noalread! anticoagulated and have no

contraindication to anticoagulation.contraindication to anticoagulation. Strength of Evidence = !




LuidelineLuideline Acute 'FBI/ /asodilators Acute 'FBI/ /asodilators #ecommendation 12.15 #ecommendation 12.15 In the asence of s!m"tomatic h!"otension$In the asence of s!m"tomatic h!"otension$

intravenous nitrogl!cerin$ nitro"russide orintravenous nitrogl!cerin$ nitro"russide or

nesiritidenesiritide ma! e consideredma! e considered as an addition toas an addition todiuretic thera"! for ra"id im"rovement ofdiuretic thera"! for ra"id im"rovement ofcongestive s!m"toms in "atients admittedcongestive s!m"toms in "atients admitted

ith AD'F. ith AD'F. Strength of ,%idence - Strength of ,%idence - Freuent lood "ressure monitoringFreuent lood "ressure monitoring is recommendedis recommended

ith these agents. ith these agents. Strength of ,%idence - Strength of ,%idence - These agents should e decreased in dosage orThese agents should e decreased in dosage or

discontinued if s!m"tomatic h!"otension ordiscontinued if s!m"tomatic h!"otension or



d sco t ued s! "to at c !"ote s o o! " !" orsening renal function develo"s. orsening renal function develo"s. Strength ofStrength of ,%idence - ,%idence -

+eintroduction in increasing doses+eintroduction in increasing doses ma! ema! econsideredconsidered once s!m"tomatic h!"otension isonce s!m"tomatic h!"otension is

resolved.resolved. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline Acute 'FBI/ /asodilators Acute 'FBI/ /asodilators #ecommendation 12.16 #ecommendation 12.16

Intravenous vasodilatorsIntravenous vasodilators

-intravenous nitrogl!cerin or-intravenous nitrogl!cerin ornitro"russide and diureticsnitro"russide and diuretics arearerecommendedrecommended for ra"id s!m"tomfor ra"id s!m"tomrelief in "atients ith acuterelief in "atients ith acute"ulmonar! edema or severe"ulmonar! edema or severeh i



h!"ertension.h!"ertension. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline Acute 'FBI/ /asodilators Acute 'FBI/ /asodilators #ecommendation 12.17 #ecommendation 12.17

Intravenous vasodilatorsIntravenous vasodilators ma! ema! e

consideredconsidered in "atients ith AD'Fin "atients ith AD'F ho have "ersistent severe 'F ho have "ersistent severe 'F

des"ite aggressive treatment ithdes"ite aggressive treatment ith

diuretics and standard oraldiuretics and standard oral

thera"ies.thera"ies.



0itro"russide0itro"russide Strength of ,%idence - Strength of ,%idence -

0itrogl!cerine$ nesiritide0itrogl!cerine$ nesiritide Strength ofStrength of



LuidelineLuideline Acute 'FBI/ Inotro"es Acute 'FBI/ Inotro"es #ecommendation 12.28 (1 of & #ecommendation 12.28 (1 of &

Intravenous inotro"es -milrinone orIntravenous inotro"es -milrinone ordoutaminedoutamine ma! e consideredma! e considered to relieveto relieve

s!m"toms and im"rove end%organ function ins!m"toms and im"rove end%organ function in"atients ith advanced 'F characteri7ed !9"atients ith advanced 'F characteri7ed !9 ,/ dilation,/ dilation +educed ,/EF+educed ,/EF And And diminished "eri"heral "erfusion or end%organdiminished "eri"heral "erfusion or end%organ

d!sfunction -lo out"ut s!ndromed!sfunction -lo out"ut s!ndrome

Particularl! Particularl

! if these "atients9if these "atients9 'ave marginal s!stolic lood "ressure -YG mm 'g$'ave marginal s!stolic lood "ressure -YG mm 'g$ 'ave s!m"tomatic h!"otension des"ite adeuate'ave s!m"tomatic h!"otension des"ite adeuate



'ave s!m"tomatic h!"otension des"ite adeuate'ave s!m"tomatic h!"otension des"ite adeuate&lling "ressure$&lling "ressure$

(r (r are unres"onsive to$ or intolerant of$ intravenousare unres"onsive to$ or intolerant of$ intravenous vasodilators. vasodilators.



LuidelineLuideline Acute 'FBI/ Inotro"es Acute 'FBI/ Inotro"es

#ecommendation 12.28 (2 of & #ecommendation 12.28 (2 of & These agentsThese agents ma! e consideredma! e considered in similar "atientsin similar "atients

ith evidence of uid overload if the! res"ond ith evidence of uid overload if the! res"ond"oorl! to intravenous diuretics or manifest"oorl! to intravenous diuretics or manifestdiminished or orsening renal function.diminished or orsening renal function.

Strength of ,%idence - CStrength of ,%idence - C 4hen ad:unctive thera"! is needed in other 4hen ad:unctive thera"! is needed in other

"atients ith AD'F$ administration of vasodilators"atients ith AD'F$ administration of vasodilatorsshould e consideredshould e considered instead of intravenousinstead of intravenous

inotro"es -milrinone or doutamine.inotro"es -milrinone or doutamine. Strength of ,%idence - CStrength of ,%idence - C Intravenous inotro"es -milrinone or doutamineIntravenous inotro"es -milrinone or doutamine



Intravenous inotro"es -milrinone or doutamineIntravenous inotro"es -milrinone or doutamineareare not recommendednot recommended unlessunless left heart &llingleft heart &lling"ressures are 3non to e elevated or cardiac"ressures are 3non to e elevated or cardiacinde# is severel! im"aired ased on directinde# is severel! im"aired ased on directmeasurement or clear clinical signs.measurement or clear clinical signs. StrengthStrength

of ,%idence - Cof ,%idence - C


LuidelineLuideline Acute 'FBI/ Inotro"es Acute 'FBI/ Inotro"es

#ecommendation 12.28 ( of & #ecommendation 12.28 ( of & It is recommendedIt is recommended that administration ofthat administration of

intravenous inotro"es -milrinone orintravenous inotro"es -milrinone ordoutamine in the setting of AD'Fdoutamine in the setting of AD'F eeaccom"anied ! continuous or freuentaccom"anied ! continuous or freuentlood "ressure monitoring andlood "ressure monitoring andcontinuous monitoring of cardiac rh!thm.continuous monitoring of cardiac rh!thm.

Strength of ,%idence - CStrength of ,%idence - C If s!m"tomatic h!"otension or orseningIf s!m"tomatic h!"otension or orsening

tach!arrh!thmias develo" duringtach!arrh!thmias develo" during



tach!arrh!thmias develo" duringtach!arrh!thmias develo" duringadministration of these agents$administration of these agents$discontinuation or dose reductiondiscontinuation or dose reduction shouldshoulde considerede considered.. Strength of ,%idence - CStrength of ,%idence - C


LuidelineLuideline Acute 'FB'emod!namic Monitoring Acute 'FB'emod!namic Monitoring


The routine use of invasiveThe routine use of invasive

hemod!namic monitoring inhemod!namic monitoring in

"atients ith AD'F is"atients ith AD'F is notnot

recommended.recommended.



Strength ofStrength of

,%idence - A ,%idence - A


LuidelineLuideline Acute 'FB'emod!namic Monitoring Acute 'FB'emod!namic Monitoring #ecommendation 12.22 #ecommendation 12.22 Invasive hemod!namic monitoringInvasive hemod!namic monitoring should eshould e

consideredconsidered in a "atient9in a "atient9 4ho is refractor! to initial thera"! 4ho is refractor! to initial thera"! 4hose volume status and cardiac &lling "ressures 4hose volume status and cardiac &lling "ressures

are unclearare unclear 4ho has clinicall! signi&cant h!"otension 4ho has clinicall! signi&cant h!"otension

-t!"icall! S1P Y @G mm 'g or orsening renal-t!"icall! S1P Y @G mm 'g or orsening renalfunction during thera"! function during thera"!

(r (r ho is eing considered for cardiac trans"lant ho is eing considered for cardiac trans"lantand needs assessment of degree and reversailit!and needs assessment of degree and reversailit!f l h t if l h t i



of "ulmon. h!"ertensionof "ulmon. h!"ertension (r (r in hom documentation of an adeuatein hom documentation of an adeuate

hemod!namic res"onse to the inotro"ic agent ishemod!namic res"onse to the inotro"ic agent isnecessar! hen chronic out"atient infusion isnecessar! hen chronic out"atient infusion is

eing consideredeing considered Strength of Evidence = C

rac cerac ce

LuidelineLuideline

Acute 'FBEvaluation for Preci"itating Acute 'FBEvaluation for Preci"itating

FactorsFactors #ecommendation 12.2 #ecommendation 12.2

ItIt is recommendedis recommended that "atients admittedthat "atients admitted ith AD'F undergo evaluation for the ith AD'F undergo evaluation for the

folloing "reci"itating factors9folloing "reci"itating factors9 Atrial &rillation or other arrh!thmias -e.g.$ Atrial &rillation or other arrh!thmias -e.g.$

atrial utter$ other S/T or /Tatrial utter$ other S/T or /T E#aceration of h!"ertensionE#aceration of h!"ertension M!ocardial ischemiainfarctionM!ocardial ischemiainfarction

E#aceration of "ulmonar! congestionE#aceration of "ulmonar! congestion Anemia$ th!roid disease Anemia$ th!roid disease Signi&cant drug interactionsSigni&cant drug interactions



Signi&cant drug interactionsSigni&cant drug interactions (ther less common factors(ther less common factors



LuidelineLuideline Acute 'FBPatient Education Acute 'FBPatient Education


ItIt is recommendedis recommended that ever!that ever!e5ort e made to utili7e thee5ort e made to utili7e the

hos"ital sta! for assessment andhos"ital sta! for assessment and

im"rovement of "atient adherenceim"rovement of "atient adherence

via "atient and famil! education via "atient and famil! educationand social su""ort servicesand social su""ort services



and social su""ort services.and social su""ort services. Strength of ,%idence - Strength of ,%idence -


LuidelineLuideline Acute 'FBDischarge Criteria Acute 'FBDischarge Criteria #ecommendation 12.24 #ecommendation 12.24

ItIt is recommendedis recommended that criteria inthat criteria in

Tale 8?.= e met efore a "atientTale 8?.= e met efore a "atient

ith 'F is discharged from the ith 'F is discharged from the

hos"ital.hos"ital. Strength of Evidence Q CStrength of Evidence Q C

In "atients ith advanced 'F orIn "atients ith advanced 'F or

recurrent admissions for 'F$recurrent admissions for 'F$

additional criteria listed in Tale 8?.=additional criteria listed in Tale 8?.=h ld id d



should e consideredshould e considered.. Strength ofStrength of

Evidence Q CEvidence Q C

LuidelineLuideline

Acute 'FBTale 8?.=. Discharge Acute 'FBTale 8?.=. DischargeCriteriaCriteria+ecommended+ecommendedforfor allall 'F'F

"atients"atients

E#acerating factors addressedE#acerating factors addressed

0ear o"timal volume status oserved0ear o"timal volume status oserved

Transition from intravenous to oral diureticTransition from intravenous to oral diureticsuccessfull! com"letedsuccessfull! com"leted

Patient and famil! education com"leted$ includingPatient and famil! education com"leted$ includingclear discharge instructionsclear discharge instructions

0ear o"timal "harmacologic thera"! achieved$0ear o"timal "harmacologic thera"! achieved$including ACEI and 11 -for "atients ith reducedincluding ACEI and 11 -for "atients ith reduced,/EF or intolerance documented,/EF or intolerance documented

Follo%u" clinic visit scheduled$ usuall! for =%8GFollo%u" clinic visit scheduled$ usuall! for =%8Gda!sda!s

Should eShould e

considered forconsidered for"atients ith"atients ithd d

(ral medication regimen stale for ?H hours(ral medication regimen stale for ?H hours

0o intravenous vasodilator or inotro"ic agent for ?H0o intravenous vasodilator or inotro"ic agent for ?Hhourshours



advanced 'Fadvanced 'F

or recurrentor recurrentadmissions foradmissions for'F'F

Amulation "rior to discharge to assess functional Amulation "rior to discharge to assess functionalca"acit! after thera"! ca"acit! after thera"!

Plans for "ost%discharge management -scalePlans for "ost%discharge management -scale"resent in home$ visiting nurse or tele"hone follo"resent in home$ visiting nurse or tele"hone follo

u" generall! no longer than ; da!s after dischargeu" generall! no longer than ; da!s after discharge

+eferral for disease management$ if availale+eferral for disease management$ if availale


LuidelineLuideline Acute 'FBDischarge Planning Acute 'FBDischarge Planning #ecommendation 12.20 #ecommendation 12.20 Discharge "lanningDischarge "lanning is recommendedis recommended as "art of theas "art of the

management of "atients ith AD'F. Dischargemanagement of "atients ith AD'F. Discharge

"lanning should address the folloing issues9"lanning should address the folloing issues9 Details regarding medication$ dietar! sodiumDetails regarding medication$ dietar! sodiumrestriction and recommended activit! levelrestriction and recommended activit! level

Follo%u" ! "hone or clinic visit earl! afterFollo%u" ! "hone or clinic visit earl! afterdischarge to reassess volume statusdischarge to reassess volume status

Medication and dietar! com"lianceMedication and dietar! com"liance

Alcohol moderation and smo3ing cessation Alcohol moderation and smo3ing cessation Monitoring of od! eight$ electrol!tes and renalMonitoring of od! eight$ electrol!tes and renalfunctionfunction



functionfunction Consideration of referral for formal diseaseConsideration of referral for formal disease

managementmanagement



and /ADsand /ADs

1ridges for 1ro3en1ridges for 1ro3en

'earts'earts"riya :aiha )D )FC "riya :aiha )D )FC )ay ><)ay ><thth >212>212



'earts'eartsyy

4ni#ersity o Wentucy4ni#ersity o Wentucy

:rand *ounds:rand *ounds

(:ectives(:ectives Ehat is the pathophysiology o heart ailure`Ehat is the pathophysiology o heart ailure`

Ehy is heart ailure rele#ant`Ehy is heart ailure rele#ant`

Ehat is the history o mechanical circulatoryEhat is the history o mechanical circulatorysupport`support`

Ehat are the #arious types o #entricular assistEhat are the #arious types o #entricular assistde#ices 7VCDs9`de#ices 7VCDs9`



!ow and when are VCDs used`!ow and when are VCDs used`

Ehat is the ne't generation o VCDs`Ehat is the ne't generation o VCDs`

Etiologies of cardiacEtiologies of cardiac

failurefailure Coronar! arter! diseaseCoronar! arter! disease Idio"athic cardiom!o"ath! Idio"athic cardiom!o"ath!

Peri"artum cardiom!o"ath! Peri"artum cardiom!o"ath! Dilated cardiom!o"ath! Dilated cardiom!o"ath! Ischemic cardiom!o"ath! Ischemic cardiom!o"ath! Acute valvular disease Acute valvular disease Arrh!thmia -su"raventricular or ventricular Arrh!thmia -su"raventricular or ventricular M!ocarditisM!ocarditis Congenital heart diseaseCongenital heart disease



Congenital heart diseaseCongenital heart disease Drug inducedDrug induced Diaetes mellitusDiaetes mellitus

'!"ertension'!"ertension

Pathogenesis of 'eartPathogenesis of 'eart

FailureFailure



/ann, '. Cir(%lation 1999;1!!;999=1!!#

0'A classes0'A classes

ClassClass Patient SymptomsPatient Symptoms

Class I (Mild)Class I (Mild) No limitation of physical activity. Ordinary physicalNo limitation of physical activity. Ordinary physical

activity does not cause undue fatigue, palpitation, oractivity does not cause undue fatigue, palpitation, or

dyspnea (shortness of breath).dyspnea (shortness of breath).

Class II (Mild)Class II (Mild) Slight limitation of physical activity. Comfortable atSlight limitation of physical activity. Comfortable at

rest, but ordinary physical activity results in fatigue,rest, but ordinary physical activity results in fatigue,

palpitation, or dyspnea.palpitation, or dyspnea.

Class IIIClass III

(Moderate)(Moderate)

Marked limitation of physical activity. ComfortableMarked limitation of physical activity. Comfortable

at rest, but less than ordinary activity causes fatigue,at rest, but less than ordinary activity causes fatigue,palpitation, or dyspnea.palpitation, or dyspnea.



Class IV (Severe)Class IV (Severe) Unable to carry out any physical activity withoutUnable to carry out any physical activity without

discomfort. Symptoms of cardiac insufficiency atdiscomfort. Symptoms of cardiac insufficiency at

rest. If any physical activity is undertaken,rest. If any physical activity is undertaken,

discomfort is increased.discomfort is increased.

www.americanheart.org

ele4an(e



("tions for Advanced("tions for Advanced

C'FC'F 5ransplant 7UUUUUU95ransplant 7UUUUUU9

Cssist De#ice 7UUU9 Cssist De#ice 7UUU9

Die7U9Die7U9 "receded by </1> months o medical"receded by </1> months o medical

therapytherapy

)ultiple hospital re/admissions)ultiple hospital re/admissions



!ospice 7UUU9!ospice 7UUU9

ransplant



Short term DeviceShort term Device

o"tionso"tions

2rid&e to re(o4er)2rid&e to de(ision

<A2

*C/>

andem -eart

Aio/ed 5!!!Centrima&



<mpella

Cir(%lation 11 3: 3#

Intraaort c 1a oon Pum"ntraaort c a oon um"

-IA1P-IA1P

Developed in late 1960sDeveloped in late 1960s Counterpulsation is synchronized to the EKG orCounterpulsation is synchronized to the EKG or

arterial waveformsarterial waveforms

Increase coronary perfusionIncrease coronary perfusion

Decrease left ventricular stroke work andDecrease left ventricular stroke work andmyocardial oxygen requirementsmyocardial oxygen requirements

Most widely used form of mechanical circulatoryMost widely used form of mechanical circulatorysupportsupport

Indications for its use includeIndications for its use include

Failure to wean from cardiopulmonary bypassFailure to wean from cardiopulmonary bypass



Failure to wean from cardiopulmonary bypassw p y yp

Cardiogenic shock after MICardiogenic shock after MI

Heart failureHeart failure Refractory ventricular arrhythmias withRefractory ventricular arrhythmias with

ongoing ischemiaongoing ischemia

1ridge to ridge91ridge to ridge9

ECM(ECM( 8mmediately stabilize8mmediately stabilize

circulationcirculation

8mpro#e end organ perusion8mpro#e end organ perusion

%#erall sur#i#al comparable%#erall sur#i#al comparablebetween ,$)% [ LVCD #ersusbetween ,$)% [ LVCD #ersus

LVCD aloneLVCD alone

$linical indicators o poor$linical indicators o poor

outcome ater ,$)% consideroutcome ater ,$)% consider

VCD implantation careullyVCD implantation careully



VCD implantation careully VCD implantation careully

,le#ated blood lactate le#els,le#ated blood lactate le#els

,le#ated L-5s,le#ated L-5s8a&ani et al. Ann Thorac Sur& 2;;;< =;>?@==%

Centrifugal "um"sCentrifugal "um"s Ccute hemodynamic Ccute hemodynamic

supportsupport $ontinuous Bow$ontinuous Bow

,'tracorporeal,'tracorporeal LV& *V or bi#entricularLV& *V or bi#entricular

supportsupport Eide a#ailabilityEide a#ailability ,ase o use,ase o use

*elati#ely low cost*elati#ely low cost Limited duration o supportLimited duration o support



Fridge to reco#eryFridge to reco#ery Fridge to decisionFridge to decision

*o% et al, Ann T-orac !ur" .///0 1/2.3

TandemTandemheartshearts

Ccute hemodynamic support Ccute hemodynamic support $entriugal pump$entriugal pump "ercutaneous placement"ercutaneous placement

LV support #ia transseptalLV support #ia transseptalcannulacannula 4sed in high ris cardiac4sed in high ris cardiac



4sed in high ris cardiac4sed in high ris cardiaccatheterization procedurescatheterization procedures

*is o #ascular in6uries due*is o #ascular in6uries dueto cannula sizeto cannula size

Aiomed JGGG Aiomed JGGG ,'tracorporeal,'tracorporeal

"neumatic pulsatile"neumatic pulsatile

pumpspumps 4ni/ or bi#entricular4ni/ or bi#entricular

supportsupport


,asy to insert and,asy to insert and

operate so used inoperate so used in



operate so used inoperate so used in

community hospitalscommunity hospitals

-lows <LRmin-lows <LRmin#irculation. 2;;B<??2>CD%CC.

,ong term Device,ong term Device

o"tionso"tions

2rid&e to transplant

-eartmate <<-eartmate UV*

horate(



Jar4i !!! Cardioest A-

Cir(%lation 11 3: 3#

ThoratecThoratec

"neumatic pump"neumatic pump

LVCD& *VCD orLVCD& *VCD or

bi#entricular supportbi#entricular support

DurableDurable

$an be used in$an be used in

smaller patientssmaller patients

-lows OLRmin-lows OLRmin Fridge to reco#eryFridge to reco#ery



dge to eco e yg y


#irculation. 2;;B<??2>CD%CC.

'eartmate'eartmate

/E/E

"neumatic or #ented"neumatic or #entedelectric plateselectric plates

5e'tured internal suraces5e'tured internal suraces %nly let/sided support%nly let/sided support -lows 12LRmin-lows 12LRmin Fridge to transplantFridge to transplant -irst de#ice to be-irst de#ice to be

appro#ed or destinationappro#ed or destination

therapytherapy eed FSCM1+=eed FSCM1+= Limited durability hal lieLimited durability hal lie



Limited durability hal lieLimited durability hal lie1? months1? months

8nection ris with8nection ris withpercutaneous dri#e linepercutaneous dri#e line

#irculation. 2;;B<??2>CD%CC.

'eartmate'eartmate

IIII C'ial Bow C'ial Bow

LV supportLV support

-lows 12LRmin-lows 12LRmin Long term durabilityLong term durability


Cppro#ed anuary >212 Cppro#ed anuary >212

or destination therapyor destination therapy

%#er 222 de#ices%#er 222 de#ices



%#er 222 de#ices%#er 222 de#ices

implanted to dateimplanted to date

Im"lantation of deviceIm"lantation of device



N Engl J Med 2007;357:885-N Engl J Med 2007;357:885-

9696

Im"lantationIm"lantation



Device com"licationsDevice com"lications ,arly,arly

FleedingFleeding

*ight sided heart ailure*ight sided heart ailure "rogressi#e multiorgan system ailure"rogressi#e multiorgan system ailure

LateLate 8nection8nection

osocomialosocomial

De#ice relatedDe#ice related



De#ice relatedDe#ice related

5hromboembolism5hromboembolism

-ailure o de#ice-ailure o de#ice

Cellular ene&ts of /ADsCellular ene&ts of /ADs ormalization o fber orientationormalization o fber orientation

*egression o myocyte hypertrophy*egression o myocyte hypertrophy

*eduction in contraction band necrosis*eduction in contraction band necrosis *e#erse #entricular dilation*e#erse #entricular dilation

8mpro#ement in ,D"V* 8mpro#ement in ,D"V*

8mpro#ed e(iciency o myocardial8mpro#ed e(iciency o myocardialmitochondriamitochondria



*eduction in abnormalities along*eduction in abnormalities along

neurohormonal and cytoine pathwaysneurohormonal and cytoine pathways

Circulation, 4470472.651'.654

Indicators of "oorIndicators of "oor

clinical outcomeclinical outcome Cd#anced age Cd#anced age

8ndependent predictor o poor sur#i#al8ndependent predictor o poor sur#i#al 8ndependent predictor o poor bridge to transplant8ndependent predictor o poor bridge to transplant

IO3 post I2/day LVCD mortalityIO3 post I2/day LVCD mortality Cge limit` M<= yo contraindication to transplant Cge limit` M<= yo contraindication to transplant

-emale-emale 8ndependent predictor o poor sur#i#al8ndependent predictor o poor sur#i#al

8ndependent predictor o poor bridge to transplant8ndependent predictor o poor bridge to transplant !igher mortality!igher mortality

L iti ti t t l t d t i it iL iti ti t t l t d t i it i



Longer waiting time to transplant due to size criteriaLonger waiting time to transplant due to size criteria

8ncreased operati#e mortality8ncreased operati#e mortality Smaller FSC Smaller FSC 8mpaired wound healing8mpaired wound healing

JC !!5:13!;5: 13!=1311

Indicators of "oorIndicators of "oor

clinical outcomeclinical outcome

Diabetes mellitusDiabetes mellitus /old increased ris o early death/old increased ris o early death Cssociated with end organ ailure Cssociated with end organ ailure

*enal ailure*enal ailure

8ncreased allograt #asculopathy ater transplant8ncreased allograt #asculopathy ater transplant

5ype 8 D) is contraindication to transplant5ype 8 D) is contraindication to transplant

Low preoperati#e serum albuminLow preoperati#e serum albumin Surrogate measure o nutritional statusSurrogate measure o nutritional status



Surrogate measure o nutritional statusSurrogate measure o nutritional status 8ncreased inections and impaired wound healing8ncreased inections and impaired wound healing -or e#ery 1 mgRdL increase in albumin& had 1N+> times-or e#ery 1 mgRdL increase in albumin& had 1N+> times

increased lielihood or bridge to transplantincreased lielihood or bridge to transplant

JC !!5:13!;5: 13!=1311

M!ocardialM!ocardial

recover! recover! $ertain proportion o$ertain proportion o

idiopathic dilatedidiopathic dilatedcardiomyopathy patientscardiomyopathy patientsha#e potential orha#e potential orcomplete cardiaccomplete cardiacreco#ery 1=/>23reco#ery 1=/>23 Hounger age Hounger age

Shorter history o heartShorter history o heartailureailure

-aster and more complete-aster and more complete



-aster and more complete-aster and more completerestoration o pumprestoration o pumpunctionunction

Diminished fbrosis seen inDiminished fbrosis seen inmyocyte biopsiesmyocyte biopsies Ann T-orac !ur" .//0 12!/4'6

Congestive 'eartCongestive 'eart

FailureFailure

arrod ,ddy& ":H> arrod ,ddy& ":H>8nternal )edicine8nternal )edicine



Sub/8 Lecture SeriesSub/8 Lecture Series



Congestive 'eart FailureCongestive 'eart Failure $linical presentation o disease$linical presentation o disease

%5 a diagnosis in and o itsel %5 a diagnosis in and o itsel

Di(erential includesDi(erential includes 4nderlying cardio#ascular disease4nderlying cardio#ascular disease

"recipitating actors"recipitating actors



Predis"osing CardiacPredis"osing Cardiac

DiseasesDiseases )yocardial inarction)yocardial inarction

$hronic ischemia$hronic ischemia

$ardiomyopathy$ardiomyopathy Crrhythmias Crrhythmias

Diastolic dysunctionDiastolic dysunction

Val#ular diseases Val#ular diseases Cortic Stenosis Cortic Stenosis



)itral Stenosis)itral Stenosis

)itral *egurgitation)itral *egurgitation

Cardiac Ph!siolog! Cardiac Ph!siolog! -rememer thisK-rememer thisK

$% Z SV ' !* $% Z SV ' !*

!* parasympathetic and!* parasympathetic and

sympathetic tonesympathetic tone

SV preload& aterload& contractilitySV preload& aterload& contractility



PreloadPreload

DeDe Passi&e stretch of m'scle prior to Passi&e stretch of m'scle prior to

contractioncontraction

)easurement Swan/:anz)easurement Swan/:anz LV,D"LV,D"

*eally a unction o LV,DV *eally a unction o LV,DV

C(ected by C(ected by compliancecompliance Low compliance Z higher LV,D" lowerLow compliance Z higher LV,D" lower

LV,DV LV,DV



-alse high estimate o preload-alse high estimate o preload

-ran/Starling right`-ran/Starling right`

Afterload Afterload

DeDe Force opposingstretching Force opposingstretching

m'sclem'scle after after contraction beginscontraction begins

)easurement SV* )easurement SV*

*eally a unction o*eally a unction o SV* SV*

$hamber radius 7dilated$hamber radius 7dilated

cardiomyopathies9cardiomyopathies9



cardiomyopathies9cardiomyopathies9

Eall thicness 7hypertrophy9Eall thicness 7hypertrophy9

Contractilit! Contractilit!

DeDe %ormal ability of the m'scle to %ormal ability of the m'scle to

contract at a gi&en force for a gi&encontract at a gi&en force for a gi&en

stretchstretch independentindependent of preload orof preload orafterload forcesafterload forces

8n other words8n other words !ow healthy is your heart muscle`!ow healthy is your heart muscle`



8schemia& !ypertrophy 7`9& )uscle loss8schemia& !ypertrophy 7`9& )uscle loss

Classif!ing 'eart FailureClassif!ing 'eart Failure

Cnatomically Cnatomically Let #ersus *ightLet #ersus *ight

"hysiologically"hysiologically Systolic #ersus DiastolicSystolic #ersus Diastolic

-unctionally-unctionally



-unctionally-unctionally !ow symptomatic is your patient`!ow symptomatic is your patient`

,eft versus +ight Failure,eft versus +ight Failure

,eft 'eart Failure,eft 'eart Failure

/ Dyspnea/ Dyspnea

/ Dec+ e'ercise/ Dec+ e'ercisetolerancetolerance

/ $ough/ $ough

/ %rthopnea/ %rthopnea/ "in& rothy/ "in& rothy

+ight 'eart+i

ght 'eart

FailureFailure

/ Dec+ e'ercise/ Dec+ e'ercisetolerancetolerance

/ ,dema/ ,dema

/ !* R VD/ !* R VD/ !epatomegaly/ !epatomegaly



sputumsputum / Cscites/ Cscites

S!stolic versus DiastolicS!stolic versus Diastolic

SystolicS

ystolic_ ]canYt_ ]canYt

pump^pump^

Cortic Stenosis Cortic Stenosis !5!5

Cortic 8nsu(iciency Cortic 8nsu(iciency

)itral *egurgitation)itral *egurgitation

)uscle Loss)uscle Loss 8schemia8schemia

-ibrosis-ibrosis

DiastolicDiastolic/ ]canYt/ ]canYt

fll^fll^

)itral Stenosis)itral Stenosis 5amponade5amponade

!ypertrophy!ypertrophy

8nfltration8nfltration

-ibrosis-ibrosis



-ibrosis-ibrosis

8nfltration8nfltration

Clinical DataClinical Data

$;* $;* WerleyYs lines C and FWerleyYs lines C and F

"ulmonary ,dema"ulmonary ,dema $ephalization$ephalization "leural ,(usions 7bilateral9"leural ,(usions 7bilateral9

,W:,W: Let atrial enlargementLet atrial enlargement

h h



Crrhythmias Crrhythmias !ypertrophy 7let or right9!ypertrophy 7let or right9

C di th Pulmonary Edema



Cardiomyopathy Pulmonary Edema


*,A#$ S;<9S=== *,A#$ S;<9S===

Systolic )urmursSystolic )urmurs )itral *egurg)itral *egurg

Cortic Stenosis Cortic Stenosis

Diastolic )urmursDiastolic )urmurs

)itral Stenosis)itral Stenosis Cortic 8nsu(iciency Cortic 8nsu(iciency



S;S; *apid flling o a diseased #entricle *apid flling o a diseased #entricle


Laboratory DataLaboratory Data

$hemistry$hemistry *enal -unction Fe Eary*enal -unction Fe Eary

F"F" 4sed in ,* departments the world o#er4sed in ,* departments the world o#er :ood negati#e correlation:ood negati#e correlation



eed baseline or positi#ityeed baseline or positi#ity "ulmonary #ersus cardiac dyspnea"ulmonary #ersus cardiac dyspnea

Treatment of C'FTreatment of C'F

5reat "recipitating -actor7s9GGGG5reat "recipitating -actor7s9GGGG

Cd6ust !eart *ate Cd6ust !eart *ate

Decrease "reloadDecrease "reload

Decrease CterloadDecrease Cterload 8ncrease $ontractility8ncrease $ontractility



8ncrease %'ygenation8ncrease %'ygenation



Treatment of C'FTreatment of C'F

%'ygen _ nasal& Fi"C"& intubation%'ygen _ nasal& Fi"C"& intubation

)orphine)orphine

"reload *eduction"reload *eduction Loop diureticsLoop diuretics

itratesitrates

C$,i R C*F C$,i R C*F

)orphine)orphine



)orphine)orphine

'eart'eart

FailureFailure Cmanda *yan& D+%+ Cmanda *yan& D+%+

$ardiology -ellow$ardiology -ellow

-ebruary 1th >22?-ebruary 1th >22?



-ebruary 1th& >22?-ebruary 1th& >22?

+earning &1ectives

+olloin& this presentation, the

parti(ipant sho%ld e ale to: 1. e(o&nize the ma&nit%de of heart fail%re epidemi( and its p%li(health impli(ations

. 'istin&%ish the different (lassifi(ations and sta&es of heart fail%re

3. e4ie %nderl)in& pathoph)siolo&) of heart fail%re

. 'is(%ss si&ns and s)mptoms of heart fail%re e0a(eration

5. <dentif) (%rrent pra(ti(e &%idelines for treatment of a(%te



de(ompensated heart fail%re



It is an E"idemicIt is an E"idemic ,stimated that o#er = million Cmericans ha#e,stimated that o#er = million Cmericans ha#e

heart ailureheart ailure ,stimated =22&222 new cases per year,stimated =22&222 new cases per year Eithin = years& hal o those diagnosed will beEithin = years& hal o those diagnosed will be

deaddead %#er 1 million hospitalizations per year with !-%#er 1 million hospitalizations per year with !-

as primary diagnosisas primary diagnosis

)ost common reason or hospitalization in those)ost common reason or hospitalization in thoseM<= years oldM<= years old

?=3 o !- cases are in adults <= and older?=3 o !- cases are in adults <= and older



!eart ailure is !eart ailure is thth in a list o Xuality o carein a list o Xuality o care

initiati#es in #ulnerable older adultsinitiati#es in #ulnerable older adults

Costs of $eart 0ailure <t is the leadin& (a%se of hospitalization in patients older than 65 )ears

of a&e and is a primar) hospital dis(har&e dia&nosis in 1.1 millionpeople of all a&es ea(h )ear.

<t is one medi(al (ondition for hi(h mortalit) (ontin%es to in(rease.+rom 199 to !!, the o4erall death rate de(lined .!P in the Gnitedtates, %t deaths from -+ in(reased #P in the same time period.

A((ordin& to the National -eart, L%n&, and 2lood <nstit%te, the

estimated dire(t and indire(t (osts asso(iated ith -+ (are in the G is33. illion )earl).

he maOorit) of the (osts " appro0imatel) to=thirds " are attri%tale toth t f i d f t -+ d ti i



the mana&ement of episodes of a(%te -+ de(ompensation i.e.,hospitalization.

Di5erent 4a!s to De&neDi5erent 4a!s to De&ne

'F'F Dilated (congesti&e) cardiomyopathy Dilated (congesti&e) cardiomyopathy is a group o heartis a group o heart

muscle disorders in which the #entricles enlarge but aremuscle disorders in which the #entricles enlarge but arenot able to pump enough blood or the bodys needs&not able to pump enough blood or the bodys needs&resulting in heart ailure+ 7,'ample / $CD& myocarditis&resulting in heart ailure+ 7,'ample / $CD& myocarditis&,t%!& !8V9,t%!& !8V9

Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy includes a group o heartincludes a group o heartdisorders in which the walls o the #entricles thicendisorders in which the walls o the #entricles thicen7hypertrophy9 and become sti(& e#en though the7hypertrophy9 and become sti(& e#en though theworload o the heart is not increased+ 7,'ample _worload o the heart is not increased+ 7,'ample _

congenital !%$)& or acXuired9congenital !%$)& or acXuired9 "estricti&e (inltrati&e) cardiomyopathy "estricti&e (inltrati&e) cardiomyopathy includes a groupincludes a group

o heart disorders in which the walls o the #entricleso heart disorders in which the walls o the #entriclesb ti( b t t il thi d d i tb ti( b t t il thi d d i t



become sti(& but not necessarily thicened& and resistbecome sti(& but not necessarily thicened& and resistnormal flling with blood between heartbeats+ 7,'amplenormal flling with blood between heartbeats+ 7,'ample

_ radiation& amyloidosis9_ radiation& amyloidosis9


'F'F Diastolic /ersus S!stolic 'eart FailureDiastolic /ersus S!stolic 'eart Failure

C+ Systolic cardiac 7heart9 dysunction 7or systolic C+ Systolic cardiac 7heart9 dysunction 7or systolic

heart ailure9 occurs when the heart muscleheart ailure9 occurs when the heart muscledoesnt contract with enough orce& so there isdoesnt contract with enough orce& so there is

not enough o'ygen/rich blood to be pumpednot enough o'ygen/rich blood to be pumped

throughout the body+throughout the body+

F+ Diastolic cardiac dysunction 7or diastolic heartF+ Diastolic cardiac dysunction 7or diastolic heartailure9 occurs when the heart contractsailure9 occurs when the heart contracts

normally& but the #entricle doesnt rela'normally& but the #entricle doesnt rela'

l l bl d h hl l bl d t th h t



properly so less blood can enter the heart+properly so less blood can enter the heart+


'F'F $linically& patients are classifed as$linically& patients are classifed as

ha#ing !- oha#ing !- o ischemicischemic oror

nonischemicnonischemic etiology based on aetiology based on ahistory o myocardial inarction 7)89history o myocardial inarction 7)89

or based on ob6ecti#e e#idence oor based on ob6ecti#e e#idence o

coronary artery disease 7$CD9 suchcoronary artery disease 7$CD9 suchas angiography or unctional testing+as angiography or unctional testing+



Controversial .efinitions



Staging of 'eart FailureStaging of 'eart Failure



Ne' ?ork $eart *ssociation

• Class <: No o4io%s s)mptoms, no limitations on patientph)si(al a(ti4it) 35 per(ent.

• Class <<: ome s)mptoms d%rin& or after normal a(ti4it),mild ph)si(al a(ti4it) limitations 35 per(ent.

• Class <<<: )mptoms ith mild e0ertion, moderate to

si&nifi(ant ph)si(al a(ti4it) limitations 5 per(ent.

• Class <V: i&nifi(ant s)mptoms at rest, se4ere to total



& ) p ,ph)si(al a(ti4it) limitations 5 per(ent.

Causes of 'eart FailureCauses of 'eart Failure $oronary artery disease$oronary artery disease "roblems with the heart muscle itsel nown"roblems with the heart muscle itsel nown

as cardiomyopathy 7myocarditis& etc9as cardiomyopathy 7myocarditis& etc9 !ypertension!ypertension "roblems with any o the heart #al#es"roblems with any o the heart #al#es Cbnormal heart rhythms 7also called Cbnormal heart rhythms 7also called

arrhythmias9arrhythmias9

5o'ic substances 7,t%!& cocaine95o'ic substances 7,t%!& cocaine9 $ongenital heart disease$ongenital heart disease DiabetesDiabetes



5hyroid problems5hyroid problems

!8V !8V

.iastolic $0 'iastoli( heart fail%re is defined as a (ondition (a%sed ) in(reased resistan(e

to the fillin& of one or oth 4entri(les; this leads to s)mptoms of (on&estion fromthe inappropriate %pard shift of the diastoli( press%re=4ol%me relation.

!P of patients

<n(reasin& in(iden(e ith a&e

/ore (ommon in omen

-N and (ardia( is(hemia are most (ommon (a%ses

Common pre(ipitatin& fa(tors in(l%de 4ol%me o4erload; ta(h)(ardia; e0er(ise;h)pertension; is(hemia; s)stemi( stressors e.&., anemia, fe4er, infe(tion,th)roto0i(osis; arrh)thmia e.&., atrial firillation, atrio4entri(%lar nodal lo(;in(reased salt intae; and %se of nonsteroidal anti=inflammator) dr%&s.



) &

More Aout DiastolicMore Aout Diastolic

D!sfunctionD!sfunction Alterations involve relaxation and/orAlterations involve relaxation and/or

filling and/or distensibility.filling and/or distensibility.

Arterial hypertension associated toArterial hypertension associated toLV concentric remodelling is the mainLV concentric remodelling is the main

determinant of DD but several otherdeterminant of DD but several other

cardiac diseases, includingcardiac diseases, includingmyocardial ischemia, and extra-myocardial ischemia, and extra-

di th l i l iblca diac pathologies also possible



cardiac pathologies also possible.cardiac pathologies also possible.

Stages of DiastoleStages of Diastole .. Isovolumetric relaxation Isovolumetric relaxation,, period occurring bet!een the end of LVperiod occurring bet!een the end of LV

systolic e"ection #$ aortic valve closure% and the opening of the mitralsystolic e"ection #$ aortic valve closure% and the opening of the mitralvalve, !hen LV pressure &eeps going its rapid fall !hile LV volumevalve, !hen LV pressure &eeps going its rapid fall !hile LV volumeremains constant.remains constant.

'.'. LV rapid fillingLV rapid filling, !hich begins !hen LV pressure falls belo! left, !hich begins !hen LV pressure falls belo! leftatrial pressure and the mitral valve opens. During this period the bloodatrial pressure and the mitral valve opens. During this period the bloodhas an acceleration !hich achieves a maximal velocity, direct relatedhas an acceleration !hich achieves a maximal velocity, direct relatedto the magnitude of atrio-ventricular pressure, and stops !hen thisto the magnitude of atrio-ventricular pressure, and stops !hen thisgradient ends.gradient ends.

(.(. diastasisdiastasis, !hen left atrial and LV pressures are almost e)ual and, !hen left atrial and LV pressures are almost e)ual andLV filling is essentially maintained by the flo! coming from pulmonaryLV filling is essentially maintained by the flo! coming from pulmonary

veins * !ith left atrium representing a passive conduit * !ith anveins * !ith left atrium representing a passive conduit * !ith anamount depending of LV pressure, function of LV +compliance+.amount depending of LV pressure, function of LV +compliance+.

.. atrial systoleatrial systole,, !hich corresponds to left atrial contraction and ends!hich corresponds to left atrial contraction and endsat the mitral valve closure. his period is mainly influenced by LVat the mitral valve closure. his period is mainly influenced by LV

li b t d d l b th i di l i t b thli b t d d l b th i di l i t b th



compliance, but depends also by the pericardial resistance, by thecompliance, but depends also by the pericardial resistance, by theatrial force and by the atrio-ventricular synchronicity #$ 0 12atrial force and by the atrio-ventricular synchronicity #$ 0 12interval%.interval%.

Patient .ifferences

-+ is a hemod)nami( disorder %t there is apoor relationship eteen meas%res of(ardia( performan(e and patient s)mptoms

+or e0ample, pts ith 4er) lo *+ ma) eas)mptomati( hile someone ith preser4ed

*+ ma) e se4erel) disaled ith s)mptoms



Body Compensatory

echanisms *pinephrine and norepinephrine release hi(h in(reases heart rate and

(ontra(tilit) hi(h in(reased m)o(ardial or load

'e(rease salt and ater e0(retion from idne)s hi(h helps maintain2 ) in(reasin& lood 4ol%me, this leads to stret(hin& of heartWs(hamers hi(h (an impair ailit) to (ontra(t

-)pertroph) and thi(enin& of heart m%s(le hi(h initiall) in(reases(ontra(tilit) %t o4er time leads to stiff (hamers and (an impair(ontra(tilit)

-+ patients ha4e hi&her le4els of epinephrine, norepinephrine,aldosterone, an&iotensin <<, endothelin, inflammator) ()toines, and4asopressin hi(h (ontri%te to heart remodelin&, pro&ression of -+,

d hi h l l i t d ith i d t lit



and hi&her le4els are asso(iated ith in(reased mortalit)

Potential +easonsPotential +easons Clternation in #entricular distensibility Clternation in #entricular distensibility

Val#ular regurgitation Val#ular regurgitation

"ericardial restraint"ericardial restraint $ardiac rhythm$ardiac rhythm

$onduction abnormalities$onduction abnormalities

*V unction*V unction Clso se#eral non/cardiac actors including Clso se#eral non/cardiac actors including

peripheral #ascular 'n reBe' autonomicperipheral #ascular 'n reBe' autonomic



peripheral #ascular 'n& reBe' autonomicperipheral #ascular 'n& reBe' autonomic

acti#ity& renal sodium handling& etc+acti#ity& renal sodium handling& etc+

'F +is3 Factors % 'istor! 'F +is3 Factors % 'istor! SmoingSmoing

,t%! use,t%! use

D)D) !5!5

DyslipidemiaDyslipidemia

5hyroid disorder5hyroid disorder $hemotherapy$hemotherapy

* di ti* di ti

$ardioto'ic drugs$ardioto'ic drugs

-am !' o sudden-am !' o sudden

death& $CD&death& $CD&conductionconduction

problems& !$)problems& !$)

!8V status!8V status



*adiation*adiation

Cardiovascular MedicalCardiovascular Medical

'# '# !' o heart ailure!' o heart ailure

Cngina Cngina

)8)8 $CF:$CF:

"$8"$8

"acemaerR8$D"acemaerR8$D

,mbolic e#ents,mbolic e#ents

arrhythmiasarrhythmias

$VC $VC "VD"VD

*heumatic D'*heumatic D'

%ther #al#ular h'%ther #al#ular h' $ongenital$ongenital



Signs and S!m"toms ofSigns and S!m"toms of

'F'F DyspneaDyspnea

"D"D

%rthopnea%rthopnea $ough$ough

,'ercise intolerance,'ercise intolerance

,dema,dema -atigue-atigue

auseaausea

*ales*ales

SISI

"ulmonary edema"ulmonary edema VD VD


$ardiomegaly$ardiomegaly

!epato6ugular reBe'!epato6ugular reBe'

"eripheral ,dema"eripheral ,dema



auseaausea

Cbdominal -ullness Cbdominal -ullness !epatomegaly!epatomegaly

'F Diagnosis and'F Diagnosis and

Assessment Assessment *emains primarily a clinical*emains primarily a clinical

diagnosis but additional inormationdiagnosis but additional inormation

#ia other diagnostics can be #ia other diagnostics can bebenefcialbenefcial

,#aluation depends on i this is frst,#aluation depends on i this is frst

presentation& change in clinicalpresentation& change in clinicalsymptoms& certainty o diagnosis& etcsymptoms& certainty o diagnosis& etc



N&*+

*symptomatic+" .ysfunction

Compensated

C$0.ecompensatedC$0

No symptoms

Normal e/ercise

Normal +" f/n

No symptoms

Normal e/ercise

*normal +" f/nNo symptoms

E/ercise

*normal +" f/n

% t f t

Chronic Congestive 'eartChronic Congestive 'eart

FailureFailure

Evolution of Clinical StagesEvolution of Clinical Stages



%ymptoms

E/ercise

*normal +" f/n

efractoryC$0

%ymptoms not controlled

'ith treatment

/entricular +emodeling /entricular +emodeling

in C'Fin C'F



essup1 NEM 2;;

S!m"toms of 'FS!m"toms of 'F

FFatigueatigue

A A cti#ity decreasecti#ity decreaseCCough 7especially supine9ough 7especially supine9

EE

demadema

SShortness o breathhortness o breath



DIT A""roac to t e""roac to t e

Patient 4ith 'eartPatient 4ith 'eart

FailureFailure iagnoseiagnose

,tiology,tiology

Se#erity 7LVSe#erity 7LVdysunction9dysunction9

I I nitiatenitiate DiureticRC$,DiureticRC$,

inhibitorinhibitor ββ/blocer/blocer

SpirololactoneSpirololactone

, , ducateducate DietDiet

,'ercise,'ercise LiestyleLiestyle

$V *is $V *is

$ $ itrateitrate %ptimize C$,%ptimize C$,

inhibitorinhibitor

%ptimize%ptimize ββ blocer/blocer



SpirololactoneSpirololactone

Digo'inDigo'in

%ptimize%ptimize ββ/blocer/blocer



Symptoms . Signs o !-Symptoms . Signs o !-

• -atigue 7low cardiac out/put9-atigue 7low cardiac out/put9• S%FS%F∀ ↑↑ V" V"• *ales*ales• SISI• ,dema,dema• *adiologic congestion*adiologic congestion• $ardiomegaly$ardiomegaly

%btain $;* to rRo non/cardiac causes e+g+%btain $;* to rRo non/cardiac causes e+g+



gginterstitial lung disease . ""!interstitial lung disease . ""!

10P in the Diagnosis of 'F10P in the Diagnosis of 'F5he role o natriuretic peptides5he role o natriuretic peptides C"/atrial natriuretic peptide C"/atrial natriuretic peptide

"roduced in atria in response to wall stress"roduced in atria in response to wall stress

F"/brain natriuretic peptidesF"/brain natriuretic peptides "roduced in #entricles in response to #olume and"roduced in #entricles in response to #olume and

pressure o#erloadpressure o#erload

$"/central ner#ous system and endothelium$"/central ner#ous system and endothelium

"roduced in response to endothelial stress"roduced in response to endothelial stress "roduced as prohormones and clea#ed to acti#e"roduced as prohormones and clea#ed to acti#e

molecule 7C"RF"9and inacti#e 5 ormsmolecule 7C"RF"9and inacti#e 5 orms



10P in the Diagnosis of 'F10P in the Diagnosis of 'F C"RF" ele#ated in C"RF" ele#ated in !eart ailure!eart ailure

Systemic and pulmonary hypertensionSystemic and pulmonary hypertension !ypertrophic and restricti#e cardiomyopathy!ypertrophic and restricti#e cardiomyopathy

"ulmonary embolism"ulmonary embolism

$%"D$%"D

$or pulmonale$or pulmonale C)8 $irrhosis C)8 $irrhosis

*enal -ailure*enal -ailure



*enal -ailure*enal -ailure

10P in the Diagnosis of 'F10P in the Diagnosis of 'F!igher le#els o F" correlate with!igher le#els o F" correlate with

higher "$E pressureshigher "$E pressures

in compensated and decompensated patientsin compensated and decompensated patients larger LV #olumeslarger LV #olumes

lower e6ection ractionslower e6ection ractions

in symptomatic !- patientsin symptomatic !- patients F" studyF" study (Circ .//.*0/12 301-3..)(Circ .//.*0/12 301-3..)

F" sensiti#ity N23 and specifcity OI3 orF" sensiti#ity N23 and specifcity OI3 or



!-!-

10P Diagnostic Cut Points10P Diagnostic Cut Points

for C'Ffor C'F

>ACC 2881?5(2&:57"64. >ACC 2881?5(2&:57"64. F" M 22 pgRL _ acute $!- presentF" M 22 pgRL _ acute $!- present

F" 122 pgRL _ 22 pgRLF" 122 pgRL _ 22 pgRL

• Diagnostic o $!- withDiagnostic o $!- with Sensiti#ity N23Sensiti#ity N23 Specifcity O<3Specifcity O<3 "redicti#e accuracy ?I3"redicti#e accuracy ?I3

*R% pulmonary embolism& LV dysunction*R% pulmonary embolism& LV dysunctionwithout acute $!- or cor pulmonalewithout acute $!- or cor pulmonale

F" 0 122 pgRL _ N?3 negati#e predicti#eF" 0 122 pgRL _ N?3 negati#e predicti#e



accuracyaccuracy

8dentiy triggers8dentiy triggers

Acute%sudden Acute%sudden

onsetonset

8schaemia8schaemia Crrhythmia Crrhythmia 8nection8nection

"ulmonary"ulmonaryembolismembolism

Ccute #al#ular Ccute #al#ular

Chronic%gradualChronic%gradual

onsetonset Cnemia Cnemia 5hyroto'icosis5hyroto'icosis

on/complianceon/compliance DietDiet *' e+g+ SC8DYs*' e+g+ SC8DYs



pathologypathology

gg

0on%Invas ve Eva uat on o t eon% nvas ve va uat on o t e

'eart Failure Patient%Im"lications'eart Failure Patient%Im"lications

of ,/ E:ection Fractionof ,/ E:ection Fraction 5o now where you5o now where you

are going you mustare going you must

now where younow where youare coming romare coming rom

,#aluate LV,#aluate LV

unctionunction

− clinicalclinical− echoecho

− gated studygated study



gated studygated study

,6ection raction,6ection raction

7obtain echo or LV gated study97obtain echo or LV gated study9• LV,-LV,- ≤≤ 23 Z systolic dysunction23 Z systolic dysunction• LV,- 2/==3 Z mi'ed systolic andLV,- 2/==3 Z mi'ed systolic and

diastolic dysunctiondiastolic dysunction• LV,-LV,- ≥≥ ==3 Z diastolic dysunction==3 Z diastolic dysunction− identiy triggersidentiy triggers treat underlying disordertreat underlying disorder

7!"5RischaemiaRpericardial7!"5RischaemiaRpericardialconstrictionRrestricti#econstrictionRrestricti#e$)Rinfltrati#e disorders9$)Rinfltrati#e disorders9



$)Rinfltrati#e disorders9$)Rinfltrati#e disorders9

EvaluationEvaluation

of C'Fof C'F LV unctionLV unction

7,-9&chamber size&wall7,-9&chamber size&wall

motionmotion

Segmental dysunction/Segmental dysunction/coronary diseasecoronary disease

)S/se#erity& #al#e area)S/se#erity& #al#e area

CS/ #al#e gradient& CS/ #al#e gradient&

#al#e area #al#e area C*R)* se#erity C*R)* se#erity

5*/ *V systolic5*/ *V systolic

*V unction*V unction

*R% 8!SS& !$)*R% 8!SS& !$)

*R% "ericardial*R% "ericardialDiseaseDisease

*R% rare causes e+g+*R% rare causes e+g+

my'oma& infltrati#emy'oma& infltrati#e

disorders/ restricti#edisorders/ restricti#e

cardiomyopathycardiomyopathy

Diastolic unctionDiastolic unction

!yperdynamic states!yperdynamic states



pressure Z "C pressurepressure Z "C pressure !yperdynamic states!yperdynamic states

Diastolic D!sfunctionDiastolic D!sfunction

I2/=23 o elderly !- patients ha#eI2/=23 o elderly !- patients ha#e

reser#ed LV systolic unctionreser#ed LV systolic unction

Diastolic dysunction may induceDiastolic dysunction may inducedyspnea on e'ertiondyspnea on e'ertion

-ran congestion usually has-ran congestion usually has

identifable precipitantidentifable precipitant



,/ D!sfunction in 'eart,/ D!sfunction in 'eart

FailureFailure $alculated ,- by$alculated ,- by

echo unreliable inecho unreliable in

remodeled LV remodeled LV Visual estimate o ,- Visual estimate o ,-

semi/Xuantitati#esemi/Xuantitati#e

7$$ LV unction7$$ LV unction

scale9scale9 :rade 8 LV ,-:rade 8 LV ,- =23=23

:rade > LV,- I=/N3:rade > LV,- I=/N3

:rade I LV,- >2/I3:rade I LV,- >2/I3

,/EF Entr! Criteria in,/EF Entr! Criteria in

ACE inhiitor and ACE inhiitor and

β%loc3er Trials%loc3er Trials

S%LVD treatment anS%LVD treatment an

pre#entionpre#ention ≤≤ I=3I=3

SCV, 7post )89SCV, 7post )89 ≤≤ 2323

4+S+ $ar#edilol !- 5rials4+S+ $ar#edilol !- 5rials

"rogram LV,-"rogram LV,- ≤≤ I=3I=3 )erit/!- LV,-)erit/!- LV,- ≤≤ 2323

$8F8S 88 LV,-$8F8S 88 LV,- ≤≤ 2323



:rade LV,-0 >23:rade LV,-0 >23

$onsider etiology$onsider etiology

• 8schemic/ $ardiomyopathy 7$)98schemic/ $ardiomyopathy 7$)9• !"5/$)!"5/$)•

Val#ular !D/$) 7CSRC*R)*9 Val#ular !D/$) 7CSRC*R)*9• )etabolic)etabolic− ↑↑RR↓↓ thyroidRhemochromatosisRthyroidRhemochromatosisR

pheochromocytomapheochromocytoma• 5o'ins5o'ins

− CnthracyclinesR,tohRcocaineRamphetamines CnthracyclinesR,tohRcocaineRamphetamines• Viral $) Viral $)• 8diopathic Dilated $)8diopathic Dilated $)• %ther%ther



• %ther%ther

5reatment5reatment

:eneral )easures:eneral )easures:eneral:eneral

measuresmeasures• $orrect triggers and$orrect triggers and

precipitants o acuteprecipitants o acute

and chronic !-and chronic !-

• Low sodium dietLow sodium diet

• -luid restriction-luid restriction• *egular e'erciseR*egular e'erciseR• Ccti#ity !* *'Ccti#ity !* *'

• 5reat ischemia5reat ischemia• $ontrol$ontrol

hypertensionhypertension• DR$ SmoingDR$ Smoing• 5reat lipid5reat lipid

abnormalitiesabnormalities

• 5reat and control5reat and controldiabetesdiabetes

• 8dentiy . *'8dentiy . *'d



Ccti#ity !* *' Ccti#ity !* *'depressiondepression

'ia&nosti( ests:CU?*CK?±2N

*(ho?NA?/<:*tiolo&)?e4erit)

*dditional Tests±%pecific T/

$Cath$CA2K

$Val4e 0

'iastoli( -+:0 (a%se±eferral

)stoli( -+:/edi(al±0?'e4i(e

<s it -eart +ail%reX)mptoms S i&ns

'F Managementanagemen

Algorithm Algorithm

4ES

4ES



Life t)le @

atient *d%(ation± -+ Clini(s +?G

Pr mar! Targets or mar! argets o

TreatmentsTreatments

in C'Fin C'F



essup1 NEM 2;;

Assess +unction 7eco' 4ate" <NA

+ I )0JBs&stolic "&s*unction

+ )0B@@JBs&stolic/"iastolic "&s*unction

+ K@@JB"iastolic "&s*unction

Assess olu$e Status

Si4ns an" S&$%to$s o*

+lui" <etention

No Si4ns an" S&$%to$s

o* +lui" <etention

oo% iuretic

L/B iaFi"e

7titrate to eu6ole$ic state

A# iniitor/A<! i* A# intolerant

#o$ination <E i* ↑ H+' os%italiFation or βBlocker intolerant

S&$%to$s =ro4nosis S&$%to$s

β



7titrate to eu6ole$ic state

S%ironolactone7NYHA #lass B #H+/+I3@J/#rI200/GI@

A"" i4oEin *ors&$%to$ control

βBlocker 7NYHA B


Thera"eutic LoalThera"eutic Loal )ild/)oderate !eart -ailure)ild/)oderate !eart -ailure

"rimary goal Z *educe mortality"rimary goal Z *educe mortality

ββ/blocers [ C$, inhibitors/blocers [ C$, inhibitors

"re#ent progression to"re#ent progression to

symptomssymptoms"re#ent progressi#e LV"re#ent progressi#e LV






Thera"eutic LoalThera"eutic Loal )oderate/Se#ere !eart -ailure)oderate/Se#ere !eart -ailure

"rimary goal Z *educe"rimary goal Z *educe

symptomssymptoms

8mpro#e Xuality o lie 7Q%L98mpro#e Xuality o lie 7Q%L9

*educe hospitalizations*educe hospitalizations"re#ent sudden death"re#ent sudden death



notro%es' $itral re%air' A' Enotro%es' $itral re%air' A' E

Leneral +# Strategies inLeneral +# Strategies in

'F'F

An4iotensin #on6ertin4 nF&$e niitorsAn4iotensin #on6ertin4 nF&$e niitors

#ar6e"ilol/#ar6e"ilol/ ββB!lockersB!lockers

iuretics 7S%ironolactoneiuretics 7S%ironolactone

i4oEini4oEinailore" <Eailore" <ECorrect Cau'e:Correct Cau'e:

Arrh&thmia' Arrh&thmia'

'chemia 'chemia

re''ure oad re''ure oad

A'&m(tomatic A'&m(tomatic Mild7Mod Mild7Mod Se%ereSe%ere *e1ractor& *e1ractor&



No A""e" Salt No A""e" Salt 2 4$ Na2 4$ Na

Acti6it& as olerate"Acti6it& as olerate" #usto$iFe" E rainin4#usto$iFe" E rainin4 Modi1ied 1rom ar#er-Ste%e#'o# ACC $3 Summit Modi1ied 1rom ar#er-Ste%e#'o# ACC $3 Summit

Severit! of 'eartSeverit! of 'eart

FailureFailureModes of DeathModes of Death

A=RA=R

=KR=KR

JKRJKR

C$0C$0

&ther &ther

%udden%udden.eath.eathn B 1!3n B 1!3

N?$* --N?$* --

=JR=JR

AFRAFR

FRFR

C$0C$0

&ther &ther

%udden%udden.eath.eath

n B 1!3n B 1!3

N?$* ---N?$* ---

FJRFJRLLRLLR

C$0C$0

&ther &ther

N?$* -"N?$* -"



/*<=-+ t%d) Kro%p. %$NCE#

1999;353:!!1=!.

AARAAR

%udden%udden

.eath

.eathn B n B

Thera"ies Provided !Thera"ies Provided !

Toda!’sToda!’sDual%Chamer ICDsDual%Chamer ICDs

Ctrium . Ctrium . Ventricle Ventricle

Fradycardia sensingFradycardia sensing

d dF d di i

"tri(m

"7#"% tachyarrhythmiadetection

"ntitachycardia acin!

Cardio3ersion

5entricle

57# 5% detection



Fradycardia pacingFradycardia pacing "ntitachycardia acin!

Cardio3ersion

/e+ibrillation

Car acar ac

+es!nchroni7ation+es!nchroni7ation

Thera"! -C+TThera"! -C+T Ctrial/bi#entricular Ctrial/bi#entricular

stimulationstimulation

,lectrical,lectricalsynchronizationsynchronization narrower Q*Snarrower Q*S

)echanical)echanical

synchronizationsynchronization re#ersere#erse

remodelingremodeling



gg

%tages of $eart 0ailure

At Ris" for #eart $ail%re

%T*GE * $igh risk for developing $0

%T*GE B *symptomatic +" dysfunction

#eart $ail%re%T*GE C Past or current symptoms of $0

%T*GE . End stage $0



%T*GE . End4stage $0

Ccute heart ailure Ccute heart ailure

A'F9 A'F9 5he rapid onset o symptoms and signs secondary to5he rapid onset o symptoms and signs secondary toabnormal cardiac unction+ abnormal cardiac unction+

7reduced $%& tissue hypoperusion [ congestion& increase in "$E"97reduced $%& tissue hypoperusion [ congestion& increase in "$E"9

8.8. Eith or without pre#ious cardiac disease+Eith or without pre#ious cardiac disease+

?.?. 5he cardiac dysunction can be related5he cardiac dysunction can be related

a9 to systolic or diastolic dysunctiona9 to systolic or diastolic dysunction

b9 to abnormalities in cardiac rhythmb9 to abnormalities in cardiac rhythm

c9 to preload and aterload mismatchc9 to preload and aterload mismatch;.;. %ten lie threatening and reXuires urgent treatment+%ten lie threatening and reXuires urgent treatment+



The Tas3 Force on Acute 'eart Failure of the Euro"ean Societ! of Cardiolog! The Tas3 Force on Acute 'eart Failure of the Euro"ean Societ! of Cardiolog!

70&8*. 0*-+9E: (+o' Cardiac &utput)#.ecreased perfusion of the rain (confusion)6

kidneys (impaired renal function),

skin (cyanosis) etc6

7

7B*C28*.

0*-+9E:

#

-ncreasedpulmonary

venous pressure,

pulmonary edema



Ccute heart ailure Ccute heart ailure

,pidemiology,pidemiology 8ncrease o pts with $!- 7aging o population [8ncrease o pts with $!- 7aging o population [

impro#ed sur#i#al9 Z increase in the number oimpro#ed sur#i#al9 Z increase in the number ohospitalisations or the decompensated heart ailure +hospitalisations or the decompensated heart ailure +

"oor prognosis"oor prognosis AMI R S'F AMI R S'F99 I23 annual mortalityI23 annual mortality AP(9 AP(9 23 annual23 annual mortalitymortality

1>3 in/hospital mortality1>3 in/hospital mortality

1+1+ $CD$CD <2/O23 7particularly in elderly population9<2/O23 7particularly in elderly population9>+>+ Dilated cardiomyopathy& arrhythmia& congenital or V!D orDilated cardiomyopathy& arrhythmia& congenital or V!D or

myocarditismyocarditis in youmger sub6ects+in youmger sub6ects+



7he 7as* %orce on "c(te $eart %ail(re o+ the E(roean Society o+ Cardiolo!y7he 7as* %orce on "c(te $eart %ail(re o+ the E(roean Society o+ Cardiolo!y

Ccute !eart -ailure Ccute !eart -ailure

$lassifcation$lassifcation

Ccute de no#o 7new onset o C!- in a Ccute de no#o 7new onset o C!- in apatient without pre#iously nownpatient without pre#iously nown

cardiac dysunction9+cardiac dysunction9+

oror Ccute decompensation o chronic Ccute decompensation o chronic

heart ailureheart ailure

Can resent itsel+ as:Can resent itsel+ as:



heart ailure+heart ailure+

7he 7as* %orce on "c(te $eart %ail(re o+ the E(roean Society o+ Cardiolo!y7he 7as* %orce on "c(te $eart %ail(re o+ the E(roean Society o+ Cardiolo!y



*PHARMACOLOGICAL !RA!"GI" # 3e! drugs.

1harmacogenetics.

4etabolic modulation. 5mmunomodulation.

*$onp%armacological trategies# 4yocardial repair and regeneration by6

•7tem cell89 progenetorcells•issue engineering

*Gene t%erapy&

*'"VIC" !H"RAP(#

2

3: VAD



* I$!"RV"$!IO$&



New drugs• NEW ENOTROPICS.

• AQUARETICS &NATRIURETICS.

• ENDOTHELIN ANTAGONISTS.

•NEW B-BLOCKERS.

•BROMOCRIBTIN.



Ada"tation in 'F% Ada"tation in 'F%S!m"atheticS!m"athetic

nervous s!stem is activatednervous s!stem is activated-eart rate↑+or(e of (ontra(tion↑'ilatation of (oronar)

arteries

erif. 4as(%lar resistan(eedistri%tion renal loods%ppl)↓'ire(t ()toto0i( effe(t



)

Apoptosis↑ A(ti4ation of the AA

Ada"tation% Ada"tation% Activation of Activation of

curs ic- -ic si ci --final -11- nov 2013

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