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HEART FAILURE “pump failure”. DEFINITION Heart failure is the inability of the heart to supply adequate blood flow and therefore oxygen delivery to the peripheral tissues and organs. Cardiac output is about 5 l /min at rest Increases to upto 25 l/ min

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Heart failure pump failure l.jpg

HEART FAILURE“pump failure”


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DEFINITION

Heart failure is the inability of the heart to supply adequate blood flow and therefore oxygen delivery to the peripheral tissues and organs


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EPIDEMIOLOGY

  • Only cardiovascular disease with increasing incidence and prevalance

    due to

  • Aging population

  • Increased survival after MI--thrombolysis

  • Improvement of medical and surgical treatment


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  • Important cause of morbidity and mortality

  • 1 yr mortality –10 – 20 %

  • NYHA class 1V -- > 50 %

  • 4 yr mortality –50 %

  • Debilitating disease

  • Significant decrease in quality of life

  • Due to symptoms

  • Decrease functional capabilities

  • Frequent hospitalizations


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CLASSIFICATION OF HEART FAILURE

This is based on:

  • How rapid symptoms develop---acute HF

    ---chronic HF

  • Which ventricle is involved---right side HF

    ---left side HF

  • Over all cardiac output---systolic HF

    ---diastolic HF


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CLASSIFICATION ACCORDING TO ONSET OFSYMPTOMS:

Acute heart failure

--characterized by a rapid onset of heart failure that may occur following

1- MI

2-myocarditis

3-arrythmias

4- infection

5- PE

If it is not fatal may progress to chronic heart failure


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Chronic heart failure

This results from the heart undergoing adaptive responses to precipitating cause and this cardiac response leads to impaired function.

1- anemia

2-thyrotoxicosis

3-non compliance to medications

4- diet—high salt


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ETIOLOGY

  • Myocardial infarction

  • Coronary artery disease

  • Valvular heart disease

  • Idiopathic cardiomyopathy

  • Viral or bacterial cardiomyopathy

  • myocarditis


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ETIOLOGY cont.

  • Pericarditis

  • Arryhthmias

  • Hypertension

  • Thyroid disease

  • Pregnancy

  • Septic shock


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ETIOLOGY cont.

  • Toxins—anthracyclines

    amphetamine

    cocaine

  • Metabolic---haemachromatosis

    wilson,s disease

    pheochromocytoma


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SYMPTOMS cont.{ FACES}

  • Fatigue

  • Activity decrease

  • Cough { specially supine,frothy red sputum

  • Edema

  • Shortness of breath { NYHA }


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SYMPTOMS

NYHA classification of dyspnoe

  • Class 1—no shortness of breath {SOB}

  • Class 11—SOB on severe exertion

  • Class 111—SOB on mild exertion

  • Class 1v---SOB at rest


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Heart failure management issues

  • High mortality

  • High readmission rates

  • Poor Rx adherance

  • On going symptoms

  • Reduced quality of life

  • Dose adjustment in the elderly


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Heart failure therapeutic goals

  • 1ry goal = reduce symptoms

  • Improve quality of life

  • Reduce hospitalization

  • Prevent sudden death


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DIET approach to the pt. with heart failure

  • D—diagnose---eteiology

    ---severity of LV dysfunction

  • I –initiate---diuretics { thiazide , frusemide }

    ---beta blockers

    ---ACEI

    ---digoxin

    ---spironolactone


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  • E—educate----diet

    ---exercise

    ---life style

  • T---titrate---optimize ACEI

    ---optimize beta blockers


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General measures

  • Correct precipitating causes

  • Treat ischemia

  • Control hypertension

  • D/C smoking

  • Treat lipid abnormality

  • Treat and control hypertension


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  • Low salt diet

  • Fluid restriction

  • Regular exercise

  • Upright position to reduce pulmonary congestion

  • Prophylactic anticoaggulation

  • Avoid –ve inatropic drugs



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INVESTIGATION

  • CBC

  • U+E

  • LFT

  • Cardiac enzymes

  • CXR

  • ECG

  • Echocardiogram


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TREATMENT

  • Diuretics

  • Digoxin

  • ACE inhibitors

  • Vasodilators

  • Beta blockers


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DRUGS

  • Diuretics ---thiazide diuretic

    ---frusemide {loop diuretic}

    ----spironolactone { K sparing}

  • Titrate to euvolumic state

  • Maintain ideal body wt ={ dry wt= normal JVP / trace or no pedal edema}


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  • ACEI

  • Cornerstone in the Rx of heart failure

  • Continue indefinitely if EF < 40 %

  • Rx for all asymptomatic pts with EF < 35%

  • Rx for all symptomatic pts with EF =35%

  • Use max. tolerated dose


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ACEI cont..

  • Captopril---capoten

  • Enalapril----renetic

  • Lisinopril----zestril

  • Fosinopril---staril


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Angiotensin receptor blockers

  • Same action and benefits as ACEI

  • Used in pts who cannot tolerate ACEI due to side effects

  • Candesartan

  • Irbesartan

  • Losartan

  • Valsartan

  • Telemisartan


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Beta blockers

  • Titrate to max. tolerated dose

  • Continue indefinitely

  • Bisoprolol

  • Carvidelol

  • metaprolol


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patient selection for successful beta blockerinitiation

  • Stable symptoms

  • Stable background heart failure medication

  • No hypotension

  • No bradycardia

  • Euvolumic status

  • Start low and titrate slowly


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Patients with heart failure who should NOT be started on beta blockers

  • Bronchospastic pulmonary disease

  • Severe bradycardia

  • High degree A / V block

  • Sick sinus syndrome

  • NYHA class 1V

  • Pts. Who require IV therapy for HF

  • Hospitalized pts specially for worsening HF

  • Unstable symptoms


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Digoxin

  • For persisting symptoms in systolic dysfunction

  • For symptomatic and rate control of AF

  • To decrease the dose in elderly and pts with renal failure


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Aldosterone antagonist

  • Spironolactone

  • Add to ACEI , diuretics , beta blockers ,+/-digoxin

  • Used in NYHA class 111 and 1V CHF

  • EF < 35%

  • It leads to 30 % ↓ in death from progressive HF



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ACC / AHA guidline summary– managementof pts with current or prior symptoms ofheart failure and a reduced left ventricularEF

  • Diuretics and salt restrictions for fluid retention

  • ACE I in all pts unless CI

  • Beta blockers in all stable pts , unless CI


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Three beta blockers proven to reduce mortalityshould be used…

  • Metaprolol

  • Bisoprolol

  • Carvidelol

  • Drugs that adversely affect the pts should be avoided or withdrawn if possible…

  • NSAID

  • Most antiarrythmic drugs

  • Most calcium channel blockers


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Drugs that should be avoided or used with tolerate ACEI. Two drugs which are approved arecaution

  • NSAID

  • Thiozolidindione group

  • PDE-5 inhibitors—sildenafil

  • Antiarryhtmics


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