1 / 43

OVERVIEW OF TREATMENT OF CONGESTIVE HEART FAILURE

OVERVIEW OF TREATMENT OF CONGESTIVE HEART FAILURE. OVERVIEW . Background and Historical Perspective Determinants of Cardiac Output and Hemodynamic Intervention Newer Therapeutics . EVOLUTION IN CONCEPTS. Cardio-renal (pre 1970) : Digoxin, diuretics

wanda
Download Presentation

OVERVIEW OF TREATMENT OF CONGESTIVE HEART FAILURE

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. OVERVIEW OF TREATMENT OF CONGESTIVE HEART FAILURE

  2. OVERVIEW • Background and Historical Perspective • Determinants of Cardiac Output and Hemodynamic Intervention • Newer Therapeutics

  3. EVOLUTION IN CONCEPTS • Cardio-renal (pre 1970) : Digoxin, diuretics • Hemodynamic 1970’s and 1980’s: + Inotropics, VD • Neurohormonal 1990’s: RAS, SNS

  4. DETERMINANTS OF CARDIAC PERFORMANCE • HEART RATE • CONTRACTILITY • PRELOAD VASODILATOR THERAPY • AFTERLOAD

  5. RATE AFTERLOAD PRELOAD LV CONTRACTILITY

  6. CO = SV x HR EF = CO

  7. HEART RATE • COMPENSATORY RESPONSE • ATROPHINE • ISUPREL • PACER

  8. CONTRACTILITY • Inherent property of the myocardium • Allows the heart to increase its extent and force of shortening independent of the Starling mechanism • Not directly measurable

  9. CONTRACTILITY • DIGITALIS • DOBUTAMINE • DOPAMINE • ISUPREL • EPINEPHRINE • CALCIUM • GLUCAGON • AMIRANOME (Miliron)

  10. STARLING’S LAW THE MORE A MYOCARDIAL FIBER IS STRETCHED DURING DIASTOLE, THE MORE IT WILL SHORTEN IN SYSTOLE IT WILL ALSO SHORTEN WITH GREATER FORCE

  11. PRELOAD The length to which a cell is stretched prior. To the next contraction The volume or pressure generated in the ventricles at end-diastole Degree to which a cell is stretched in diastole (preload) force during systole

  12. AFTERLOAD IMPEDANCE OF BLOOD FROM THE VENTRICLE Determined by: The volume and mass of blood ejected from the ventricle The compliance and total cross-sectional area of the vascular space into which the blood is ejected.

  13. AFTERLOAD – RESISTANCE PROXIMAL IMPEDENCE

  14. SYSTEMIC VASCULAR RESISTANCE SVR= (MAP-RAP) (80) CO MAP= MEAN ARTERIAL PRESSURE RAP= RIGHT ATRIAL PRESSURE CO= CARDIAC OUTPUT

  15. BASIC HEMODYNAMIC PARARMETERS Preload = PCWP Afterload = SVR

  16. LVEDP = LA = PVP = PCWP = PAP

  17. 1 2 4 3

  18. 1 2 4 3

  19. VASODILATOR DRUGS

  20. Clinical Profile of Nesiritide • Vasodilation (venous > arterial) • Rapidly improves symptoms of congestion • Does not increase heart rate (decreases myocardial oxygen demand) • Is not proarrhythimic • Neurohormonal suppression (decreases aldosterone, endothelin-1) • Mild diuresis/natriuresis

  21. Clinical Profile Nesiritide (cont.) • No evidence of tachyphylaxis • Symptomatic hyptension as low as 4% in the VMAC study • Dosing convenience (bolus plus standard-dose IV infusion

  22. PATIENT PRESENTATION

  23. EVOLUTION IN CONCEPTS • Cardio-renal (pre 1970): Digoxin, diuretics • Hemodynamic 1970’s and 1980’s: + Inotropics, VD • Neurohormonal 1990’s: RAS, SNS

  24. CLINICAL APPROACH

  25. NEUROHORMONAL FACTORS IN HEART FAILURE PROGRESSION • Circulating (RAS, SNS) Abnormality in regional blood flow, renal sodium retention • Endothelin (ET-1, ET-2, ET-3) Vasoconstrictors • Natriuretic Peptide, (ANP) Vasodilators, suppresses RAS • Cytokines (TNF , Interleukin) Depresses contractility, anorexia and cachexia 

  26. Neurohormonal Intervention in Heart Failure Heart Failure Renin- angiotensin system Sympathetic nervous system ACE inhibition Beta Blockade

  27. ACE INHIBITORs (ANGIOTENSIN CONVERTING ENZYMES INHIBITORS) ARBs (ANGIOTENSION RECEPTOR BLOCKERS)

  28. BETA BLOCKERs ALPHA AND BETA BLOCKERs

  29. Effect of Carvedilol on Left Ventricular Ejection Fraction P<.001 Patients receiving diuretics, ACE inhibitors, digoxin; follow-up 6 months; placebo (n=84), carvedilol (n=261). Mulitcenter Oral Carvedilol Heart Failure Assessment Adapted from Bristow et al. Circulation. 1996;94:2807-2816. P<.05 vs placebo.

  30. CLINICAL ASSESSMENT Warm vs. Cold (Perfusion)- Pulse Pressure Dry vs. Wet (Congestion)- Jugular Venus Pressure

  31. Rapid Assessment of Hemodynamic Status

  32. Profiles and Therapies of Advanced Heart Failure

  33. WARM UP THEN DRY OUT

  34. NEWER THERAPEUTICS • Biventricular Pacing • EECP • Measurement of BNP levels

More Related