congestive heart failure hanna al-makhamreh, md facc interventional cardiology
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Congestive Heart Failure
Hanna Al-Makhamreh, MD FACCInterventional cardiology
Heart Failure
Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).
The Vicious Cycle of Congestive Heart Failure
Decreased Blood Pressure andDecreased Renal perfusion
Stimulates the Release of renin, Which allows
conversion of Angiotensin
to Angiotensin II. Angiotensin II stimulates
Aldosterone secretion which causes retention of
Na+ and Water, increasing filling pressure
LV Dysfunction causesDecreased cardiac output
Types of Heart Failure
Systolic Heart Failure: decreased cardiac output Decreased Left ventricular ejection fraction
Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic
pressures May have normal LVEF
.
Causes of Low-Output Heart Failure
Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) peripartum, HIV, connective tissue disease,
substance abuse, doxorubicin Hypertension Valvular Heart Disease(MR,AR)
Diastolic Dysfunction Hypertension Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy AS
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 Weakness
Physical Examination in Heart Failure
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
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.)
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
Cardiomegaly Cephalization of the pulmonary
vessels Kerley B-lines Pleural effusions
Cardiomegaly
Pulmonary vessel congestion
Pulmonary Edema due to 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
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.
Classification of Heart Failure
New York Heart Association (NYHA) Class I – symptoms of HF only at levels
that would limit normal individuals. Class II – symptoms of HF with
ordinary exertion Class III – symptoms of HF on less than
ordinary exertion Class IV – symptoms of HF at rest
Classification of Heart Failure (cont.)
ACC/AHA Guidelines Stage A – High risk of HF, without
structural heart disease or symptoms Stage B – Heart disease with
asymptomatic left ventricular dysfunction
Stage C – Prior or current symptoms of HF
Stage D – Advanced heart disease and severely symptomatic or refractory HF
Chronic Treatment of Systolic Heart Failure
Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension
Lifestyle modification Lower salt intake Alcohol cessation Medication compliance
Maximize medications Discontinue drugs that may contribute to heart
failure (NSAIDS, antiarrhythmics, calcium channel blockers)
Order of Therapy
1. Loop diuretics2. ACE inhibitor (or ARB if not
tolerated)3. Beta blockers4. Digoxin5. Hydralazine, Nitrate6. Potassium sparing diuretcs
Diuretics
Loop diuretics Furosemide, buteminide For Fluid control, and to help relieve
symptoms
Potassium-sparing diuretics Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF
ACE Inhibitor
Improve survival in patients with all severities of heart failure.
Begin therapy low and titrate up as possible:
Enalapril – 2.5 mg po BID Captopril – 6.25 mg po TID Lisinopril – 5 mg po QDaily
If cannot tolerate, may try ARB
Beta Blocker therapy
Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV.
Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma Heart block
Management of Refractory Heart Failure
Inotropic drugs: Dobutamine, dopamine, milrinone,
nitroprusside, nitroglycerin Mechanical circulatory support:
Intraaortic balloon pump Left ventricular assist device (LVAD)
Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption
with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.