Academic in service chronic heart failure
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Academic in service Chronic Heart Failure. โดย นสภ. นภาลัย อมรเทพดำรง มหาวิทยาลัยนเรศวร. โรคหัวใจล้มเหลว ( heart failure).

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Academic in service Chronic Heart Failure

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Academic in service chronic heart failure

Academic in service Chronic Heart Failure

.


Heart failure

(heart failure)

  • oxygen


Heart failure1

: heart failure ()

  • O2


Symptoms of heart failure

Symptoms of Heart Failure


Academic in service chronic heart failure

  • Systolic heart failure: EF< 40% EF 40-60% mild systolic dysfunction.

  • Diastolic heart failure : normal ejection fraction (EF > 60%)

  • Combination of systolic and diastolic heart failure


2 functional classification

2. Functional classification

a. NYHA funcional class I

b. NYHA functional class II

c. NYHA functional class III

d. NYHA functional class IV


3 staging of disease progression aha acc

3. Staging of Disease Progression (AHA/ACC)

  • Stage A

  • Stage B

  • Stage C

  • Stage D Refractory HF


Causes

Causes

  • 1.

  • a. Ischemic heart disease myocardial infarction systolic heart failure > diatolic heart failure

  • b. Cardiomyopathies Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Restrictive cardiomyopathy

  • c. Myocarditis


Academic in service chronic heart failure

2.

  • Valvular stenosis or regurgitation (aortic, pulmonic, mitral, tricuspid valve)

  • a. stenosis : diastolic heart failure systolic heart failure

  • b. regurgitation insufficiency : systolic heart failure


Academic in service chronic heart failure

3.

  • 2 pressure overload volume overload

  • Systemic HT HF

  • Pulmonary HT

  • Shunt PDA, ASD, VSD


Academic in service chronic heart failure

4.

  • Ventricular fibrillation or tachycardia

  • Atrial fibrillation or tachycardia

  • Bradycardia

  • Complete heart block


Precipitating factors

Precipitating factors

pulmonary HT

Corticosteroids orNSAIDs

myocardial contractility -blocker

propranolol, metoprolol nondihydropyridine - CCB

verapamil, diltiazem


Acute exacerbation of chronic systolic heart failure

ACUTE EXACERBATION OF CHRONIC SYSTOLIC HEART FAILURE

1. non-pharmacological therapy

  • O2 O2

  • Na 2


Non pharmacological therapy

non-pharmacological therapy ()

  • dialysis

  • shock


2 pharmacological therapy

2. pharmacological therapy

CI

2.2

PCWP

20


Academic in service chronic heart failure

1. CI > 2.2 L/min/m2 PCWP 12-20 mmHg cardiac output ventricular filling pressure (preload)

2. CI > 2.2 L/min/m2 PCWP > 20 mmHg intravascular volume overload preload (diuretics vasodilators)


Academic in service chronic heart failure

()

3. CI < 2.2 L/min/m2 PCWP > 20 mmHg

hypoperfusion intravascular volume overload preload (diuretics vasodilators) cardiac contractility vasodilators afterload ( BP)

4. CI < 2.2 L/min/m2 PCWP 12-20 mmHg

hypoperfusion intravascular volume overload cardiac contractility vasodilators afterload


Academic in service chronic heart failure

  • 1. preload

  • a. Diuretics

    1. Thiazides thiazide-like diuretics

    2. Loop diuretics : thiazide

  • b. vasodilators

    1. ACEIs : preload afterload

    2. Sodium nitroprusside : preload afterload

    3. IV nitroglycerin Nitrates : preload > afterload

    4. Hydralazine : afterload > preload


2 cardiac contractility positive inotropic agents

2. cardiac contractility (positive inotropic agents)

a. Digoxin : 0.8-1.2 ng/mL

b. Catecholamines

(1) Dopamine : dopamine renal perfusion 10 mcg/kg/min cardiac contractility

(2) Dobutamine : 1-10 mcg/kg/min

c. Phosphodiesterase inhibitors : cardiac contractility dopamine dobutamine

d. Nesiritide


Chronic systolic heart failure

Chronic systolic heart failure

  • Non-pharmacologic therapy

  • Na <3

  • Pharmacologic therapy


A vasodilators preload afterload cardiac output

a. Vasodilators preload / afterload cardiac output

  • (1) ACEIs : preload afterload sympathetic nervous system angiotensin II ventricular hypertrophy


Aceis

ACEIs ()

  • ACEIs AHA/ACC stage A stage B, C D ACEIs


2 angiotensin receptor blockers

(2) Angiotensin receptor blockers

  • ACEIs angioneurotic edema ACEIs ARBs ACEIs ARBs


Academic in service chronic heart failure

ARBs ()

  • chronic HF stage C ACEIs, diuretics beta-blockers ARBs

  • AHA/ACC ARBs ACEIs aldosterone antagonist ( 3 ) hyperkalemia


3 hydralazine oral nitrate

(3) Hydralazine oral nitrate

  • hydralazine oral nitrates ACEIs ACEIs hydralazine nitrate combination hydralazine + oral nitrate ACEIs hydralazine oral nitrate clinical trials hydralazine oral nitrates ARBs hydralazine + oral nitrate


Hydralazine oral nitrate

Hydralazine + oral nitrate ()

  • hydralazine nitrate stage C ACEIs, beta-blocker diuretics


B diuretics

b. Diuretics

  • preload

  • diuretics diuretics intravascular volume depletion tissue hypoperfusion, prerenal renal failure, reflex tachycardia myocardial infarction


B diuretics1

b. Diuretics

  • ACEIs beta-blocker stable thiazide loop diuretics (thiazides creatinine clearance < 30 ml/min)


C beta blockers

c. Beta-blockers

  • sympathetic nervous system RAAS EF

  • beta-blockers acute HF myocardial contractility decompensation BP, HR, signs and symptoms of worsening heart failure bronchospasm asthma COPD


C beta blockers1

c. Beta-blockers


D digoxin

d. Digoxin

  • cardiac contractility sympathetic system preload stage C ACEIs diuretics beta-blocker


D digoxin1

d. Digoxin()

  • Pt normal renal function dose = 0.125 mg/day

  • Pt with decreased renal function, the elderly, or those receiving interacting drugs (e.g., amiodarone) should receive 0.125 mg every other day

  • digoxin 0.8-1.2 ng/mL


E spironolactone eplerenone

e. Spironolactone Eplerenone

  • aldosterone antagonist aldosterone ventricular wall remodeling

  • heart failure ( stage C NYHA functional class III-IV) EF < 40%


E spironolactone eplerenone1

e. Spironolactone Eplerenone

  • AHA/ACC aldosterone antagonist

  • aldosterone antagonists renal failure (serum creatinine >2.5 mg/dL >2.0 mg/dL ) hyperkalemia (serum K > 5.0 mEq/L) K ventricular tachycardia fibrillation


E spironolactone eplerenone2

e. Spironolactone Eplerenone


F calcium channel blockers

f. Calcium channel blockers

  • systolic heart failure CCB heart failure sympathetic nervous system stimulation ischemic heart disease

  • CCB systolic heart failure amlodipine systolic heart failure ischemic heart disease


F calcium channel blockers1

f. Calcium channel blockers

  • diastolic heart failure non-dihydropyridines verapamil diltiazem 2 heart rate ventricular filling time preload ( diastolic heart failure beta-blocker calcium channel antagonist cardiac contractility)


Heart failure warfarin

Heart failure - warfarin

  • Chronic Heart Failure Warfarin blood flow Warfarin (decrease warfarin elimination ) INR


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