HEART FAILURE

Dr. Akhtar Husain

Associate Professor
DEFINITION

HF is a pathophysiologic state in which

an abnormality of cardiac function is
responsible for failure of the heart to
pump blood at a rate commensurate
with the requirements of the
metabolizing tissues, or to do so only
from an elevated filling pressure.
CARDIAC DIAGNOSIS
 Etiologic: Cor.HD, HHD, RHD, Cong.HD,
Corpulm.,Cardiomyopathy,
Infectious, Traumatic.
 Anatomic:Valves, Chambers, Infarction.
 Physiologic: CHF, Angina, Arrhythmias.
 Functional: Class I-IV
Precipitating Causes

1. Infection 7. Cardiac infection

2. Arrhythmias 8. Acute MI
3. Pulm. Embolism 9. Drugs
4. Stress 10. Thyrotoxicosis
5. Anemia 11. Fluid overload
6. Pregnancy 12. Noncompliance
REMODELING
Remodeling is an alteration in the structure of the
muscular, vascular or interstitial compartments of
the mycardium.
- Concentric hypertrophy
- Eccentric hypertrophy
- Fibrosis
- Change in shape
- Vascular changes
DILATED CARDIOMYOPATHY
Left ventricular dysfunction
Inotropic agents

Perceived reduction in
? circulating volume/pressure

Vasoconstriction Sympathetic tone Renin-

Salt and water retention angiotensin-aldosterone
Arginine vasopressin

• Vasodilators • Sympatholytic agents

• Diuretics • Beta blockers
• DA1 agonists • ACE inhibition
• ANF • AVP antagonist
SYMPTOMS

 Dyspnea: Exertional, PND, orthopnea

 Cough, sputum, hemoptysis
 Nocturia
 Fatigue
 Mental confusion & delirium
 Edema
 RUQ abdominal pain
NYHA Functional Classification

Class I: No limitation of physical activity.

Class II: Slight limitation of physical activity.

Class III: Marked limitation of physical activity.

Class IV: Symptoms at rest.

PHYS. EXAM.

 Respiratory distress
 Tachycardia, diaphoresis, cyanosis
 Cold extremities
 Pulsus alternans
 High jugular venous pressure
 Cardiomegaly
 S3 gallop
PHYS. EXAM.(Cont.)

 Pulmonary rales
 Hydrothorax
 Tender hepatomegaly
 Ascites
 Edema
TYPES OF HEART
FAILURE
 Acute VS Chronic
 Right sided VS Left sided
 Systolic VS Diastolic
 Low output VS high output
 Compensated VS Decompensated
THERAPEUTIC GOALS

 To improve symptoms.
 To reduce frequency of exacerbations
of CHF.
 To improve survival.
DIURETICS

 Frusemide po or IV (5-20mg/hr)
 Metolazone 2.5-5mg
 Bumetanide 1-5mg
 Hydrochlorthiazide 25-50mg
 Spironolactone 12.5-25mg tid
HEART FAILURE PARADIGMS
 Cardiorenal Model
– Digoxin
– Diuretics
 Cardiocirculatory Model
– Vasodilators
 Neurohormonal Model
– ACE inhibitors
– B-blockers
– Spironolactone
 Genetic Model
Therapy?
ACE INHIBITORS
1. Captopril, Enalapril, Lisinopril and Ramipril
2. Improves symptoms
3. Attenuates progression of CHF
4. Attenuates cardiac remodelling
5. Improves survival
6. Useful in asymptomatic LV dysfunction
7. Side effects:
• Cough, angioedema, hypotension, renal failure,
hyperkalemia
INOTROPIC THERAPY

1. Digoxin
2. β-agonists – Dobutamine
3. Phosphodiesterase Inhibitors
– Amrinone, Milrinone
BETA-BLOCKERS
1. Carvedilol, Metoprolol and Bisoprolol
2. Attenuates cardiac remodelling
3. Improvement in E.F.
4. Acute pulmonary edema and severe
CHF patients must be decongested
first
5. Side effects
 Clinical Evidence of Efficacies of Major
Heart Failure Drug Therapy (cont’d)
Start Target Reduce Heart
Drug Dose Dose Reduce Failure Improve
(mg) (mg) Symptoms Exacerbations Survival

Spirinolactone 12.5-25 25 qd + + + + + + + +
Diuretics +++ ? ?
Furosemide 20-40 NA
Bumetanide 1-2
Torsemide 1-10
Metolazone 2.5-5
Digoxin 0.125 0.125 + + + + ++ 0
Hydralazine/Isosorbide 25/10 100 tid/40 qid ++ ++ ++
Dinitrate
ARBs ++ ++ +/0
Losartan 25 50 qd
Candesartan 4 16 qd
Valsartan 80 160 qd
Amlodipine 2.5-5 5 qd ++ ++ 0
 Clinical Evidence of Efficacies of Major
Heart Failure Drug Therapy
Target Reduce Heart
Drug Start Dose Dose Reduce Failure Improve
(mg) (mg) Symptoms Exacerbations Survival
ACE Inhibitors +++ +++ +++
Captopril 6.25-12.5 50 tid
Enalapril 2.5-5 10 bid
Lisinopril 2.5-5 10-20 qd
Ramipril 1.25-2.5 5 bid
β-Blockers + + + ++ +++
Carvedilol 3.125-6.25 25 bid
Metoprolol succinate 12.5 100 qd
(metroprolol CR/XL)
Bisoprolol
MAJOR MORTALITY CLINICAL TRIALS IN SUPPORT OF THE USE OF
NEUROHORMONAL ANTAGONISTS IN HEART FAILURE (cont’d)

NYHA Follow-Up
Drug Class Treatments N Class (m) MPA (%)

Digoxin
DIG Trial DIG vs PCB 6800 II-III 37 11.3 vs 11.4
Vasodilators
V-HeFT-I H + I vs PRA 642 II-III 27.6 16.8 vs 19.1
V-HeFT-II H + I vs PRA 804 II-III 30 13 vs 15
PRAISE-II AML vs PCB 1652 III-IV 48 8.4 vs 7.9
ELITE-II LOS vs CAP 3152 II-III 18 11.6 vs 10.5
Val-HeFT VAL vs PCB 5010 II-III 24 9.9 vs 9.7

ENA = enalapril; PCB = placebo; CAP = captopril; RAM – ramipril; CAR = carvedilol; BIS = bisoprolol; TXL = Toprol XL (metoprolol succinate);
BUC = bucindolol; SPI = spironolactone; DIG = Digoxin; II+I = hydralazine + isosorbide dinitrate; PRA = Prazosin; AML = amlodipine; LOS = losartan;
VAL = valsartan; NYHA =New York Heart Association; Post MI = post myocardial infarction.
*MPA = Mortality per annuam – annualized mortality based on mortality rate at the end of year one in the placebo group (calculated as total
mortality/duration).
 MAJOR MORTALITY CLINICAL TRIALS IN SUPPORT OF THE USE OF
NEUROHORMONAL ANTAGONISTS IN HEART FAILURE
NYHA Follow-
Drug Class Treatments N Class Up (m) MPA (%)
ACE Inhibitors
CONSENSUS ENA vs PCB 253 IV 12 36 vs 52
SOLVD-T ENA vs PCB 2569 II-III 41.4 10 vs 11
SOLVD-P ENA vs PCB 4228 I-II 37.4 4.8 vs 5.1
SAVE CAP vs PCB 2231 Post MI 42 5.7 vs 7.1
AIRE RAM vs PCB 1986 Post MI 15 13.6 vs 18.4
β-Blockers
US Carvedilol CAR vs PCB 1094 II-III 6.5 6.4 vs 11.1
ANZ Trial CAR vs PCB 415 I-II 19 6.5 vs 8.3
CIBIX-II BIS vs PCB 2647 II-IV 16 8.8 vs. 13.2
MERIT-HF TXL vs PCB 3991 II-III 12 7.2 vs 11.0
BEST BUC vs PCB 2523 II-IV 24 6.8 vs 16.6
COPERNICUS CAR vs PCB 2289 III-IV 24 11.4 vs 18.5
Spironolactone
RALES SPI vs PCB 1663 III-IV 24 17.5 vs 23
ENA = enalapril; PCB = placebo; CAP = captopril; RAM – ramipril; CAR = carvedilol; BIS = bisoprolol; TXL = Toprol XL (metoprolol succinate);
BUC = bucindolol; SPI = spironolactone; DIG = Digoxin; II+I = hydralazine + isosorbide dinitrate; PRA = Prazosin; AML = amlodipine; LOS = losartan;
VAL = valsartan; NYHA =New York Heart Association; Post MI = post myocardial infarction.
*MPA = Mortality per annuam – annualized mortality based on mortality rate at the end of year one in the placebo group (calculated as total
mortality/duration).
HEART FAILURE PARADIGMS
 Cardiorenal Model
– Digoxin
– Diuretics
 Cardiocirculatory Model
– Vasodilators
 Neurohormonal Model
– ACE inhibitors
– B-blockers
– Spironolactone
 Genetic Model
Therapy?
CONCLUSION
1. Heart Failure is a complicated milieu of pump
dysfunction, myocardial remodeling, hormonal,
cytokines & neuroregulatory perturbation with
subsequent circulatory insufficiency.

2. The compensatory mechanisms are useful, in the

short term, to maintain adequate body tissue
perfusion.

3. They are deleterious in the long term.

CONCLUSION (cont.)
4. Remodeling & apoptosis are responsible for the
progression of the disease.

5. Understanding pathophysiology is important for the

optimal care of CHF patients.