Heart failure 2013 Therapy

Congestive Heart Failure

3. Treatment

March 2013 ghennersdorf DGK ESC SES 1

Medical Science Tanzania Cardiology Lectures

Prof. Hennersdorf SES

General signs and symptoms


Definition of Heart Failure CHF

• New York Heart Association (NYHA)– I no visible signs and symptoms– II signs and symptoms at high level exercise– III signs and symptoms at low level exercise– IV no physical exercise possible, bed rest

necessary


Worldwide used as functional definition of CHF!

Treatment Goals


IV

III

II

I

??

??

??

HTX option

Main treatment goalfor chronic disease

Main treatment goalfor acute disease

Therapeutic objectives

• Acute CHF– Treatment of life threat– Improvement of life quality

• Chronic CHF– Improvement of life quality– Reduction of Disability– Increase of longevity


Adding life to years rather than years to life

Main approachVasodilation

Organ protectionVolume control

Therapeutic options


Acute Heart Failure

Therapeutic options (ER, ICU)• Physical approach in cardiogenic pulmonary edema

– Oxygen delivery– Bed rest / upright position– Secure (central) venous line– Urinary catheter– Blood letting

• Drugs (iv administration)– Diuretics (short term, furosemide)– Digitalis (?; fast AF ?)– Thrombembolic prophylaxis (heparin; PTT necessary)

• Drugs orally (cave hypotension)– Nitroglycerine sublingually– Consider ACEI sublingually


Therapeutic options (cardiogenic shock)

• Volume expansion under hemodynamic control– Pulmonary artery cath– Arterial pressure line

• Mechanical assistance: IABP• Cathlab: PCI• Surgery: revascularization• Drugs

– Catecholamines: Dopamin, Dobutamin– Phosphodiesterase (PDE)-Inhibitors: Amrinone, Milrinone (not

evidence based)– Thrombembolic prophylaxis: heparine (PTT)– Fast acting diuretics

• Acid base control• Electrolyte contol (potassium)


Therapeutic options


Chronic Heart Failure

Evidence


Therapeutic challenge


Systolic heart failure: mostly common in CHD and RHDDrugs and recommendations according to guidelines

Diastolic heart failure: mostly common in hypertensionLong term follow up dependent on treatment of underlying diseaseDrugs recommendations not yet established

Therapeutic options

• First line recommendation: Prevention– Prevention of CHD, Hypertension, valvular

disease, infections– Information, home care, transmission of simple

behavior rules:• Hygiene and clean water supply• Motion: physical activity, limited sport action• Nutrition: salt restriction• Refrain smoking


Therapeutic options• Conservative

– RAS modification• ACE-I• AT1-receptor antagonists• Aldosterone antagonists (Eplerenone ®)

– beta-AR competition• Betablockers

– classical 3D options• Diuretics (fast acting, medium acting; cave potassium)• Diet• Digitalis (?) not first choice!

– Others: (Pulmonary artery Hypertension)• Bosentan • Sildenafil


Avoid use of NSAIDs like COXIBs

ß-Blockade in CHF


ß-Blockade in CHF


ß-Blockade in CHF


Muscle cell; contractilityNENEE

Muscle cell; contractility

NENENENEEEE

Muscle cell; contractility

NENENENEEEE

Betablockade: receptor recovery,function improves

AR Reduction

AR Recovery

Reduction of adrenergic receptors AR

ß-Blockade in CHF


Recommended: ß1-selective drugs like metoprolol, bisoprolol+ vasodilatation: carvedilol, nevibolol

Therapeutic options. ACE-I

• Trials– CONSENSUS 1987 Captopril– SOLVD 1999 Enalapril– SAVE 1992 Captopril– VHEFT 1991 Enalapril/Hydralazin– CIBIS III 2005 Enalapril/Bisoprolol


Demonstrate highly significant improvement of survival in different stages of heart failure (II –IV): Evidence Class A - IA

Dosage recommendations


Dosage recommendations


Improvement of HF in cardiac CXR


before treatment after treatment

Therapeutic options

• Surgical– Heart transplantation, bridging– Cardiomyoplasty

• Resynchronizing pacemaker therapy (CRT)• Stem cell replacement


Therapeutic options

• HTX– Surgically solved– Concomitant therapy problems (rejection) solved– Donor problems unsolved and will persist


But: therapeutic choice for subsets of younger patients with severe symptoms mostly on

iv therapy and/or ICU care without chance to recover appropriately.

Bridging procedure desirable

Heart transplantation HTX


Heart transplantation


Heart transplantation


3rd september 1967

original OR theatreGroote Schuur HospitalCape Town SAR

Christian Neethling Barnard

Artificial heart


Heartmate® for bridging procedures

Survival after HTX


Therapeutic options: cardiac resynchronization therapy CRT


Therapeutic options


Therapeutic options: resynchronization therapy


Therapeutic options: stem cells


Therapeutic challenge: home care

• Medication starts in the hospital• Medication continues in household enviroment, rural areas • Doctor‘s contacts rare• Patient‘s survey difficult.• Therefore: narrow control schedules concerning

– Nurse directed home care– Continuous medical education of both patient and personal

(nurses/doctors)– Outpatient visits– Establishing telemedical processes


Therapeutic home care options• Home care (nurse driven)

– Scheduled visits on regular basis (nurse, AMO)– Visits following questionnaire– Data acquisition and transmission

(telemedicine?)• Severity of symptoms• Daily activities ability• Controls

– Medication– Weight (listing by patient)– Blood pressure– other


CHF Questionnaire; example


How do you feel since last visit? Scale of 10 ptsIn your opinion, are there main changes:

breathingweight gainUrinary outputpalpitation?

How do you think developed your personal daily activities (DAs)?

worsesamebetter

which kind of DAs is mostly impaired?homeleisureemployment

What about your medication:intake OK?complaints?self made changes?incompatibilty?wishes?

Suggestions?

Heart Network


Patient

Hospital

Home Care

OPD

District Hospital

Dispensary

Heart Network: nurse


+

Hospital

Nurse

home care

Heart Network: Internet


Patient data file, database: EPF*Access by authorized personal throughout the country

*electronic patient file

Heart Network

• Telecardiology (telemedicine)– Electronic provision of data transmission– Generation of medical data in remote areas (rural)– Overcoming of doctors shortages – Secure transmission line– Targets:

• Hospital Centers• Home care physician• Home care nurse• Specialized medical call centers


Heart Network


• Telemedical patient kit – Smartphone with Apps (Skype)– Balance– ECG device– Blood pressure device– Glukose test kit– Finger tip pulse oxymeter– Questionnaire

The End


Documents

Heart failure 2013 Therapy