Low output heart failure systolic heart failure hfref
This presentation is the property of its rightful owner.
Sponsored Links
1 / 63

Low-Output Heart Failure Systolic Heart Failure (HFREF): PowerPoint PPT Presentation


  • 285 Views
  • Uploaded on
  • Presentation posted in: General

Low-Output Heart Failure Systolic Heart Failure (HFREF): Decreased Left ventricular ejection fraction Diastolic Heart Failure (HFPEF): Elevated Left and Right ventricular end-diastolic pressures Normal LVEF High-Output Heart Failure

Download Presentation

Low-Output Heart Failure Systolic Heart Failure (HFREF):

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Low output heart failure systolic heart failure hfref

  • Low-Output Heart Failure

    • Systolic Heart Failure (HFREF):

      • Decreased Left ventricular ejection fraction

  • Diastolic Heart Failure (HFPEF):

    • Elevated Left and Right ventricular end-diastolic pressures

    • Normal LVEF

  • High-Output Heart Failure

    • Seen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism, beri-beri, carcinoid, anemia

    • Often have normal cardiac output

  • Right-Ventricular Failure

    • Seen with pulmonary hypertension, large RV infarctions.


  • Causes of low output heart failure

    Causes of Low-Output Heart Failure

    • Systolic Dysfunction

      • Coronary Artery Disease

      • Idiopathic dilated cardiomyopathy (DCM)

        • 50% idiopathic (at least 25% familial)

        • 9 % myocarditis (viral)

        • tachycardia, peripartum, hypertension, HIV, connective tissue disease, substance abuse (alcohol), doxorubicin/herceptin

    • Hypertension

    • Valvular Heart Disease

  • Diastolic Dysfunction

    • Hypertension

    • Coronary artery disease

    • Hypertrophic obstructive cardiomyopathy (HCM)

    • Restrictive cardiomyopathy


  • Low output heart failure systolic heart failure hfref

    (Mal)adaptation-hemodynamic


    Mal adaptation neurohormonal

    (Mal) adaptation-neurohormonal

    • Activation of the sympathetic nervous system

      • Vasoconstriction/increased afterload

      • Tolerance

      • Arhythmogenic


    Low output heart failure systolic heart failure hfref

    • Activation of renin-angiotensin system

      • Na resorption

      • Vasoconstriction

      • Apoptosis/fibrosis


    Low output heart failure systolic heart failure hfref

    • Antidiuretic hormone

    • Proinflammatory cytokines

      • TNFalpha

      • IL-6


    Clinical presentation of heart failure

    Clinical Presentation of Heart Failure

    • Due to excess fluid accumulation:

      • Dyspnea (most sensitive symptom)

      • Edema

      • Hepatic congestion

      • Ascites

      • Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)

    • Due to reduction in cardiac ouput:

      • Fatigue (especially with exertion)

      • Weakness


    Low output heart failure systolic heart failure hfref

    • S3 gallop

      • Low sensitivity, but highly specific

  • Cool, pale, cyanotic extremities

    • Have sinus tachycardia, diaphoresis and peripheral vasoconstriction

  • Crackles or decreased breath sounds at bases (effusions) on lung exam

  • Elevated jugular venous pressure

  • Lower extremity edema

  • Ascites

  • Hepatomegaly

  • Splenomegaly

  • Displaced PMI

    • Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>


  • Lab analysis in heart failure

    Lab Analysis in Heart Failure

    • CBC

      • Since anemia can exacerbate heart failure

  • Serum electrolytes and creatinine

    • before starting high dose diuretics

  • Fasting Blood glucose

    • To evaluate for possible diabetes mellitus

  • Thyroid function tests

    • Since thyrotoxicosis can result in A. Fib,

      and hypothyroidism can results in HF.

  • Iron studies

    • To screen for hereditary hemochromatosis as cause of heart failure.

  • ANA

    • To evaluate for possible lupus

  • Viral studies

    • If viral mycocarditis suspected


  • Laboratory analysis cont

    Laboratory Analysis (cont.)

    • BNP

      • With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures

      • Usually is > 400 pg/mL in patients with dyspnea due to heart failure.


    Chest x ray in heart failure

    Chest X-ray in Heart Failure

    • Cardiomegaly

    • Cephalization of the pulmonary vessels

    • Kerley B-lines

    • Pleural effusions


    Cardiomegaly

    Cardiomegaly


    Pulmonary edema due to heart failure

    Pulmonary Edema due to Heart Failure


    Kerley b lines

    Kerley B lines


    Cardiac testing in heart failure

    Cardiac Testing in Heart Failure

    • Electrocardiogram:

      • May show specific cause of heart failure:

        • Ischemic heart disease

        • Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular block

        • Amyloidosis: pseudo-infarction pattern

        • Idiopathic dilated cardiomyopathy: LVH

  • Echocardiogram:

    • Left ventricular ejection fraction

    • Structural/valvular abnormalities


  • Further cardiac testing in heart failure

    Further Cardiac Testing in Heart Failure

    • Coronary arteriography

      • Should be performed in patients presenting with heart failure who have angina or significant ischemia

      • Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.

      • Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.


    Further testing in heart failure

    Further testing in Heart Failure

    • Endomyocardial biopsy

      • Not frequently used

      • Amyloidosis, giant-cell myocarditis


    Classification of heart failure

    Classification of Heart Failure


    Low output heart failure systolic heart failure hfref

    Aggravating Factors

    • Medications

    • New heart disease

    • Myocardial ischemia

    • Pregnancy

    • Arrhythmias (AF)

    • Infections

    • Thromboembolism

    • Hyper/hypothyroidism

    • Endocarditis

    • Obesity

    • Hypertension

    • Physical activity

    • Dietary excess


    Low output heart failure systolic heart failure hfref

    Heart Failure and Myocardial Ischemia

    • Coronary HD is the cause of 2/3 of HF

    • Segmental wall motion abnormalities are not specific if ischemia

    • Angina coronary angio and revascularization

    • No angina

      • Search for ischemia and viability in all ?

      • Coronary angiography in all ?


    Low output heart failure systolic heart failure hfref

    ACE-i. Mechanism of Action

    VASOCONSTRICTION

    VASODILATATION

    ALDOSTERONE

    PROSTAGLANDINS

    VASOPRESSIN

    tPA

    Kininogen

    SYMPATHETIC

    Kallikrein

    Angiotensinogen

    RENIN

    BRADYKININ

    Angiotensin I

    A.C.E.

    Kininase II

    Inhibitor

    ANGIOTENSIN II

    Inactive Fragments


    Low output heart failure systolic heart failure hfref

    ACE-I. Clinical Effects

    • Improve symptoms

    • Reduce remodelling / progression

    • Reduce hospitalization

    • Improve survival


    Low output heart failure systolic heart failure hfref

    Mortality Reduction with ACE-i

    StudyACE-iClinical Seting

    CONSENSUSEnalaprilCHF

    SOLVD treatment EnalaprilCHF

    AIRERamiprilCHF

    Vheft-IIEnalaprilCHF

    TRACETrandolaprilCHF / LVD

    SAVECaptoprilLVD

    SMILEZofenoprilHigh risk

    HOPERamiprilHigh risk


    Low output heart failure systolic heart failure hfref

    ACE-i

    0.8

    0.7

    Placebo

    0.6

    Probabiilityof

    Death

    p< 0.001

    0.5

    0.4

    p< 0.002

    0.3

    Enalapril

    0.2

    0.1

    0

    0

    1

    2

    3

    4

    5

    6

    7

    8

    9

    10

    11

    12

    CONSENSUS

    N Engl J Med 1987;316:1429

    Months


    Low output heart failure systolic heart failure hfref

    ACE-i

    30

    Asymptomatic

    ventricular

    dysfunction post MI

    Placebo

    n=1116

    20

    Mortality,

    %

    Captopril

    n=1115

    10

    n = 2231

    3 - 16 days post AMI

    EF < 40

    12.5 --- 150 mg / day

    ² -19%

    p=0.019

    0

    SAVE

    N Engl J Med 1992;327:669

    0

    3

    4

    1

    2

    Years


    Low output heart failure systolic heart failure hfref

    ACE-i. Indications

    • Symptomatic heart failure

    • Asymptomatic ventricular dysfunction

      - LVEF < 35 - 40 %

    • Selected high risk subgroups

    AHA / ACC HF guidelines 2001

    ESC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • ACE-i. Practical Use

    • Start with very low dose

    • Increase dose if well tolerated

    • Renal function & serum K+ after 1-2 w

    • Avoid fluid retention / hypovolemia (diuretic use)

    • Dose NOT determined by symptoms


    Low output heart failure systolic heart failure hfref

    ACE-i. Dose (mg)

    InitialMaximum

    Captopril 6.25 / 8h 50 / 8h

    Enalapril 2.5 / 12 h 10 to 20 / 12h

    Fosinopril 5 to 10 / day 40 / day

    Lisinopril 2.5 to 5.0 / day 20 to 40 / day

    Quinapril 10 / 12 h40 / 12 h

    Ramipril 1.25 to 2.5 / day 10 / day

    AHA / ACC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • ACE-I. Adverse Effects

    • Hypotension (1st dose effect)

    • Worsening renal function

    • Hyperkalemia

    • Cough

    • Angioedema

    • Rash, ageusia, neutropenia, …


    Low output heart failure systolic heart failure hfref

    ACE-I. Contraindications

    • Intolerance (angioedema, anuric renal fail.)

    • Bilateral renal artery stenosis

    • Pregnancy

    • Renal insufficiency (creatinine > 3 mg/dl)

    • Hyperkalemia (> 5,5 mmol/l)

    • Severe hypotension


    Low output heart failure systolic heart failure hfref

    ß-Adrenergic Blockers

    Mechanism of action

    • Density of ß1 receptors

    • Inhibit cardiotoxicity of catecholamines

    • Neurohormonalactivation

    • HR

    • Antiischemic

    • Antihypertensive

    • Antiarrhythmic

    • Antioxidant, Antiproliferative


    Low output heart failure systolic heart failure hfref

    ß-Adrenergic Blockers

    100

    90

    80

    Survival

    %

    Carvedilol

    70

    p=0.00014

    35% RR

    60

    Placebo

    N = 2289

    III-IV NYHA

    50

    0

    4

    8

    12

    16

    20

    24

    28

    Months

    COPERNICUS

    NEJM 2001;344:1651


    Low output heart failure systolic heart failure hfref

    ß-Adrenergic Blockers

    When to start

    • Patient stable

      • No physical evidence of fluid retention

      • No need for i.v. inotropic drugs

    • No contraindications

    • In hospital or not


    Low output heart failure systolic heart failure hfref

    ß-Adrenergic Blockers

    Dose (mg)

    InitialTarget

    Bisoprolol 1.25 / 24h 10 / 24h

    Carvedilol 3.125 / 12h25 / 12h

    Metoprolol succinnate12,5-25 / 24h200 / 24h

    • Start Low, Increase Slowly

    • Increase the dose every 2 - 4 weeks


    Low output heart failure systolic heart failure hfref

    ß-Adrenergic Blockers

    Adverse Effects

    • Hypotension

    • Fluid retention / worsening heart failure

    • Fatigue

    • Bradycardia / heart block


    Low output heart failure systolic heart failure hfref

    Aldosterone Inhibitors

    ALDOSTERONE

    Spironolactone

    -

    Competitive antagonist of the

    aldosterone receptor

    (myocardium, arterial walls, kidney)

    • Retention Na+

    • Retention H2O

    • Excretion K+

    • Excretion Mg2+

    • Collagen

    • deposition

    • Fibrosis

    • - myocardium

    • - vessels

    Edema

    Arrhythmias


    Low output heart failure systolic heart failure hfref

    1.0

    0.9

    0.8

    0.7

    0.6

    0.5

    0

    6

    12

    24

    30

    36

    18

    Spironolactone

    Annual Mortality

    Aldactone 18%; Placebo 23%

    Survival

    Aldactone

    N = 1663

    NYHA III-IV

    Mean follow-up 2 y

    p < 0.0001

    RALES

    NEJM 1999;341:709

    Placebo

    months


    Low output heart failure systolic heart failure hfref

    • Spironolactone.Indications

    • Recent or current symptoms despite ACE-i, diuretics, dig. and b-blockers

    • AHA / ACC HF guidelines 2001

    • Recommended in advanced heart failure (III-IV), in addition to ACE-i and diuretics

    • Hypokalemia

    • ESC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • Spironolactone.Practical use

    • Do not use if hyperkalemia, renal insuf.

    • Monitor serum K+ at “frequent intervals”

    • Start ACE-i first

    • Start with 25 mg / 24h

    • If K+ >5.5 mmol/L, reduce to 25 mg / 48h

    • If K+ is low or stable consider 50 mg / day

    • New studies in progress


    Low output heart failure systolic heart failure hfref

    Angiotensin II Receptor Blockers (ARB)

    RENIN

    Angiotensin IANGIOTENSIN II

    Angiotensinogen

    ACE

    Other pathways

    AT1

    Receptor

    Blockers

    RECEPTORS

    AT1

    AT2

    Vasoconstriction

    Proliferative

    Action

    Vasodilatation

    Antiproliferative

    Action


    Low output heart failure systolic heart failure hfref

    Angiotensin II Receptor Blockers (ARB)

    • Candesartan, Eprosartan, Irbesartan

      Losartan, Telmisartan, Valsartan

    • Not indicated with beta blockers

    • Indicated in patients intolerant to ACE-I

    AHA / ACC HF guidelines 2001

    ESC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • Positive Inotropes

    • Digitalis

    • Sympathomimetics

      • Catecholamines

      • B-adrenergic agonists

    • Phosphodiesterase inhibitors

      • Amrinone, Milrinone, Enoximone

    • Calcium sensitizers

      • Levosimendan, Pimobendan


    Low output heart failure systolic heart failure hfref

    Positive Inotropic Therapy

    • May increase mortality

      Exception: Digoxin, Levosimendan

    • Use only in refractory CHF

    • NOT for use as chronic therapy


    Low output heart failure systolic heart failure hfref

    - PlasmaNoradrenaline

    - Peripheral nervous system activity

    - RAAS activity

    - Vagaltone

    - Normalizes arterial baroreceptors

    Digitalis. Mechanism of Action

    Blocks Na+ / K+ ATPase => Ca+ +

    •Inotropic effect

    •Natriuresis

    •Neurohormonal control

    NEJM 1988;318:358


    Low output heart failure systolic heart failure hfref

    Digitalis. Clinical Effects

    • Improve symptoms

    • Modest reduction in hospitalization

    • Does not improve survival


    Low output heart failure systolic heart failure hfref

    Digitalis. Indications

    • When no adequate response to

    ACE-i + diuretics + beta-blockers

    AHA / ACC Guidelines 2001

    • In combination with ACE-i + diuretics

    if persisting symptoms

    ESC Guidelines 2001

    • AF, to slow AV conduction

    Dose 0.125 to 0.250 mg / day


    Low output heart failure systolic heart failure hfref

    50

    40

    30

    20

    10

    0

    Digitalis

    Mortality

    %

    Placebo

    n=3403

    p = 0.8

    N=6800

    NYHA II-III

    Digoxin

    n=3397

    0

    12

    24

    36

    48

    DIG

    N Engl J Med 1997;336:525

    Months


    Low output heart failure systolic heart failure hfref

    • Diuretics. Indications

    • 1.Symptomatic HF, with fluid retention

      • Edema

      • Dyspnea

      • Lung Rales

      • Jugular distension

      • Hepatomegaly

      • Pulmonary edema (Xray)

    AHA / ACC HF guidelines 2001

    ESC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • Loop Diuretics / Thiazides. Practical Use

    • Start with variable dose. Titrate to achieve dry weight

    • Monitor serum K+ at “frequent intervals”

    • Reduce dose when fluid retention is controlled

    • Teach the patient when, how to change dose

    • Combine to overcome “resistance”

    • Do not use alone


    Low output heart failure systolic heart failure hfref

    Thiazides, Loop Diuretics. Adverse Effects

    • K+, Mg+ (15 - 60%) (sudden death ???)

    • Na+

    • Stimulation of neurohormonal activity

    • Hyperuricemia (15 - 40%)

    • Hypotension. Ototoxicity. Gastrointestinal. Alkalosis. Metabolic

    Sharpe N. Heart failure. Martin Dunitz 2000;43

    Kubo SH , et al. Am J Cardiol 1987;60:1322

    MRFIT, JAMA 1982;248:1465

    Pool Wilson. Heart failure. Churchill Livinston 1997;635


    Low output heart failure systolic heart failure hfref

    • Diuretic Resistance

    • Neurohormonal activation

    • Rebound Na+ uptake after volume loss

    • Hypertrophy of distal nephron

    • Reduced tubular secretion (renal failure, NSAIDs)

    • Decreased renal perfusion (low output)

    • Altered absortion of diuretic

    • Noncompliance with drugs

    Brater NEJM 1998;339:387

    Kramer et al. Am J Med 1999;106:90


    Low output heart failure systolic heart failure hfref

    Managing Resistance to Diuretics

    • Restrict Na+/H2O intake (Monitor Natremia)

    • Increase dose (individual dose, frequency, i.v.)

    • Combine: furosemide + thiazide / spiro / metolazone

    • Dopamine (increase cardiac output)

    • Reduce dose of ACE-i

    • Ultrafiltration

    Motwani et al Circulation 1992;86:439


    Low output heart failure systolic heart failure hfref

    Drugs to Avoid (may increase symptoms, mortality)

    • Inotropes, long term / intermittent

    • Antiarrhythmics (except amiodarone)

    • Calcium antagonists (except amlodipine)

    • Non-steroidal antiinflammatory drugs (NSAIDS)

    • Tricyclic antidepressants

    • Corticosteroids

    • Lithium

    ESC HF guidelines 2001


    Low output heart failure systolic heart failure hfref

    • Refractory End-Stage HF

    • Review etiology, treatment & aggrav. factors

    • Control fluid retention

      • Resistance to diuretics

      • Ultrafiltration ?

    • iv inotropics / vasodilators during decompensation

    • Consider resynchronization

    • Consider mechanical assist devices

    • Consider heart transplantation


    Cardiac resynchronization therapy in patients with severe systolic heart failure

    Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure

    • For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy


    Indications for crt therapy

    Indications for CRT Therapy


    Low output heart failure systolic heart failure hfref

    • Heart Transplant. Indications

    • Refractory cardiogenic shock

    • Documented dependence on IV inotropic support to maintain adequate organ perfusion

    • Peak VO2 < 10 ml / kg / min

    • Severe symptoms of ischemia not amenable to revascularization

    • Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities

      Contraindications: age, severe comorbidity


    Low output heart failure systolic heart failure hfref

    Ventricular Arrhythmias / Sudden Death

    • Antiarrhythmics ineffective (may increase mortality)

      Amiodarone do not improve survival

    • -blockers reduce all cause mortality and SD

    • Control ischemia

    • Control electrolyte disturbances

    • ICD (Implantable Cardiac Defibrillator)

      • In secondary prevention of SD

      • In sustained, hemodynamic destabilizing VT

      • Ongoing research will establish new indications


    Device therapy for stage c hf r ef cont

    Device Therapy for Stage C HFrEF (cont.)


    Low output heart failure systolic heart failure hfref

    • Diastolic Heart Failure

    • Incorrect diagnosis of HF

    • Inaccurate measurement of LVEF

    • Primary valvular disease

    • Restrictive (infiltrative) cardiomyopathies (Amyloidosis…)

    • Pericardial constriction

    • Episodic or reversible LV systolic dysfunction

    • Severe hypertension, ischemia

    • High output states: Anemia, thyrotoxicosis, etc

    • Chronic pulmonary disease with right HF

    • Pulmonary hypertension

    • Atrial myxoma

    • LV Hypertrophy

    • Diastolic dysfunction of uncertain origin


    Treatment of hf p ef

    Treatment of HFpEF


    Stages phenotypes and treatment of hf

    Stages, Phenotypes and Treatment of HF


  • Login