CHRONIC CONGESTIVE

HEART FAILURE

2004 - 2005
 BACKGROUND:

HF PREVALENCE  from 3 - 20 ‰ at 45 years

to 80-160 ‰ over 75 years
N.Sharpe, 1998
MORTALITY  with aging
5% deaths through HF below 45 years
1/3 deaths through HF to 75 years
2/3 deaths through HF above 75 years
Chignon J, 1998
PHARMACOLOGICAL APPROACH
a. medication: intake / abuse / drug associations
b. changes in: - pharmacokinetics
- pharmacodinamics
- social, economic, mental context.
 DEFINITION
(after ESC)

• SUBJECTIVE:
• HF symptoms:
• dyspnea/ortopnea/ nocturnal paroxysmal d.
• edema
• tachycardia
• rales
• LV gallop
• distended neck veins

• OBJECTIVE: systolic/diastolic dysfunction

• RETROSPECTIVE: response to correct HF treatment

 HF DIAGNOSIS: STEPS

• Recognize HF picture
• Etiology
• Pathogenesis: systolic/diastolic dysfunction
• Recognize decompensation: edema, dyspnea
• Assess morbidity/mortality predictive factors
 1. RECOGNIZE HF

• LV FAILURE
• LV FAILURE: asymptomatic at rest, symptomatic at effort
• edema
• Cardiac asthma
• Rest symptomatic LV failure

• RV FAILURE
 2. ETIOLOGY

CORONARY ARTERY DISEASE

- MYOCARDIAL INFARCTION
- CHRONIC ISCHEMIA

Systemic HYPERTENSION
CARDIOMYOPATHIES
- DILATIVE, HYPERTROPHIC, RESTRICTIVE
- ACUTE MYOCARDITIS
- OTHER: METABOLIC, ENDOCRINE, NEUROMUSCULARE, TOXIC, etc.
VALVE DISEASES
- SEVERE AORTIC STENOSIS
- MITRAL REGURGITATION
- AORTIC REGURGITATION
- MITRAL STENOSIS
OTHER
- ARRHYTHMIAS / BLOCKS
- INCREASED CARDIAC OUTPUT
- CONGENITAL CARDIAC DISEASES
- COR PULMONALE
- CONSTRICTIVE PERICARDITIS
 „adapted” LV insufficient LV
* dilation
* remodelling
* hemodynamic factors;
neurohumoral factors

3. LV DYSFUNCTION
* POPULATION AT RISK
* CAD
* Hypertension
* valvular disease
* cardiomyopathies at onset
LV DYSFUNCTION
AGGRAVATING FACTORS
* MYOCARDIAL HIPERTROPHY
* VASCULAR/ VENTRICULAR
DIASTOLIC SYSTOLIC
REMODELLING
-LVHc + EFn • cardiac dilation
* ARRHYTHMIAS
-distensibility •EF 
* ISCHEMIA
-relaxation * HYPERTENSIVE CRISIS
-E/A <1
 DIASTOLIC DYSFUNCTION
= LV can not be filled at low pressure

Consequences * congestive syndrome  pulmonary

 peripheral
* EndD LV P > 12 mmHg

CLINIC  signs of congestive HF

 cardiac silhouette normal
 normal EF

Asymptomatic diastolic dysfunction ↔ ECHO

↔ angiography/scintigraphy

Symptomatic: LV failure  pulmonary HT  right HF  congestive syndrome 

chronic
 low cardiac output
DIASTOLIC DYSFUNCTION

ETIOLOGY:

* PERICARDITIS
* ENDOMYOCARDIAL FIBROSIS
* Relaxation and ventricular compliance deterioration:
concentric LV hypertrophy
CAD
RESTRICTIVE CARDIOPATHIES
* Pulmonary venous return decrease: HYPOVOLEMIA
* Secondary to systolic dysfunction: MITRAL STENOSIS

AGGRAVATING FACTOR: ATRIAL FIBRILLATION

 DIASTOLIC DYSFUNCTION

DYSFUNCTION
SYSTOLIC DIASTOLIC

HISTORY OF
* MI ++ +/-
* HTN + ++
ANAMNESIS
* BRUTAL ONSET +/- ++
X-RAY
* CARDIOMEGALY ++ -
ECG
* Q WAVE ++ +/-
* LV H +/- ++
ECHO EF  EF n
E/A < 1
 4. INVESTIGATIONS
1. HF detection
- Chest X-ray: cardio-thoracic index, pulmonary stasis
- Echocardiography: LV dysfunction
- Ergospirometry: VO2 max
2. HF etiology
- ECG: ischemia / infarction, hypertrophy, arrhythmia
- Echocardiography: valve disease, systolic / diastolic dysfunction
- Rare causes: - thyroid dysfunction
- anemias
- amiloidosis, sarcoidosis
- Cardiac catheterization
- PBM (myocardial biopsy)
3. HF severity
- Isotopic ventriculography
- Myocardial scintigraphy
- Ergospirometry
4. HF prognosis
- Holter monitoring
- Assess - renal function
- liver function
- hydro-electrolitic equilibrium
- plasma NA peptide (> 900ng/ml)
 Establish diagnosis
Assessments in all cases

Necessary Supports Opposes

History with symptoms +++ If absent

Objective evidence +++ If absent

Response to treatment ++
 Tests for diagnosis
Test

Necessary Supports Opposes

Electrocardiogram ++ If normal

Echocardiography +++ If normal

Chest x-ray If congestion If normal

Blood count If normal

Blood chemistry If normal

 Aditional tests

Test

Necessary Supports Opposes

Exercise test If normal

Natriuretic peptide If elevated If normal

Cardiac cath. If normal

NYHA Classification
( New York Heart Association) 1964

CLASS I: no activity limitation – patients have cardiac

dysfunction, had before HF symptoms and are under medication
for HF
CLASS II: moderate limitation of physical activity:
asymptomatic in resting, but usual effort leads to dyspnoea,
fatigue, palpitations or angina
CLASS III: important limitation of physical activity :
asymptomatic at rest, but an effort below the usual intensity
leads to symptoms.
CLASS IV: HF symptoms are present at rest and aggravated at
minimal effort. The patient is not able to perform any physical
activity without symptoms.
 Weber and Janicki Classification 1985

CLASA A VO2 max > 20 ml/min/kg

CLASA B VO2 max = 16-20 ml/min/kg
CLASA C VO2 max = 10-15 ml/min/kg
CLASA D VO2 max < 10 ml/min/kg
CLASA E VO2 max < 6 ml/min/kg
 5. POTENTIAL REVERSIBLE CONDITIONS
THAT AGGRAVATE HF

* HYPERVOLEMIA
* PRIMARY CARDIOMYOPATHY
* CAD + ATRIAL ARRHYTHMIA
* DYSELECTROLYTEMIAS
- alcalosis with hypo-K+
- hypo-Na+
* ALCOHOL
* INADEQUATE TREATMENT
-digitalic toxicity
-dysfunction -systolic
-diastolic - diuretics !!!
- antiarrhythmics
6. DETRIMENTAL PROGNOSIS FACTORS
CLINIC
- age
- gender (M)
- cls IV NYHA
- ischemia
- cachexia
- indiscipline
HEMODYNAMICS
EF 
SF < 20%
pCP > 16 mmHg
EFFORT CAPACITY
VO2max < 14ml/kg/min
N.H. STIMULATION
NA 
Endothelin > 5pcg/ml
 THERAPEUTIC APPROACH IN HF

• GENERAL ADVICE AND MEASURES

• Diet-salt intake restriction
• Obesity – weight reduction
• Smoking cessation
• Physical activity (individualize!)

• SPECIFIC MEASURES
• Excessive alcohol intake reduction
• CV risk factors management
• Blood pressure control
1. ACE inhibitors
- first-line therapy in patients with reduced EF < 45%, with or without
symptoms
- in all HF stages.
- fluid retention: ACE-i + Diuretic.

Recommendations:
- avoid excessive diuresis before treatment
- start with a low dose and build up to maintenance dosage with
weekly monitoring – creatinine and plasma ions
- avoid potassium-sparing diuretics during therapy initiation
- avoid NSAIDs

If no satisfying response:
- change with another ACE-i or
- Choose an AT1-receptor inhibitor
ESC recommendations on ACE-I therapy in HF
2. Beta-blockade in HF
Indications
-stable mild, moderate and severe HF of ischemic and non-ischemic
origin (if no contraindications)
-patients with LV dysfunction with/without HF post-MI for survival
benefit

Initiation and uptitration of beta-blockade in HF:

- stable patient on a background therapy with ACE-i + Diuretic ±
Digoxin
- no fluid retention
- no hypotension ( SBP < 90 mm Hg)
- no bradycardia (HR < 55 / min)
- titrate slowly and carefully from low initial dose to target doses
 BETA-BLOCKERS in HF

Β-BLOCKER INITIAL DOSE (mg) TITRATION (mg) MAX DAILY DOSE

(mg)

BISOPROLOL 1,25 2,5/3,75/5/7,5/10 10

CARVEDILOL 3,125 6,25/12,5/25/50 50
METOPROLOL
Succinate CR 12,5/25 25/50/100/200 200
Tartrate 5 10/15/30/50/75/100 150
 Patients should be addressed to a specialist if:

• Severe HF class III/IV

• Unknown etiology
• Relative CI: bradicardia, low blood pressure
• Low dose intolerance
• Previous beta-blocker use with treatment cessation because of
symptoms
• Suspicion of asthma or CAD

Beta-blockers: contraindications in HF

• Asthma
• Severe bronchitis
• Symptomatic bradicardia or hypotension
 3. DIURETICS

• Loop-diuretics or thiazides
Always together with an ACE-i
• If GFR < 30 ml/min (glomerular filtration rate) then no
thiazides (exception: if thiazides are adjuvant to loop-
diuretics)

Insufficient response:

1. Increase diuretic dose

2. Associate loop-diuretics and thiazides
3. Persistent fluid retention: loop-diuretics twice a day
4. Severe HF: monitor creatinine and electrolytes
Potassium-sparing diuretics: triamteren, amiloride,
spironolactone

• Only if hypo-K+ persists after therapy initiation with ACE-I

and diuretics

• Initiate with low dose for 1 week, then assess plasma K+

and creatinine after 5 - 7 days and increase correctly the
dose. Monitor K+ and creatinine every 5 – 7 days till K + is
constant.
 MEDICATION INITIAL MAX SIDE EFFECTS
DOSE DOSE
(mg) (mg)
l.POTASSIUM-SPARING D.
* SPIRONOLACTONE 25 100
* AMILORID 5 40 HYPER-K+
* TRIAMTEREN 50 100
2.THIAZIDES
* HYDROCHLOROTHIAZID 25 50 DYSELECTROLYTEMIA
* METOLAZONE 2,5 10 THIAZIDIC DIABETES
METABOLIC
DISORDERS
3.LOOP-DIURETICS
* FUROSEMID 10 240
* BUMETANID 0,5 10 DYSELECTROLYTEMIA
* TORASEMID 5 100 METABOLIC
DISORDERS
* ETACRINIC ACID 50 200
4. DIGITALIS GLYCOSIDES are indicated in:
-atrial fibrillation
-any symptomatic HF stage
-sinus rhythm, if persistent HF (systolic LV
dysfunction) even if treated with ACE-i + Diuretic

Digoxin + Beta-blocker: superior association vs. monotherapy

 5. Vasodilators

• May be used as adjunctive therapy in HF for the relief of

angina or acute dyspnea (nitrates) or concomitant
hypertension (DHP calcium antagonists)
• AT1 bl better choice than nitrates /hydralazine when
intolerance to ACE-I
• Alpha-blockers are not recommended in HF
• DHP calcium antagonists have no effect on survival in
HF due to LV systolic dysfunction
6. Chronic anticoagulant therapy in HF (INR = 2-3) – indications:
- atrial fibrillation permanent/paroxystic
- mitral stenosis – left atrium with thrombus or spontaneous contrast
image
- LV with thrombus (after MI)
- after pulmonary or systemic embolism
- cardiomegaly with EF < 30%
- cardiac patients with long time immobilization, at high risk for
thrombosis (obesity, chronic venous insufficiency)
 LV SYSTOLIC DYSFUNCTION

ASYMPTOMATIC ACE-i
ACE-i + Beta-blocker (after MI)
SYMPTOMATIC - class II NYHA
- Without fluid retention ACE-i
ACE-i + Beta-blocker
If the patient remains symptomatic
•Reconsider diagnosis
•Treat ischemia (nitrates, revascularization)
•Add diuretic
-with fluid retention
• first: ACE-i + Diuretic
• 2nd: ACE-i + Diuretic + Beta-blocker.
ACE-I intolerance ► AT1 Bs
• 3rd: associate Digitalis (even in sinus rhythm !).

If response is obtained, digitalis can be dropped out.

HF WORSENING imposes following associations:
-Spironolactone and / or
-Loop-diuretic + thiazide
HF class IV NYHA despite of optimal therapy and correct diagnosis
-Continue with mentioned measures
-Add palliative therapy in final stages (opioids)

LV DIASTOLIC DYSFUNCTION
Recommendations
-Beta-blockers
-Calcium antagonists (Verapamil)
-ACE-i
-Diuretics (caution!)
-Arrhythmias’ control sustained VT  Amiodarone
Symptomatic A.F.  Digitalis