Heart failure
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Tamás Fenyvesi MD3rd Department of Medicine2016 , November
Circulatory failure
Heart
Insufficient oxygen and nutrient supply to the tissues,and cells+ insufficient removal of the metabolic endproducts
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+ insufficient removal of the metabolic endproducts causes:
cardiac extracardiac1.decreased venous return2.increased vascular capacity3.decreased oxyhemoglobin
Heart failure:the heart is unable to pump sufficient blood , provided the
venous return is normal
mechanical myocardial1. pressure overload 1. ischaemic heart disease
AS, hypertension diffuse or segmental
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2. volume overload 2. myocardial diseasevalvular regurg.,shunts
3. insufficient fillingmitral or tricuspid
stenosis4. Pericardial disease
Classifications of impaired ventricular fuction
1. Forward failure vs backward failure2. Left heart failure vs right heart failure3. Systolic vs diastolic dysfunction
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3. Systolic vs diastolic dysfunction4. Acute vs chronic5. Low output vs high output
“Backward” failure
James Hope 18321. ventricular volume and pressure2. atrial volume and pressure behind the failing ventricle3. atrial contraction
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3. atrial contraction4. venous pressure 5. capillary pressure6. transsudation into the interstitial tissue7. extracellular fluid volume
“Forward failure”Sir James Mackenzie 1913
decreased cardiac output:kidneys sodium retention
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kidneys sodium retention(RAS activation)
liver dysfunctionmuscular weakness, fatiguebrain confusion
„left” or „right” heart failure
This is implicitly „backward failure”congestion behind the originally failing ventricle
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left ventricle pulmonary congestion,pulm edema
right ventricle liver and peripheralcongestion oedema etc
Acute heart failure
The sudden development of the syndromeno time for compensatory mechanisms to activate
massive myocardial infarction
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massive myocardial infarctionheart block with very slow ventricular rate< 35/mintachyarrhythmia with very rapid rate > 180/minrupture of a valveocclusion of a large segment of pulmonary artery
sudden reduction of cardiac output
stroke volume
symp PRA
catechol vasoconstr AII
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catechol vasoconstr AII
prostaglandin bradykinin vasopressin aldosteronedilate dilate constr constr
constrictor > dilatator
Low-output vs high-output failure
1. Low output is the typical: most of the heart diseasesimpaired peripheral circulation, cold, pale or cyanotic extremities
2. High output: cardiac output is high before the development
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2. High output: cardiac output is high before the developmentof failure
anaemia, hyperthyroidismAV shunts, Paget’s disease, Beriberi (B1 vit defic)gravidityhot, hyperemic extremities
Compensatory mechanismsExtracardiac cardiacpreload
afterloadnatriuresis
volume decomp
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volume decomp atrial dilat vasodilat
vasoconstr cardiac output ANP
RASsymp,ADH
RBF GFR FFsodium retention
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ACC Heart Failure GuidelinesSlide Deck
Based on the ACC/AHA 2005 Guideline Update
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for the Diagnosis and Management of Chronic Heart Failure in the Adult
January 2006
Definition of Heart Failure
HF is a complex clinical syndrome that canresult from any structural or functional
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cardiac disorder that impairs the ability ofthe ventricle to fill with or eject blood.
“Heart Failure” vs. “Congestive Heart Failure”
Because not all patients have volume overload atthe time of initial or subsequent evaluation, theterm “heart failure” is preferred over the older
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term “heart failure” is preferred over the older term “congestive heart failure.”
Causes of HF in Western World
For a substantial proportion of patients, causes are:
1. Coronary artery disease
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1. Coronary artery disease
2. Hypertension
3. Dilated cardiomyopathy
Class I —No limitation: Ordinary physical activity does notcause undue fatigue, dyspnea, or palpitation.
Class II —Slight limitation of physical activity:Such patients are comfortable at rest.Ordinary physical activity results in fatigue, palpitation dyspnea, or angina.
Class III —Marked limitation of physical activity:
NYHA Classification of HF
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Class III —Marked limitation of physical activity:Although patients are comfortable at rest, less than ordinary activity will lead to symptoms.
Class IV —Inability to carry on any physical activity without discomfort: Symptoms of congestivefailure are present even at rest. With any physical activity, increased discomfort isexperienced.
Stages of Heart Failure
At Risk for Heart Failure:
STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
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STAGE B Asymptomatic LV dysfunction
Heart Failure:
STAGE C Past or current symptoms of HF
STAGE D End-stage HF
Stage A
Patients at High Risk for Developing Heart Failure
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Developing Heart Failure
Stage B
Patients with Asymptomatic LV Dysfunction
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LV Dysfunction
Stage C
Patients with Past or CurrentSymptoms of Heart Failure
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Symptoms of Heart Failure
Stage D
Patients with Refractory End -Stage HF
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Stage D Therapy
Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory
Discussion of Options for End-of-Life Care
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies.
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Stages of Heart Failure
COMPLEMENT, DO NOT REPLACE NYHA CLASSES
• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of
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patient (in response to Rx and/or progression of disease)
• Stages - progress in one direction due to cardiac remodeling
Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms
• Incorrect diagnosis of HF• Inaccurate measurement of
LVEF• Primary valvular disease• Restrictive (infiltrative)
cardiomyopathies
• HF associated with high metabolic demand (high-output states)
• Anemia, thyrotoxicosis, arteriovenous fistulae
• Chronic pulmonary
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cardiomyopathies• Amyloidosis, sarcoidosis,
hemochromatosis• Pericardial constriction• Episodic or reversible LV
systolic dysfunction• Severe hypertension,
myocardial ischemia
• Chronic pulmonary disease with right HF
• Pulmonary hypertension associated with pulmonary vascular disorders
• Atrial myxoma• Diastolic dysfunction of
uncertain origin• Obesity
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BNP - echodyspnea
BNP - echodyspnea
EKG, RTG, BNP
<100 100-500 >500 pg/ml
EKG, RTG, BNP
<100 100-500 >500 pg/ml
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<100 100-500 >500 pg/ml
HF echo: LVD HF 95%unlikely COPD echo
PE
<100 100-500 >500 pg/ml
HF echo: LVD HF 95%unlikely COPD echo
PE
Maisel Rev CV Med 2003;4:S3-12Maisel Rev CV Med 2003;4:S3-12
Systolic vs diastolic heart failure
Implicit in the physiological definition the defect to pumpadequate volume of blood is a systolic heart failure
the abnormality may be caused by a defect ofventricular filling i.e. diastolic heart failure
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ventricular filling i.e. diastolic heart failureslowed or incomplete ventricular relaxation
possible causes:acute or chronic ischaemiaconcentrical hypertrophyrestrictive cardiomyopathy
most clinical manifestations are combined
Diastolic dysfunctionFibrosis Cellular dysarray PassiveHypertrophy chamber
stiffnessAsynchrony Diastolic
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Asynchrony DiastolicAbnormal loading pressureIschemia RelaxationAbnormal Ca++ flux
Diastolic heart failure became a centralissue of cardiology.
Diastolic heart failure is heart failure with preserved systolic function
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with preserved systolic functionor normal ejection fraction (HFNEF)EF>50%
Systole and diastole
“So that the coming together,
depends on the going apart,
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depends on the going apart,
the systole depends on the diastole;
the flow depends on the ebb.”
DH Lawrence
Symptoms of heart failure
1.dyspnea2.fatigue and weakness
hypoperfusion of the sceletal musculaturehyponatremia caused by diuretics
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hyponatremia caused by diuretics3.nocturia
redistribution of cardiac output at night: RBF4.liver distension
epigastrial dyscomfort
General mechanisms of dyspnoe:left atrial pressure
pulmonary capillary pressure
interstitial fluid volume in the lungs
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elasticity of the lung
increased work of breathing low cardiac output impaired perfusion of the respiratory
muscles fatigue sensation of dyspnoe
Physical signs of heart failure1
•visible dyspnoe •gray color of the face•cold extremities and acrocyanosis •decreased pulse pressure•extension of the veins (jugular)
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•extension of the veins (jugular) •palpable liver •symmetrical edema (pitting)
ankle-sacral-generalized•ascites•hydrothorax •rales „moist” at the end of inspiration
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RAGACSKA IMRE, LM20080822104759048.avi
Physical signs of heart failure 2
tachycardiapulsus alternans ?
auscultation of the heart
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auscultation of the heartS3 gallopaccentuated P2syst murmur- tricusp regurg
cardiac cachexia
Pulsus alternans
44this is just an interesting possibility
Framingham criteria for congestive heart failure
Major criteria:paroxysmal nocturnal dyspnea or orthopneaneck vein distensionrales
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ralescardiomegalyacute pulmonary edemaS3 gallopincreased venous pressure > 16cm H2Ocirculation time > 25 sechepatojugular reflux
Framingham criteria for congestive heart failure
Minor criteria: ankle edemanight coughdyspnea on exertion
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dyspnea on exertionhepatomegalypleural effusionvital capacity 1/3 from maximumtachycardia > 120/min
Minor or major criterion:weight loss > 4,5 kg in 5 days in
response to treatment
The main causes of heart failureIschaemic heart disease !!
myocardial infarction necrosisremodeling
Systemic hypertension LV hypertrophy
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Systemic hypertension LV hypertrophy
Valvular heart disease pressure load, ASvolume load AI
Cardiomyopathies obstructivedilatativerestrictive
Algoritm of diagnostic approach to HF
Suspition of HF
EKG,,RTG, BNP
Dg. rejected
abnormal
norm
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abnormal
echocardiography
Cause,type,severity?
abnormal
therapy
additional Workup, eg.
coronarography
norm
Epidemiology of heart failure~ 4 million pts in the USA
yearly incidence > 400.000 hospitalization 1000 000
most prevalent cause of death > 300.000Hospital mortality 30-50% / year
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Hospital mortality 30-50% / yearin the mixed population
5 years survival afterdiagnosis only 25% in men and
38% in womenyearly cost 22billion $
Annual incidence of heart failure per 1000 population in
Framingham
2831
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25
30
35
50
1 2 35 6
9
13
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0
5
10
15
20
45-54 55-64 65-74 75-84 85-94
femalemale
Prevalence of heart failure
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Prevalence of HFPrevalence of HF
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SpainSpain
Den.Copen.6,4
Den.Copen.6,4
SvedenVästeras6,7
SvedenVästeras6,7
EnglandPoole7,5
EnglandPoole7,5
FinlandHelsinki8,2
FinlandHelsinki8,2
USACHS8,8
USACHS8,8 proportion with preserved
LV systolic function
proportion with preserved
LV systolic function
Overall 2.5% in the communitySenni, Circ 1998; 98:2282
Overall 2.5% in the communitySenni, Circ 1998; 98:2282
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4,8 4,25,1
3,14,5
2,91,7 1,23 1,5
0
3
6
Nether.Rotter.2,1
Nether.Rotter.2,1
USAOlmsted2,2
USAOlmsted2,2
PortugalEPICA4,2
PortugalEPICA4,2
SpainAsturias4,9
SpainAsturias4,9
6,46,4
Age(years) 66-103 75-86 70-84 75 ≥50 >40 >25 >44 55-95Mean 78 - 76 75 - 60 68 63 65Age(years) 66-103 75-86 70-84 75 ≥50 >40 >25 >44 55-95Mean 78 - 76 75 - 60 68 63 65
Hogg JACC 2004; 43:317Hogg JACC 2004; 43:317
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2016 ESC Guidelines for the diagnosis andtreatment of acute and chronic heart failureThe Task Force for the diagnosis and treatment of acute and chronicheart failure of the European Society of Cardiology (ESC)
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Cardiology (ESC)Developed with the special contribution of the Heart FailureAssociation (HFA) of the ESC
THE END!
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2016 ESC Guidelines for the diagnosis andtreatment of acute and chronic heart failureThe Task Force for the diagnosis and treatment of acute and chronicheart failure of the European Society of Cardiology (ESC)
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Cardiology (ESC)Developed with the special contribution of the Heart FailureAssociation (HFA) of the ESCAuthors/Task
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