treating heart failure
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Treating heart failure. First talk in series of 3. Common causes of chronic heart failure. Myocardial dysfunction: Hypertension Ischaemic heart disease. The cardiomyopathies (e.g. alcohol). Valvular heart disease Stenosis Incompetence. High output states.

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treating heart failure

Treating heart failure

First talk in series of 3

common causes of chronic heart failure
Common causes of chronic heart failure
  • Myocardial dysfunction:
    • Hypertension
    • Ischaemic heart disease.
    • The cardiomyopathies (e.g. alcohol).
  • Valvular heart disease
    • Stenosis
    • Incompetence.
  • High output states
common causes of acute heart failure
Common causes of acute heart failure
  • Acute myocardial dysfunction:
    • Cardiogenic shock after MI.
    • Myocarditis.
  • Acute valve defects
    • Rupture in infective endocarditis
  • Altered rhythm
    • Fast – poor filling = low CO = shock
    • Slow – low rate = low CO = shock
  • Massive pulmonary embolism
left right or both
Left, right or both?
  • We distinguish left and right sided failure.
  • Biventricular failure and left heart failure are common.
  • Isolated right heart failure (“cor pulmonale”) is less common.
prevention is better than cure
Prevention is better than cure
  • Detect and effectively manage HBP.
  • Smoking, diabetes mellitus and other vascular risk factors.
  • Alcohol.
symptoms of left heart failure
Symptoms of left heart failure
  • Chronic:
    • Dyspnoea, orthopnoea and PND.
    • Cough and wheeze.
    • Malaise
  • Acute:
    • Same plus…
    • Symptoms of low blood pressure
    • Cough – frothy pink sputum
signs of left heart failure
Signs of left heart failure
  • Fine basal crackles.
  • Third or fourth heart sound (or both – “Gallop rhythm”).
  • Central cyanosis.
  • Low BP, if the problem is acute.
symptoms of right heart failure
Symptoms of right heart failure
  • Chronic (usually in presence of LHF)
    • Peripheral swelling (dependent parts)
  • Acute (e.g. after massive PE)
    • Hepatic pain
signs of right heart failure
Signs of right heart failure
  • Pitting oedema of legs and sacrum
  • Raised JVP
  • Hepatomegaly.
  • Ascites.
prognosis and aims of treatment
Prognosis, and aims of treatment
  • 5-year survival with LVF is as bad as many cancers
  • Save life in the acute circumstance.
  • Relieve symptoms.
  • Prolong life (spironolactone and -blockers).
differential diagnoses
Differential diagnoses
  • Left heart failure:
    • Asthma
    • Pneumonia
  • Right heart failure:
    • Nephrotic syndrome.
    • Chronic liver disease
initial investigation
Initial investigation
  • Biochemistry and haematology
    • Renal impairment, albumin, thyroid function and haemoglobin
  • Chest X-ray:
    • cardiac size, presence of pulmonary oedema or effusions.
  • ECG:
    • cardiac size and evidence of muscle disease
  • Echocardiography:
    • Dimensions, valve function
drugs for heart failure
Drugs for heart failure
  • Diuretics
    • Thiazides
    • Loop
    • Potassium sparing
  • Vasodilators
    • ACE-inhibitors
    • A2 receptor antagonists
    • Nitrates
  • Inotropic agents
  • (Beta blockers)
thiazides
Thiazides
  • Mainly used for hypertension.
  • Not potent naturesis, so less useful for heart failure.
  • Example: bendrofluazide.
  • Adverse effects:
    • Hypokalaemia
    • Hyperuricaemia and gout
    • Hypercalcaemia
    • Reduced glucose tolerance.
    • Impotence
the loop diuretics mode of use
The loop diuretics: mode of use
  • Potent naturesis and diuresis.
  • Steep dose-response curve.
  • Given i.v. for acute pulmonary oedema. Symptoms may be ameliorated within 30 min.
  • Given orally (often twice daily) in the ‘maintenance’ treatment of CCF.
  • Examples: frusemide (furosemide) and bumetanide.
the loop diuretics mechanism of action
The loop diuretics: mechanism of action
  • Filtered by the glomerulus.
  • Action is from the LUMINAL side of the tubular cells (so action correlates inversely with renal function).
  • Inhibition of Na Cl absorption in the ascending loop of Henle
  • At high concentration frusemide is a vasodilator.
loop diuretics adverse effects
Loop diuretics: adverse effects
  • Severe dehydration – even shock.
  • Hypokalaemic metabolic alkalosis.
  • Hypomagnesaemia.
  • Ototoxicity: especially with i.v. use.
  • Hyperuricaemia and gout
  • Calcium excretion.
  • Reduced glucose tolerance.
potassium sparing diuretics e g spironolactone
Potassium-sparing diuretics: e.g. spironolactone.
  • Antagonists of aldosterone.
  • Not usually potent enough alone.
  • Usually + loop diuretic.
  • Reduce mortality (+ACE-i and loop diuretic)
  • Adverse effects:
    • Hyperkalaemia (especially with ACE-i)
    • Gynaecomastia
vasodilators ace inhibitors
Vasodilators: ACE-inhibitors.
  • ACE converts A1 to A2.
  • A2 is an arteriolar constrictor.
  • A2 increases adrenalin release from adrenal medulla.
  • A2 causes aldosterone release (hence salt retention).

These actions increase heart work by raising the peripheral resistance (afterload).

This action increases heart work by raising the venous return (pre-load).

vasodilators ace inhibitors1
Vasodilators: ACE-inhibitors.
  • ACE-i lower preload and afterload by blocking the synthesis of A2.
  • Example: enalapril.
  • No parenteral formulation: ACE-i are used orally in chronic left, or biventricular, heart failure.
vasodilators ace inhibitors2
Vasodilators: ACE-inhibitors.
  • Adverse effects include:
    • Renal failure (especially in Renal Artery Stenosis).
    • Chronic cough.
    • Hypotension (especially with the first dose).
vasodilators ace inhibitors3
Vasodilators: ACE-inhibitors.
  • Contraindications and cautions:
    • Renal artery stenosis.
    • Aortic stenosis.
    • Previous angioedema
    • Pregnancy
vasodilators a2 receptor antagonists
Vasodilators: A2 receptor antagonists
  • Competitive antagonism of A2 at its receptors.
  • Example: losartan.
  • Used for hypertension.
  • More recently, also licensed for heart failure.
  • Unlike ACE-i, A2 antagonists do not cause cough
vasodilators nitrates
Vasodilators: nitrates
  • Examples: GTN (brief action) isosorbide (longer action).
  • All cause release of NO in smooth muscle  relaxation (mainly veins).
  • Reduced venous return.
  • GTN: first pass metabolism.
  • Isosorbide metabolised to active form. Available for i.v. use.

Angina

Angina and CCF (the intravenous form is used in acute CCF.

vasodilators nitrates1
Vasodilators: nitrates
  • Adverse effects during intravenous use:
    • Dose-related hypotension.
  • Adverse effects during oral use:
    • Headache.
inotropic drugs
Inotropic drugs
  • Most commonly needed after large MI, with ‘cardiogenic shock’.
  • Low BP, poor renal/splanchnic perfusion. Acute renal failure.
  • High mortality rate.
inotropic drugs1
Inotropic drugs
  • Example: dobutamine.
  • Given i.v. and very short half-life. So, infusion rate determines plasma concentration.
  • Lower infusion rates:  contractility and CO.
  • Higher infusion rates: arterial constriction (and tendency to reduced splanchnic perfusion).
oral inotropes
Oral inotropes
  • Digoxin: mainly used to control ventricular rate in atrial fibrillation.
  • Digoxin does have some + inotropic action.
  • And is used in advanced CCF in the hope of benefit.
blockers
-Blockers.
  • -Blockers are negatively inotropic, and make CCF worse if used incautiously.
  • But they have other actions too (inc. anti-arrhythmic).
  • And reduce mortality in patients on treatment with diuretic and ACE-i.
  • Example: carvedilol.
emergency management of lvf causing pulmonary oedema
Emergency management of LVF causing pulmonary oedema
  • High flow oxygen.
  • Sit upright.
  • Intravenous loop diuretic.
  • Cautious use of diamorphine (beware BP; beware type-2 resp failure).
  • IV infusion of nitrate (by pump).
  • Inotropic support if BP low.
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