Heart failure Management

By Dr. Bahiru
Arba Minch General Hospital

By Dr. Bahiru AMGH 1

Heart failure
Definition:
 The cur­rent American College of Cardiology Foundation
(ACCF)/American Heart Association (AHA) guidelines define
HF as a complex clinical syndrome that results from structural
or functional impairment of ventricular filling or ejection of
blood, which in turn leads to the cardinal clinical symptoms of
dyspnea and fatigue and signs of HF, namely edema and rales.
Heart failure

EPD
 >20 m people are affected ww.
Prevalence is 2% in developed countries.
Relative incidence is lower in women but prevalence is
higher b/c of their longer life expectancy

By Dr. Bahiru AMGH 3

Heart failure
Etiology
Depressed Ejection Fraction (<40%)
Coronary artery disease Nonischemic dilated cardiomyopathy
Myocardial infarction Familial/genetic disorders
Myocardial ischemia Infiltrative disorders
Chronic pressure overload Toxic/drug-induced damage
Hypertension Metabolic disordera
Obstructive valvular diseasea Viral
Chronic volume overload Chagas’ disease
Regurgitant valvular disease Disorders of rate and rhythm
Intracardiac (left-to-right) shunting Chronic bradyarrhythmias
Extracardiac shunting Chronic tachyarrhythmias
Chronic lung disease
Cor pulmonale
Pulmonary vascular disorders
 

By Dr. Bahiru AMGH 4

Heart failure

Preserved Ejection Fraction (>40–50%)

Pathologic hypertrophy Restrictive cardiomyopathy
Primary (hypertrophic Infiltrative disorders (amyloidosis,
cardiomyopathies) sarcoidosis)
Secondary Storage diseases (hemochromatosis)
(hypertension) Fibrosis
Aging
Endomyocardial
disorders
 

By Dr. Bahiru AMGH 5

 Heart failure

High-Output States

Metabolic disorders Excessive blood flow requirements

Thyrotoxicosis Systemic arteriovenous shunting
Nutritional disorders Chronic anemia
(beriberi)

By Dr. Bahiru AMGH 6

 Heart failure

 CAD and Hypertension are the most common causes of HF in

western
 RHD the most common cause in Africa and Asia.
 In 20–30% of the cases of HF with a depressed EF, the exact
etiologic basis is not known.
 These patients are referred to as having nonische­mic, dilated, or
idiopathic cardiomyopathy if the cause is unknown.

By Dr. Bahiru AMGH 7

 Heart failure

Prognosis
 30-40 % dies with 1 yr and 60-75% within 5 yr of dx b/c of
worsening or arrhythmias.
 NYHA class IV has annual mortality rate about 30-70%.
 NYHA class II has annual mortality rate about 5-10%.

By Dr. Bahiru AMGH 8

Pathogenesis

By Dr. Bahiru AMGH 9

Pathogenesis

 Heart failure begins after an index event produces an initial

decline in the heart’s pumping capacity.

 After this initial decline in pumping capacity, a variety of

compensatory mechanisms are activated.

By Dr. Bahiru AMGH 10

Pathogenesis

• In the short term, these systems are able to restore

cardiovascular function to a normal homeostatic
range with the result that the patient remains
asymptomatic.
• However, sustained activation of these systems leads
to secondary end-organ damage within the ventricle,
with worsening left ventricular remodeling and
subsequent cardiac decompensation

By Dr. Bahiru AMGH 11

 Pathogenesis

 In the short term, these systems are able to restore

cardiovascular function to a normal homeostatic range
with the result that the patient remains asymptomatic.

 However, sustained activation of these systems leads to

secondary end-organ damage within the ventricle, with
worsening left ventricular remodeling and subsequent
cardiac decompensation

By Dr. Bahiru AMGH 12

DIAGNOSIS
 The diagnosis of HF is relatively straightforward when the
patient presents with classic signs and symptoms of HF;
 however, the signs and symptoms of HF are neither specific nor
sensitive.
 Accordingly, the key to making the diagnosis is to have a high
index of suspicion, par­ticularly for high-risk patients.

By Dr. Bahiru AMGH 13

Framingham criteria for diagnosis of CHF
Major criteria
– Paroxysmal nocturnal dyspnea
– Neck vein distention
– Rales
– Cardiomegaly
– Acute pulmonary edema
– S3 gallop
– Positive hepatojugular reflux

By Dr. Bahiru AMGH 14

Framingham criteria for diagnosis of CHF
Minor criteria
– Extremity edema
– Night cough
– Dyspnea on exertion
– Hepatomegaly (tender)
– Pleural effusion
– Vital capacity reduced by one-third from normal
– Tachycardia (≥ 120 beats/min)

By Dr. Bahiru AMGH 15

Investigations
 Routine: CBC, Electrolytes, OFT, U/A
 ECG
 CXR
 Echocardiography
 Biomarkers
 Exercise testing

By Dr. Bahiru AMGH 16

New York Heart Association Classification
 Stage A includes patients who are at high risk for developing HF but
without structural heart disease or symptoms of HF (e.g., DM or HTN)
 Stage B includes patients who have structural heart disease but without
symptoms of HF (e.g., previous MI and asymptomatic LV dysfunction)
 Stage C includes patients who have structural heart disease and have
developed symptoms of HF (e.g., previous MI with dyspnea and fatigue)
 Stage D includes patients with refractory HF requiring special
interventions (e.g., patients with refractory HF who are awaiting cardiac
transplantation)

By Dr. Bahiru AMGH 17

 Class I
 Patients with cardiac disease but without resulting limitation of physical activity.
Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea, or
anginal pain.
 Class II
 Patients with cardiac disease resulting in slight limitation of physical activity. They
are comfortable at rest. Ordinary physical activity results in fatigue, palpitation,
dyspnea, or anginal pain.
 Class III
 Patients with cardiac disease resulting in marked limitation of physical activity.
They are comfortable at rest. Less than ordinary activity causes fatigue,
palpitation, dyspnea, or anginal pain.
 Class IV
 Patients with cardiac disease resulting in inability to carry on any physical activity
without discomfort. Symptoms of heart failure or the anginal syndrome may be
present even at rest. If any physical activity is undertaken, discomfort is increased.

By Dr. Bahiru AMGH 18

Heart Failure Management
General principles
Treatment of congestion
Treatment of underlying cause
Treatment of precipitant
Chronic care and follow up

By Dr. Bahiru AMGH 19

Heart Failure Management
 Distinctive phenotypes of presentation have diverse
management targets.
 These range from
chronic heart failure with reduced ejection fraction
(HFrEF) or
heart failure with preserved ejection fraction (HFpEF),
acute decom­pensated heart failure (ADHF), and
Advanced heart failure

By Dr. Bahiru AMGH 20

 HF with preserved ejection fraction
 General principles
 Therapeutic targets in HFpEF include
control of congestion,
stabiliza­tion of heart rate and blood pressure, and
Efforts at improving exercise tolerance
 Experience has demonstrated that lowering blood pressure
alleviates symptoms more effectively than targeted therapy with
specific agents.

By Dr. Bahiru AMGH 21

Acute Decompensated HF
 General principles
 The first principle is to identify and tackle known precipitants of
decompensation. these includes:
medication nonadherence and use of prescribed medicines
such as NSAIDs,
 cold and flu
Active infection and
overt or covert pul­monary thromboembolism
arrhythmias
By Dr. Bahiru AMGH 22
 volume management in ADHF
 iv diuretics

By Dr. Bahiru AMGH 23

 Heart failure with reduced ejection fraction
 RAAS blockers and beta blockers form the cornerstone of
pharmacotherapy with
 reduction in symptoms,
 improvement in QOL,
 decreased burden of hospitalizations, and
 a decline in mortality from both pump failure and
arrhythmic deaths.

By Dr. Bahiru AMGH 24

 23% reduction in mortality and a 35% reduc­tion in the
combination endpoint of mortality and hospitalizations for
heart failure in patients treated with ACEIs.
 Patients treated with beta blockers provide a further 35%
reduction in mortality on top of the ben­efit provided by ACEIs
alone.

By Dr. Bahiru AMGH 25

 beta blocker use in HFrEF should ideally be restricted to
carvedilol, bisoprolol, and metoprolol succinate—agents tested
and proven to improve survival in clinical trials.

 Clinical experience suggests that, in the absence of symptoms to

suggest hypotension, pharmacotherapy may be up-titrated every
2 weeks in stable ambula­tory patients as tolerated

By Dr. Bahiru AMGH 26

Thank you!!

By Dr. Bahiru AMGH 27