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DEFINITION
The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. (E. Braunwald) The inability of the heart to pump blood forward at a sufficient rate to meet the metabolic demands of the body (forward failure), or the ability to do so only if the cardiac filling pressure are abnormally high (backward failure), or both. (Pathophysiology of Heart Disease 4 th ed, Liily, Leonard S)
DEFINITION
Heart Failure is a clinical syndrome in which patients have the following features :
Signs typical of HF
(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly)
And
Objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart soud, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration)
Symptoms
Heart Failure
Stage C Structural heart disease with prior or current symptoms of HF Stage D Refractory HF requiring specialized interventions
e.g. patient with -Hypertension -Atherosclerosis disease -Diabetes -Obesity -Metabolic syndr -Using cardiotoxin -with Familial history
Structural heart disease
e.g. patient with -Previous MI -LV remodeling: including LVH, low EF -Asymptomatic valvular disease
e.g. patient with -Known structural heart disease -Shortness of breath and fatigue, reduced exercise tolerance
Development of HF symptoms
e.g. patient with -Who have marked symptoms at rest despite maximal medical therapy (recurrently hospitalized /cannot be safely discharged from hospital without specialized intervention
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults
AFTERLOAD
TREATMENT
The goal of treatment : relieve symptoms and signs prevent hospital admission improve survival Treatment strategy for the use of drugs in patients with HR-REF Three neurohumoral antagonist ACE inhibitor (or Angiotensin Receptor Blocker (ARB)) Beta-blocker MRA (Mineralocorticoid Receptor Blocker) The aforementioned drugs commonly used in conjunction with a diuretic given to relieve the symptoms and signs of congestion
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Symptoms typical of HF
Symptoms typical of HF
Signs typical of HF
Signs typical of HF
Reduced LVEF
Normal or only mildly reduced LVEF and LV not dilated Relevant structural heart disease (LV hypertrophy/LA enlargement) and/or diastolic dysfunctions
Diuretics
Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion
Most patients are prescribed loop diuretics rather than thiazides due to higher efficiency of induced diuresis and natriuresis
Self-adjustment of diuretic dose based on daily weight-measurements and other clinical signs of fluid retention should be encouraged in HF outpatient care. Patient education is required
ACE inhibitors
Patients who should get ACEI LVEF 40%, irrespective of symptoms
Initiation of an ACEI : Check renal function and serum electrolytes Consider dose up-titration after 2-4 weeks Do not increase dose if worsening renal function or hyperkalaemia It is common to up-titrate slowly but more rapid titration is possible in closely monitored patients
Reduce the dose of diuretics and other hypotensive agents (except ARB/ b-blocker / dosterone antagonist)
Cough troublesome cough switch to an ARB
ARBs
Patients who should get an ARB LVEF 40% and either As an alternative in patients with mild to severe symptoms (NYHA fc II-IV) who are intolerant of an ACEI Or in patients with persistent symptoms (NYHA fc IV) despite treatment with an ACEI and beta blocker
ARBs (dosage)
Starting dose (mg) Target dose (mg)
ARB
Candesartan 4 or 8 mg o.d 32 o.d
Valsartan
Losartan
40 b.i.d
50 o.d
160 b.i.d
150 o.d
Beta-blockers
Patients who should get a beta-blocker LVEF 40%
Initiation of a beta-blocker Beta-blocker may be initiated prior to hospital discharge in recently decompensated patients with caution
Visits every 2-4 weeks to up-titrate the dose of beta-blocker (slower dose uptitration may be needed in some patients). Do not increase dose if signs of worsening HF, symptomatic hypotension (e.g. dizziness) or excessive bradycardia (pulse rate <50/minute) at each visit
Beta-blockers (dosage)
Starting dose (mg) Target dose (mg)
1.25 mg o.d
3.125 b.i.d 12.5/25 o.d 1.25 o.d
10 o.d
25-50 b.i.d 200 o.d 1o.d
Initiation of spironolactone (eplerenone) Check renal function and serum electrolytes Consider up-titration after 4-8 weeks. Do not increase dose if worsening renal function or hyperkalaemia
Ivabradine
Ivabradine is a drug that inhibits the I f channel in the sinus node. Its only known pharmacological effect is to slow heart rate in patients in sinus rhythm (it does not slow the ventricular rate in AF)
Digoxin
In patients in sinus rhythm with symptomatic HF and LVEF 40%, this treatment improve patient well -being and reduce hospital admission for worsening HF Patients in AF with ventricular rate at rest >80, and at exercise >110-120 beat/minute should get digoxin
In patients with sinus rhythm and left ventricular systolic dysfunction (LVEF 40%) receiving optimal doses of diuretic, ACEI or/and ARB, beta-blocker and aldosterone antagonist if indicated, who are symptomatic, digoxin may be considered )
Arrhythmia, bradycardia, and atrioventricular block in patients with heart failure with reduced EF and heart failure with preserved EF
Atrial Fibrillation
The most common arrhythmia in HF
increases the risk of thrombo-embolic complications (particularly stroke) and may lead to worsening of symptoms The following issues need to be considered in patients with HF and AF, especially a first episode of AF or paroxysmal AF: Identification of correctable causes (e.g. hyperthyroidism, electrolyte disorders, uncontrolled hypertension, mitral valve disease). Identification of potential precipitating factors (e.g. recent surgery, chest infection or exacerbation of chronic pulmonary disease/asthma, acute myocardial ischaemia, alcohol binge) as this may determine whether a rhythm-control strategy is preferred to a rate-control strategy. Assessment for thromboembolism prophylaxis.
Atrial Fibrillation
Thrombo-embolism prophylaxis
Ventricular arrhythmia in HF
Chronic obstructive pulmonary disease and Asthma may cause diagnostic difficulties, especially in HF-PEF
Beta-blockers are contraindicated in asthma but not in COPD selective beta-1 adrenoceptor antagonist (i.e. bisoprolol, metoprolol succinate, or nebivolol) Preferred
Oral corticosteroids cause sodium and water retention worsening of HF
Diabetes Melitus
Associated with poorer functional status and worse prognosis
Thiazolidinediones (glitazones) sodium and water retention and increased risk of worsening HF and hospitalization
Metformin is NOT recommended in patients with severe RENAL or HEPATIC IMPAIRMENT
HYPERTENSION
Defined as the rapid onset of, or change in, symptoms and signs of HF. It may occur with or without previous cardiac disease.
ESC guidelines for the Diagnosis & Treatment of Acute and Chronic Heart Failure 2012
Epidemiology
In Europe, Scottish data, in a hospital registry survey 4,7% of hospitalizations in women, and 5,1% in men were do to HF The crude incidence of HF of all grades of severity varies from 2,3 to 3,7 per 1000 per annum
CHD is the aetiology of AHF in 60-70% of patient, particularly in the elderly peoples, while in young subjects, frequently cause by DCM, arrhythmia, congenital or valvular heart disease, or myocarditis
Clinical classification
Worsening or decompensated chronic HF
There is usually a history of progressive worsening of known chronic HF on treatment and evidence of systemic and pulmonary congestion
Pulmonary oedema
Present with severe respiratory distress, tachypnoea and orthopnoea with rales over on lung fields. Artery O2 saturation is usually <90%
Hypertensive HF
Signs and symptoms of HF accompanied by high blood pressure and usually relatively preserved left ventricular systolic function
Cardiogenic shock
Defined as evidence of tissue hypoperfusion induced by HF after adequate correction of preload and major arrhythmia
Isolated right HF
Characterized by a low output syndrome in the absence of pulmonary congestion
ACS and HF
Clinically depicted symptoms and laboratory evidence of an ACS.
Vasodilators
EPIDEMIOLOGY
Most of the knowledge about the epidemiology, risk factors,prognosis, treatment, and prevention of HF is based on North American and European studies
Europe The prevalence of symptomatic HF range from 2-3% Prevalence in 70- to 80-year-old people is between 10 and 20%. 15 million HF pts in 900 million total population Overall 50% of patients are dead at 4 years. Forty per cent of patients admitted to hospital with HF are dead or readmitted within 1 year
(ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure ,2008)
USA Nearly 5 million HF pts. 500,000 pts are HF for the 1st time each year. Last 10 years number of hospitalizations has increased. Nearly 300,000 patients die of HF each year.
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001
Acute onset
Non-acute onset
BNP/NT-pro BNP
Echocardiography
Echocardiography
If heart failure confirmed, determine aetiology and start appropiate treatment