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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