Heart Failure: Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

HEART FAILURE
Departemen Kardiologi FK USU

RSUP. H. Adam Malik
Medan
Definition
Heart failure is defined as 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 pressures are
abnormally high (backward failure), or both.
Pathophysiology
Frank-Starling Law
loss of fibers or contractility
reduced cardiac output
arrhythmia reduced renal

perfusion
cardiac
dilatation venous
increased renin increased
congestion
secretion sympathetic
tone
increased
filling pressure
Na+, H2O increased arteriolar
retention heart rate constriction
increased capillary
hydrostatic pressure increased
resistance
incomplete
edema diastolic cardiac
filling hypertrophy
Causes of left ventricular failure
• Volume over load: Regurgitate valve
High output status
• Pressure overload: Systemic hypertension
Outflow obstruction
• Loss of muscles: Post MI, Chronic ischemia
Connective tissue diseases
Infection, Poisons
(alcohol,cobalt,Doxorubicin)
• Restricted Filling: Pericardial diseases, Restrictive

cardiomyopathy, tachyarrhythmia
Diagnosis
IDENTIFICATIONS OF HF PATIENTS
 With a Syndrome of Decrease Exercise

Tolerance
 With a Syndrome of Fluid Retention
 With No Symptoms or Symptoms of Another
Cardiac or Non Cardiac Disorder
(MI, Arrythmias, Pulmonary or Systemic
Thromboembolic Events)
SYMPTOMS AND SIGN
 Breathlessness, Ankle Swelling, Fatique

→ Characteristic Symptoms
 Peripheral Oedema, JVP ↑, Hepatomegaly

→ Signs of Congestion of Systemic Veins
 S3  , Pulmonary Rales , Cardiac Murmur 

Framingham Criteria
 Major Criteria:
 PND
 JVD
 Rales
 Cardiomegaly
 Acute Pulmonary Edema
 S3 Gallop
 Positive hepatic Jugular reflex
 ↑ venous pressure > 16 cm H2O
Framingham Criteria
 Minor Criteria:
 Extremitas edema
 Night cough
 Dyspnea on exertion
 Hepatomegaly
 Pleural effusion
 ↓ vital capacity by 1/3 of normal
 Tachycardia
 Weight loss 4.5 kg over 5 days management
Precipitating Factors
 Increased metabolic demand
 Increased circulating volume
 Condition that increased afterload
 Condition that impaired contractility
 Failure to take prescribe medication
 Arrhytmia
ECG
 A low Predictive Value
 LAH and LVH maybe Associated wit LV
Dysfunction
 Anterior Q-wave and LBBB a good predictors
of EF ↓↓
 Detecting Arrhytmias
CHEST X-RAY
 A Part of Initial Diagnosis of HF

→ Cardiomegaly, Pulmonary Congestion
 Relationship Between Radiological Signs and
Haemodynamic Findings may Depend on the
Duration and Severity HF
HAEMATOLOGY & BIOCHEMISTRY
 A Part of Routine Diagnostic
 Hb, Leucocyte, Platelets
 Electrolytes, Creatinine, Glucose, Hepatic Enzyme,
Urinalysis
 TSH, C-RP, Uric Acid
ECHOCARDIOGRAPHY
 The Preferred Methods
 Helpful in Determining the etiology
 Follow Up of Patients Heart Failure
STRESS ECHOCARDIOGRAPHY
 For Detecting Ischaemia
 Viability Study
NUCLEAR CARDIOLOGY
 Not Recommended as a Routine Use
CMR
( CARDIAC MAGNETIC RESONANCE IMAGING)
 Recommenmded if Other Imaging Techniques not

Provided Diagnostic Answer
INVASIVE INVESTIGATION
 Elucidating the Cause and Prognostic Informations
 Coronary Angiography :
in CAD’s Patients
 Haemodynamic Monitoring :
To Assess Diagnostic and Treatment of HF
 Endomyocardial Biopsy :
in Patients with Unexplained HF
NATRIURETIC PEPTIDES
 Cardiac Function ↓↓ (LV Function ↓↓) →
↑↑ Plasma Natriuretic Peptide Concentration
(Diagnostic Blood Use for HF)
 Natriuretic Peptide ↑↑ :
Greatest Risk of CV Events
Natriuretic Peptide ↓↓ :
Improve Outcome in Patients with
Treatment
 Identify Pts. With Asymptomatic LV

Dysfunction (MI, CAD)
ALGORITHM FOR THE DIAGNOSIS OF THE HF
(ESC, 2001)
Suspected Heart Failure Because
of symptoms and signs
If Normal
Assess Presence of Cardiac Disease by ECG, X-Ray Heart Failure
or NatriureticPeptides (Where Available) Unlikely
Tests Abnormal
Imaging by Echocardiography (Nuclear If Normal

Angiography or MRI Where Available) Heart Failure
Unlikely
Tests Abnormal
Assess Etiology, Degree, Precipitating

Factors and Type of Cardiac Dysfunction
Additional Diagnosis Tests
Where Appropriate (e.g.
Coronary Angiography)
Choose Therapy
Aims of treatment
1. Prevention
a) Prevention and/or controlling of diseases leading
to cardiac dysfunction and heart failure
b) Prevention of progression to heart failure once
cardiac dysfunction is established
2. Morbidity
Maintenance or improvement in quality of life
3. Mortality
Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure

European Heart Journal (2001) 22, 1527-1560
Treatment options
 Non-pharmacological management
 General advice and measures
 Exercise and exercise training
 Pharmacological therapy
 Angiotensin-converting enzyme (ACE) inhibitors
 Diuretics
 Beta-adrenoceptor antagonists
 Aldosterone receptor antagonists
 Angiotensin receptor antagonists
 Cardiac glycosides
 Vasodilator agents (nitrates/hydralazine)
 Positive inotropic agents
 Anticoagulation
 Antiarrhythmic agents
 Oxygen
 Devices and surgery
 Revascularization (catheter interventions and surgery), other forms of surgery
 Pacemakers
 Implantable cardioverter defibrillators (ICD)
 Heart transplantation, ventricular assist devices, artificial heart
 Ultrafiltration, haemodialysis
Pharmacological therapy
Angiotensin-Converting Enzyme Inhibitors
 Recommended as first-line therapy.

 Should be uptitrated to the dosages shown to be
effective in the large, controlled trials, and not
titrated based on symptomatic improvement.
 Moderate renal insufficiency and a relatively low blood
pressure (serum creatinine  250 µmol.l-1 and systolic
BP  90 mmHg) are not contraindications.
 Absolute contraindications: bilateral renal artery
stenosis and angioedema.

Diuretics
 Essential for symptomatic treatment when

fluid overload is present and manifest.
 Always be administered in combination

with ACE inhibitors if possible.

β-Blocker
 Has been traditionally contraindicated in pts with

CHF
 Now they are the main stay in treatment on CHF
& may be the only medication that shows
substantial improvement in LV function
 In addition to improved LV function multiple
studies show improved survival
 Contraindication: decompensated HF,
Bradicardia/ AV Block, Asma bronchiale
Aldosterone Receptor Antagonists - Spironolactone
 Recommended in advanced HF (NYHA III-IV),

in addition to ACE inhibition and diuretics to
improve survival and morbidity

Angiotensin II Receptor Antagonists
 ARB’s could be considered in patients who do

not tolerate ACE inhibitors for symptomatic
treatment.
 It is unclear whether ARBs are as effective as

ACE inhibitors for mortality reduction.
 In combination with ACE inhibition, ARBs may

improve heart failure symptoms and reduce
hospitalizations for worsening heart failure.

Cardiac Glycosides
 indicated in atrial fibrillation and any degree of

symptomatic heart failure.
 A combination of digoxin and beta-blockade

appears superior than either agent alone.
 In sinus rhythm, digoxin is recommended to

improve the clinical status of patients with
persisting heart failure despite ACE inhibitor and
diuretic treatment.

Vasodilator Agents In Chronic Heart Failure
 No specific role for vasodilators in the treatment of HF
 Used as adjunctive therapy for angina or concomitant
hypertension.
 In case of intolerance to ACE inhibitors ARBs are
preferred to the combination hydralazine–nitrates.
 HYDRALAZINE-ISOSORBIDE DINITRATE
 Hydralazine (up to 300 mg) in combination with ISDN (up to 160

mg) without ACE inhibition may have some beneficial effect on
mortality, but not on hospitalization for HF.
 Nitrates may be used for the treatment of concomitant angina or

relief of acute dyspnoea.

Positive Inotropic Therapy
 Commonly used to limit severe episodes of

HF or as a bridge to heart transplantation
in end-stage HF.
 Repeated or prolonged treatment with oral
inotropic agents increases mortality.
 Currently, insuffcient data are available to
recommend dopaminergic agents for heart
failure treatment.

Anticoagulation
Recommendation
1. All pts with HF and AF should be treated with

warfarin unless contraindicated.
2. Patients with LVEF 35% or less.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Antiplatelet Drugs
Recommendation
There is insufficient evidence concerning the

potential negative therapeutic interaction
between ASA and ACE inhibitors.
Antiplatelet agent for pts with HF who have

underlying CAD.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Antiarrhythmics
 No indication for the use of antiarrhythmic agents in HF
 Indications for antiarrhythmic drug therapy include AF

(rarely flutter), non-sustained or sustained VT.
 CLASS I ANTIARRHYTHMICS
should be avoided
 CLASS II ANTIARRHYTHMICS
Beta-blockers reduce sudden death in heart failure
 CLASS III ANTIARRHYTHMICS
Amiodarone is the only antiarrhythmic drug without
clinically relevant negative inotropic effects.

Classification of HF
Activity Levels (NYHA Classification)
I asymptomatic at rest
symptoms with heavy exercise
II asymptomatic at rest
symptoms with moderate exercise
III asymptomatic at rest
symptoms with activities of daily living
IV symptoms at rest
Exercise testing and O2 consumption

ACC/AHA – A New Approach To The Classification of HF
Stage Descriptions Examples
A Patient who is at high risk for Hypertension; CAD; DM;
developing HF but has no rheumatic fever; cardiomyopathy.
structural disorder of the heart.
B Patient with a structural disorder LV hypertrophy or fibrosis;

of the heart but who has never LV dilatation; asymptomatic VHD;
developed symptoms of HF. MI.
C patient with past or current Dyspnea or fatigue ec LV systolic

symptoms of HF associated with dysfunction; asymptomatic
underlying structural heart patients with HF.
disease.
D Patient with end-stage disease Frequently hospitalized pts ; pts

awaiting heart transplantation etc
ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure in the Adult 2001
Intervention
Surgical
Revascularization
Non Surgical
 Pts with heart failure of ischaemic origin revascularization 
symtomatic improvement.
 A strong negative correlation of operative mortality and LVEF,
a low LVEF (<25%) was associated with increased
operative mortality. Advance HF symptoms (NYHA IV)
resulted in a greater mortality rate.
 Off pump coronary revascularization may lower the surgical
risk for HF.
 Heart Transplantation is an accepted mode of treatment for
end-stage HF.
Algorithm for Management HF
Conclusion
DIAGNOSIS OF HEART FAILURE
 Clinical Signs and Symptoms

 Echocardiography (LVEF) The Preferred
Method
 Natriuretic Peptide Helpful in The Diagnosis
Process
 Additional Test Should be Perfomed
Where Diagnosis Doubt Persist
Conclusion
 Management of HF must be starting from

the earlier stage (AHA/ACC stage A).
Treatment at each stage can reduce
morbidity and mortality.
 Before initiating therapy :

 Established the correct diagnose.
 Consider management outline.
NO MATTER WHAT,
PREVENTION
IS BETTER THAN
TREATMENT
Thank YoU

Heart Failure: Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Heart Failure: Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

Uploaded by

Copyright:

Available Formats

HEART FAILURE

Departemen Kardiologi FK USU

reduced cardiac output

arrhythmia reduced renal

• Restricted Filling: Pericardial diseases, Restrictive

 With a Syndrome of Decrease Exercise

 Breathlessness, Ankle Swelling, Fatique

 Peripheral Oedema, JVP ↑, Hepatomegaly

 S3  , Pulmonary Rales , Cardiac Murmur 

 A Part of Initial Diagnosis of HF

 Not Recommended as a Routine Use

 Recommenmded if Other Imaging Techniques not

 Elucidating the Cause and Prognostic Informations

 Identify Pts. With Asymptomatic LV

Imaging by Echocardiography (Nuclear If Normal

Assess Etiology, Degree, Precipitating

Guidelines for the diagnosis and treatment of chronic heart failure

 Recommended as first-line therapy.

Guidelines for the diagnosis and treatment of chronic heart failure

 Essential for symptomatic treatment when

 Always be administered in combination

Guidelines for the diagnosis and treatment of chronic heart failure

 Has been traditionally contraindicated in pts with

 Recommended in advanced HF (NYHA III-IV),

Guidelines for the diagnosis and treatment of chronic heart failure

 ARB’s could be considered in patients who do

 It is unclear whether ARBs are as effective as

 In combination with ACE inhibition, ARBs may

Guidelines for the diagnosis and treatment of chronic heart failure

 indicated in atrial fibrillation and any degree of

 A combination of digoxin and beta-blockade

 In sinus rhythm, digoxin is recommended to

Guidelines for the diagnosis and treatment of chronic heart failure

 Hydralazine (up to 300 mg) in combination with ISDN (up to 160

 Nitrates may be used for the treatment of concomitant angina or

Guidelines for the diagnosis and treatment of chronic heart failure

 Commonly used to limit severe episodes of

Guidelines for the diagnosis and treatment of chronic heart failure

1. All pts with HF and AF should be treated with

2. Patients with LVEF 35% or less.

There is insufficient evidence concerning the

Antiplatelet agent for pts with HF who have

 Indications for antiarrhythmic drug therapy include AF

Guidelines for the diagnosis and treatment of chronic heart failure

Exercise testing and O2 consumption

B Patient with a structural disorder LV hypertrophy or fibrosis;

C patient with past or current Dyspnea or fatigue ec LV systolic

D Patient with end-stage disease Frequently hospitalized pts ; pts

ACC/AHA Guidelines for the

 Clinical Signs and Symptoms

 Management of HF must be starting from

 Before initiating therapy :

You might also like