heart failure for koas

7/25/2019 Heart Failure for Koas

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Heart Failure: Living

with a Hurting Heart


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Congestive Heart Failure

Heart (or cardiac) failureis the state inwhich the heart is unable to pump blood at arate commensurate with the requirements of

the tissues or can do so only from highpressures

Braunwald 8

th

Edition, 2001


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Framingham Criteria for Congestive HeartFailure

Diagnosis of C! requires the simultaneous

presence of at least 2 ma"or criteria or 1 ma"orcriterion in con"unction with 2 minor criteria#

$he !ramingham eart %tudy criteria are 100&

sensiti'e and (8& speci)c for identifying personswith de)nite congesti'e heart failure#

Congestive Heart Failure


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Major symptoms Minor symptoms *aro+ysmal nocturnal dyspnea ec- 'ein distention .ales .adiographic cardiomegaly

/increasing heart sie on chestradiography

cute pulmonary edema %3 gallop 4ncreased central 'enous

pressure /516 cm 27 at rightatrium

epato"ugular reu+ 9eight loss 5:#; -g in ; days in

response to treatment

Bilateral an-le edema octurnal cough Dyspnea on ordinary e+ertion epatomegaly *leural e


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normal heart pumps blood in a smooth and

synchronied way#


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eart !ailureeart

heart failure heart has a reduced ability to

pump blood#


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%ystolic /or squeeing heart failure Decreased pumping function of the heart, which

results in uid bac- up in the lungs and heartfailure

Diastolic /or rela+ation heart failure 4n'ol'es a thic-ened and sti< heart muscle

s a result, the heart does not )ll with bloodproperly

$his results in uid bac-up in the lungs and heartfailure

!ypes of Heart Failure


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%igns and %ymptoms fatigue, wea-ness,lethargy

wt# gain, inc# abd#girth, anore+ia

ele'ated nec- 'eins

epatomegaly >?. may not see signs of@A!

"ight Heart Failure


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9hat does this

show


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9hat is this called

Can #ou Have "$F %ithout L$F&

COR PULMONALE


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CAD=coronary artery disease; LVH=left ventricular hypertrophy.

Coronary arterydisease

ypertension /@A Aal'ular heart

disease lcoholism

4nfection /'iral

Diabetes Congenital heart defects 7ther

7besity

ge

%mo-ing

igh or low hematocrit le

7bstructi'e %leep pnea

"is' Factors for Heart Failure


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ore deaths from heartfailure than from all formsof cancer combined

;;0,000 new cases=year

:#( million symptomaticpatients estimated 10million in 203(

pidemiology of Heart Failurein the S

F.ich #J Am Geriatric Soc# 1GG(:;G68HG(:#

merican eart ssociation# 2001 Heart and Stroke Statistical Update# 2000#

*+,

-+.

/0

0

1

-

2

3

/0

/1

/44/ 1000 10*.5

H

eartFailure6atientsinS

(Millio

ns)


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*leural e


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FFigh ris- of fatal dysrhythmias /e#g#,sudden cardiac death, 'entriculartachycardia with ! and an E! J3;&

! lead to se'ere hepatomegaly, especiallywith .A failure

!ibrosis and cirrhosis I de'elop o'er time

.enal insuKciency or failure

Heart FailureComplications


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Classifying Heart Failure:

!erminology and Staging


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E"ection !raction /E! E"ection !raction /E! is the percentage of

blood that is pumped out of your heartduring each beat

7ey 8ndicator for 9iagnosingHeart Failure


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Classication of HF: Comparison ;etweenCC


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edical history is ta-en to re'eal symptoms *hysical e+am is done$ests

Chest LIray

Blood tests

Electrical tracing of heart /Electrocardiogram or

MECNO

Pltrasound of heart /Echocardiogram or MEchoO

LIray of the inside of blood 'essels /ngiogram

How Heart Failure 8s 9iagnosed


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Cardiomegaly


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6ulmonary vessel congestion


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6ulmonary dema due to HeartFailure


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7erley ; lines


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eart rate.hythmConduction 4schaemic

4nfarctionypertrophyBBB

*rolonged Q$ inter'al*erimyocarditis

C>


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%hould be perform as soon as possibleCardiomegalyCongestion

E


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Blood countElectrolyte /a, RPrea, creatinineNlucoselbuminepatic enymes 4.

Cardiac mar-ersatriuretic peptides /B* S $Ipro B*

LaAoratory test

rterial Alood gas


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ssessment of o+ygenation /p72

.espiratory function /pC72

cidIbase balance /p%hould be assessed in se'ere respiratory

distress

rterial Alood gasanalysis


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Neneral )ndings %ie and shape of the 'entricle @A e"ection fraction /@AE! .egional wall motion synchronicity of 'entricular

contraction

@A remodeling /concentric 'ersus eccentric @A or .A hypertrophy /DDThypertension, C7*D,

'al'e disease

orphology and se'erity of 'al'e lesions itral inow and aortic outow properties .A

pressure gradient 7utput state /low or high

chocardiography

chocardiography


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%ystolic dysfunction .educed @AE! /J:;& Enlarged left 'entricle$hin @A wall Eccentric @A remodeling ild or moderate mitral regurgitation *ulmonary hypertension .educed mitral )lling

%igns of increased )lling pressure

chocardiography(cont+)

chocardiography


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Diastolic dysfunction ormal @AE! /U:;&I;0& ormal @A sie$hic- @A wall, dilated atria

Concentric @A remodeling o or minimal mitral regurgitation *ulmonary hypertension bnormal mitral )lling pattern

%igns of increased )lling pressure

chocardiography(cont+)


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Cardiac Magnetic "esonance 8maging

Dar- blood imaging 9all thic-ness, morphology of the

myocardium, tumor masses

Bright blood imaging 9all thic-ness, geometry of the'entricle

yocardial tagging Cardiac rotation, shear motion,torsion, myocardial twist

*hase contrast imaging Blood ow 'elocity, cardiacoutput, pressure gradients

Contrast enhancement yocardial )brosis, ischemicone, infarct sie

. coronary angiography Coronary anatomy, coronaryplaques

%tress imaging 9all motion abnormalities,recruitable stro-e wor-, ischemicterritory

*erfusion and di


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eart failure patients with angina *atients with prior myocardial infarction or -nown

coronary artery disease *atients /younger than 6; yr with une+plained

heart failure *ositi'e e+ercise test in patients with

cardio'ascular ris- factors eart failure patients with positi'e scintigraphy,

stress echocardiography, or positron emissiontomography results eart failure patients with se'erely dys-inetic

myocardium

8ndications for Coronary ngiography


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6athophysiology

6athologic 6rogression of C$


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dapted from Cohn ?# N Engl J Med# 1GG633;:G0H:G8#

6athologicremodeling

Low ejectionfraction 9eath

Symptoms:9yspneaFatiguedema

Chronic

heartfailure

=eurohormonalstimulationMyocardialtoBicity

Sudden

9eath

6umpfailure

Coronaryartery disease

Hypertension

Cardiomyopat

hy$alvulardisease

Myocardialinjury

6athologic 6rogression of C$9isease

9iaAetes

Compensatory Mechanisms:


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Compensatory Mechanisms:"enin@ngiotensin@ldosteroneSystem

"enin ngiotensinogen

ngiotensin 8

ngiotensin 88

6eripheral$asoconstrictio

n

fterload

Cardiac Dutput

Heart Failure

Cardiac %or'load

6reload

6lasma $olume

Salt E %ater "etention

dema

ldosterone Secretion

C

7aliuresis

;etaStimulation CD =a

FiArosis


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9rug !herapy


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Heart Failure !reatments:Medication !ypes

CE inhibitor/angiotensinIcon'ertingenyme

.B /angiotensinreceptor bloc-ers

BetaIbloc-er

Digo+in

Diuretic

ldosteronebloc-ade

$ype 9hat it doesE+pands blood 'essels whichlowers blood pressure,neurohormonal bloc-ade

%imilar to CE inhibitorTlowers blood pressure

.educes the action of stresshormones and slows the heartrate

%lows the heart rate and impro'esthe heartVs pumping function /E!

!ilters sodium and e+cess uid fromthe blood to reduce the heartVswor-load

Bloc-s neurohormal acti'ation and


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4mpro'e %ymptoms Diuretics /water

pills

digo+in

4mpro'e %ur'i'al Betabloc-ers

CEIinhibitors ldosterone bloc-ers

ngiotensin receptorbloc-ers /.BVs

"ational for Medications(%hy does my doctor have me on so manypills&&)

if l h


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Lifestyle Changes

Eat a lowIsodium, lowIfatdiet

@ose weight

%tay physically acti'e

.educe or eliminate

alcohol and ca


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$ransplant rti)cial hearts ew MgadgetsO to help doctors manage

heart failure

Dther !herapies&


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good solution to the failing heartH get anew heart

Pnfortunately we are limited by supply, notdemand

ppro+imately 2200 transplants areperformed yearly in the P%, and thisnumber has been stable for the past 20

years#

Heart !ransplantation


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=ewer >eneration rticialHearts


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.apid onset of symptoms and signs secondary to

abnormal cardiac functionCan present as new onset and without pre'iously

-nown cardiac dysfunction or D!

7ften life threatening and requires urgent treatment

! may present with one or se'eral clinical

conditions1# 9orsening or Decompensated Chronic eart !ailure

2# ypertensi'e eart !ailure

3# *ulmonary 7edema

:# Cardiogenic %hoc-

;# 4solated .ight !

6# C% and !

cute Heart Failure

Cli i l l i i


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9ryandwarm

%etandwarm

9ryandcold

%etandcold

Clinical classications

*ulmonarycongestion

$issue

perfusion

SC >uidelines for the diagnosis and treatment of acute and chronic heart failure

uropean Heart ournalG 1003

C d i it ti f t


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4schaemic heart disease cute coronary syndrome echanical complications of acute 4 .A infarction

Aal'ular

Aal'e stenosis Aal'ular regurgitation Endocarditis ortic dissection

yopathies *ostpartum cardiomyopathy cute myocarditis

Causes and precipitating factors


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ypertension=arrhythmias

Circulatory failure %epticaemia

$hyroto+icosis naemia $amponade *ulmonary embolism

Decompensation of preIe+isting C! Aolume o'erload 4nfection Cerebro'ascular insult %urgery .enal dysfunction sthma, C7*D Drug and alcohol abuse


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Based on presenting symptoms andclinical )ndings

istory*hysical e+amination

ECNChest LIrayEchocardiography

@aboratory /BN, etc

9iagnostic of cute Heart Failure



M it i


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on in'asi'eAital %ign7+ygenationPrine output

ECN4n'asi'erterial line /haemodynamic unstableCentral 'enous lines*ulmonary artery catheterCoronary angiography

Monitoring

> l f t t t


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4mmediate /ED=4CP=4CCP

4mpro'ed symptom .estore o+ygenation and impro'e organ perfusion @imit cardiac=renal damage inimie 4CP length of stay

4ntermediate /hospital

%tabilie patient S optimie treatment strategy 4nitiate appropriate pharmacology therapy Consider de'ice therapy inimie hospital length of stay

@ong term and pre discharge management *lan follow up strategy Education *re'ention Quality of life

>oals of treatment

M t


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4mmediate symptomatic treatment*atient distressed or in pain 55 analgesia,

sedation*ulmonary congestion 55 diuretic,

'asodilatorrterial o+ygen saturation J G;& 55

increase !i72, consider C**, 4**A,

mechanical 'entilationeart rate and rhythm disorder 55

pacing, antiarrhythmics, electro'ersion

Management



D


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s early as possible in hypo+aemic patients toachie'e 72saturation U G;& /5 G0& in C7*D#

Class 4, le'el C 4A with *EE* as soon as possible in e'ery

patient with acute cardiogenic pulmonaryoedema Contraindication

I unconscious patients

I an+ietyI immediate need E$ intubation

I se'ere obstructi'e airway disease

I se'ere .ight !

DBygen



M hi


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orphine should be considered in the early stageof se'ere ! with restlessness, dyspnoea,an+iety, chest pain#

.espiration should be monitored

Caution hypotension, bradycardia, ad'anced Abloc-, C72retention

Morphine



L di ti


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Diuretics are recommended in ! patients withcongestion and 'olume o'erload# Class 4, le'el B d'erse euidelines for the diagnosis and treatment of acute and chronic heart failure


$ dil t


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Aasodilators are recommended at an early stagefor ! without hypotension or seriousobstructi'e 'al'ular disease#

Class 4, le'el B

d'erse euidelines for the diagnosis and treatment of acute and chronic heart failure


8 t i t


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4notropic agents should be considered in lowoutput states, in the presence of hypoperfusion orcongestion#

Dobutamine /class 44a, le'el B

Dopamine /class 44b, le'el C ilrinone and eno+imone /class 44b,le'el B @e'osimendan /class 44a, le'el B orepinephrine /class 44b, le'el C

Cardiac glycoside /class 44b, le'el C

8notropic agents




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%hat have we

learned&


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eart failure is common and has highmortality

Drug therapy impro'es sur'i'al Betabloc-ers, CEI4, aldosterone antagonists

ewer de'ice therapies are showing promisefor symptom relief and impro'ed sur'i'al Bi'entricular pacing, 4CDVs

$ransplants remain rare, but technology formechanical assist de'ices continues toimpro'eI stay tunedW

8n Summary+

heart failure for koas

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