1. 1. Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI, FAPSC, FAPSIC, FAHA, FCCP, FRCPG Associate Professor of Cardiology National Institute of Cardiovascular Diseases(NICVD), Sher-e-Bangla Nagar, Dhaka-1207 Consultant, Medinova, Malibagh branch Honorary Consultant, Apollo Hospitals, Dhaka and STS Life Care Centre, Dhanmondi drtoufiq19711@yahoo.com CRT 2014 Washington DC, USA
2. 2. Definition Classification Patho physiology Stages of Heart Failure Clinical Features Investigations Treatment
3. 3. Definition Heart failure is a condition when heart fails to meet the metabolic needs of the body provided the venous return is adequate. Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. It has become an epidemic all over the world including our country. As the life is prolonged with modern management of different cardiovascular diseases, so is the chance of having more of heart failure patients. Source: AHA/ACC Guideline, 2005 Source: ACC/AHA 2005 Guideline Update
4. 4. Classification: Heart Failure may be classified as follows: Depending on the time of onset: Acute Heart Failure: Accelerated hypertension, AMI Chronic Heart Failure: Cardiomyopathy Depending on the ventricle involved: Left Heart Failure: Systemic HTN, MS Right Heart Failure: Cor-pulmonale, Pulmonary Embolism Source: ACC/AHA 2005 Guideline Update
5. 5. Classification Depending on the cardiac output: Low output failure: Classic heart failure High output failure: Thyrotoxicosis, Anemia Depending on the consequence of the heart failure: Forward Failure-tissue hypoperfusion Backward failure-Congestive heart failure Source: ACC/AHA 2005 Guideline Update
6. 6. Pathophysiology Increased workload on Heart Activation of Compensatory Mechanisms Compensated Heart Failure Self-defeating Effects of Compensatory Mechanisms Decompensated Heart Failure
7. 7. Compensatory Mechanisms Activation of neurohormonal system Sympathetic Activation: Myocardial Contractility Herat Rate Vasoconstriction Activation of RAS system : Vasoconstriction Intravascular Volume (due to Na+ & fluid retention) Remodeling of the ventricle: Hypertrophy Dilatation
8. 8. How compensatory mechanisms are self-defeating? Sympathetic activity -Energy expenditure Vasoconstriction- After load Activation of RAS Preload-venous congestion ( backward failure) Hypertrophy Death of cardiac cells Dilatation Wall stress
9. 9. Etiology & Precipitating Factors Etiological factors: Different causes of myocardial dysfunction Systolic dysfunction-IHD, Cardiomyopathy Diastolic dysfunction-HTN, AS, HCM Combined-IHD, Valvular diseases Sudden load on preserved ventricular function Ruptured sinus of Valsalva-Acute LV failure Acute pulmonary embolism - Acute RV failure
10. 10. Precipitating Factors Precipitating factors: Anemia Infection-RTI, UTI Arrhythmias Drugs- -blockers, Anti-arrhythmic, Anti-cancer
11. 11. How MS leads to Left & Right HF Mitral Steno sis Increased LA pressure Increased pulmonary venous pressure Atrial fibrillation Left heart failure Increased pulmonary arteriolar pressure Pulmonary arterial HTN RV hypertrophy RV failure Anemia/Infection
12. 12. Stages of Heart Failure Source: ACC/AHA 2005 Guideline Update Stage Criteria Example Stage-A At high risk for heart failure but without structural heart disease or symptoms of HF. Hypertension Coronary Artery Disease Diabetes Mellitus Cardiotoxins Family history of cardiomyopathy Stage-B Structural heart disease but without signs or symptoms of HF. Previous MI LV systolic dysfunction Asymptomatic valvular disease Stage-C Structural heart disease with prior or current symptoms of heart failure. Known structural heart disease, Shortness of breath & fatigue, Reduced exercise tolerance Stage-D Refractory HF requiring specialized interventions. Patients who have marked symptoms at rest despite maximal medical therapy
13. 13. Cardinal Symptoms of Heart Failure 1. Undue tiredness 2. Fatigability 3. Reduced exercise tolerance 4. Shortness of breath 5. Awakening from sleep at night 6. Swelling of the leg 1, 2 & 3 represent the features of Forward failure 4, 5, & 6 represents the features of Backward failure
14. 14. Diagnosis of Heart Failure History: Physical examination: Investigations: Routine: 1.CXR; 2. ECG; 3. Echocardiography; 4. CBC Selective: 1. Cardiac cath; 2. Coronary angiogram;3. Renal function test; 4. Thyroid function test; 5. Radionucliede study 6. Brain Natriuretic Peptide (BNP): useful marker to identify the patient with heart failure.
15. 15. Management of Heart Failure: Principles: Treatment of heart failure per se: Medical (pharmacological/interventional) treatment Surgical treatment Electrical- ICD; Resynchronization Treatment of the underlying causes: Correction of precipitating causes: Objectives: To alleviate the symptoms To correct the underlying cause To improve prognosis
16. 16. Correction of Precipitating Causes: Control of the infection Correction of the anemia Correction & prevention of arrhythmias Withdrawal / substitution of offending drugs Treatment of Underlying Causes: Revascularization for IHD Treatment of HTN Treatment of valvular disease
17. 17. Treatment of HF Treatment depends on the stage of heart failure. -Treat HTN -Quit smoking -Treat lipid disorder -Encourage exercise -Control of metabolic syndrome -Discourage alcohol intake Drugs: -ACE inhibitors or ARB in appropriate patients Stage-A: Stage-B: - Treat HTN -Quit smoking - Treat lipid disorder -Encourage exercise - Discourage alcohol intake Drugs: - ACE inhibitors or ARB in appropriate patients -Beta-blockers in appropriate patients -Device-ICD
18. 18. Treatment of HF Stage-C: -Treat HTN -Quit smoking -Treat lipid disorder -Encourage exercise -Discourage alcohol intake -Dietary sodium restriction Drugs for routine use: -Diuretics -ACE inhibitors -Beta-blockers Drugs in selected patients: -Aldosterone antagonists -ARB -Digitalis -Hydralazine/Nitrates Devices in selected patients: -Biventricular pacing -ICD
19. 19. Treatment of HF Stage-D: -Treat HTN -Quit smoking -Treat lipid disorder -Encourage exercise -Discourage alcohol intake -Dietary sodium restriction Options: Mechanical assist devices Heart transplantation Continuous I.V inotropic infusion Compassionate end of life care
20. 20. Drugs Used in HF Management: Conventional Drugs: Diuretic- Loop diuretics- Frusemide, Torsemide Thiazides- Hydrochlorothiazide, Chlorthalidone,METOLAZONE Potassium sparing- SPIRANOLACTONE, Triamterene,amioloride ACE Inhibitors- Captopril,Lisinopril ARBS- Losartan, Valsartan Vasodilators -Nitrates, Hydralizine Beta-blockers-Carvidolol,Metoprolol Succinate Inotrops (Digoxin, Dobutamine, Noradrenaline)
21. 21. Newer Drugs: Recombinant human type B natriuretic peptide NESIRITIDE Neutral endopeptidase inhibitors: Omapatrilet, Sampatrilet, Candoxatrilat Calcium sensitizers- Levosimendan Nesiritide: Recombinant human B type natriuretic peptide Nesiritide vs. Nitroglycerine: Nesiritide reduces right atrial pressure, PCWP, cardiac index greater than Nitroglycerine. Offers greater relief of dyspnoea than Nitroglycerine. Drugs Used in HF Management
22. 22. Stem cell therapy Stem cell regeneration Replace or repair myocardial cells using gene therapy Further Therapy
23. 23. Drugs Symptomatic Relief Prognostic improvement Frusemide + - Thiazide + - Spironolactone + + ACE inhibitors + + ARBs + + Beta-blockers + + Digoxin + - Drugs for Heart Failure
24. 24. MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Heart Failure) To see the effect of Metoprolol Succinate on mortality, hospitalization & other clinical events in chronic heart failure. 3991 patients; follow up I year. Dose 12.5- 25 mg/d 200mg/d Significantly fewer cardiovascular death compared with placebo group. JAMA 2001
25. 25. COMET (Carvedilol or Metoprolol European Trial): Purpose: To compare the effects of Carvediol and Metoprolol on clinical outcome in patients with heart failure. No. of patients: 3029 Treatment regimen: Carvedilol, titrated from 6.25mg to 25 mg b.i.d, or Metoprolol Tertarate IR, titrated from 12.5 mg to 50mg b.i.d. Result: In the Carvedilol group, 34% of patients died compared to 40% in the Metoprolol IR group. Lancet 2003
26. 26. COPERNICUS (Carvedilol Prospective Randomized Cumulative Survival Trial): To see the effects of Carvedilol on mortality in patients with severe heart failure. No of patients: 2289 Treatment regimen: Carvedilol 3.125 mg b. d 25mg b. d or placebo Result: 35% decrease in the risk of death in the Carvedilol group NEJM 2001
27. 27. CONSENSUS (Cooperative North Scandinavian Enalapril Survival Study) : Purpose: To investigate the effect of Enalapril, in addition to conventional therapy, on mortality in severe congestive heart failure. No. of patients: 253 Treatment regimen: Enalapril, 2.5mg/day up to 20 mg bid, or placebo. Result: Crude mortality was reduced by 40% in the Enalapril group compared to placebo group. AJC 1992
28. 28. Purpose: To compare the effects of 2 Lisinopril dosages on mortality and Morbidity in patients with chronic heart failure. No. of patients: 3164 Treatment regime: Lisinopril, 2.5 or 5mg once daily, plus Lisinopril, upto 30mg, or placebo once daily. Result: Mortality was 8% lower in high-dose group than in low-dose group. EHJ 1999 ATLAS (Assessment of Treatment with Lisinopril And Survival):
29. 29. ELITE II (Evaluation of Losartan In The Elderly): Purpose: To compare the effects of Losartan or Captopril on all-cause mortality &, secondary, on sudden cardiac death and/or resuscitated cardiac arrest in patients with symptomatic Heart failure. No. of patients: 3152 Treatment regimen: Losartan, 12.5mg titrated as tolerated to 50mg once daily, or Captopril, 12.5 mg titrated as tolerated to 50mg t. i. d. Result: No significant differences in all-cause mortality, sudden death or resuscitated cardiac arrest with slight favour for Losartan. Lancet 2000.
30. 30. Val-HeFT(Valsartan Heart failure Trial) Purpose: To investigate the effects of valsartan on mortality, morbidity and quality of life in patients treated with ACEI Patients: 5010; >18yrs, NYHA II- IV Dose: valsartan 40mg bd- 160mg bd Placebo controlled Result: Significantly decreased mortality and morbidity; improved NYHA class,EF,signs & symptoms of HF and quality of life NEJM 2001
31. 31. DIG (Digitalis Investigation Group) Purpose: To investigate the effects of digoxin on mortality as well as on hospitalization in heart failure patients No. of patients: 5548 Result: Digoxin in low doses reduces hospitalization & mortality. EHJ 2006
32. 32. Management of End-stage/ Refractory HF: When symptoms of heart failure persist or experience rapid recurrence of symptoms despite optimal medical therapy, these group of patients are considered to have end- stage HF or refractory HF. Management: Step-1: Hospitalization. Step-2: Low doses of a loop diuretic combined with moderate dietary sodium restriction. Step-3: Progressive increments in the doses of a loop diuretic & frequently the addition of a second diuretic that has a complementary mode of action. Step-4: Intravenous dopamine or dobutamine.
33. 33. Re-synchronization Therapy: In approximately 30% of patients with heart failure, the disease process not only depresses cardiac contractility but also affects the conduction pathway. Such dyssyncrony has been associated with clinical instability and an increased risk of death in patients with HF. Cardiac re-synchronization reduces the degree of ventricular dyssyncrony, increase in LVEF, decrease LV end-diastolic dimension and also decrease in the magnitude of mitral regurgitation. As a result, there occur significant improvement in functional capacity, clinical status, and quality of life.
34. 34. Indication of Cardiac Resynchronization Therapy Severe heart failure (NYHA-III&IV) LBBB QRS width >120 msec. Echocardiography :evidence of in coordinate LV contraction
35. 35. Resynchronization
36. 36. Cardiac Transplantation Severe symptomatic despite maximal medical treatment. Freedom from other major diseases e.g., DM, renal failure, malignancy, pulmonary disease. One year survival 90% Five year survival 60%.
37. 37. Heart failure is a disease of wide spectrum Pathophysiologically heart failure is considered under a single umbrella. Etiology and causes are so varied that heart failure touches almost every chapter of cardiology.
38. 38. Diagnostically, it is not a formidable problem,though assessment of the course of the disease demands meticulous observation and judgment from the physicians
39. 39. Management of heart failure now progressed a long way and still is evolving. There are so many options available that one must be vigilant to keep pace with the evolving concepts of management.
40. 40. Recommendations for Biomarkers in HF
41. 41. Recommendations for Noninvasive Cardiac Imaging
42. 42. Recommendations for Invasive Evaluation
43. 43. Recommendations for Treatment of Stage B HF
44. 44. Stage C HFrEF: evidence-based, guideline-directed medical therapy
45. 45. Recommendations for Pharmacological Therapy for Management of Stage C HFrEF.
46. 46. Recommendations for Treatment of HFpEF
47. 47. Recommendations for Device Therapy for Management of Stage C HF.
48. 48. Indications for CRT therapy algorithm
49. 49. Recommendations for Inotropic Support, MCS, and Cardiac Transplantation.
50. 50. Stages in the development of HF and recommended therapy by stage.
51. 51. Classification of patients presenting with acutely decompensated heart failure.
52. 52. Recommendations for Therapies in the Hospitalized HF Patient
53. 53. Recommendations for Hospital Discharge
54. 54. Pharmacological management of patients with newly discovered AF. AF indicates atrial fibrillation; and HF, heart failure.
55. 55. Pharmacological management of patients with recurrent paroxysmal AF. AF indicates atrial fibrillation.
56. 56. Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF.
57. 57. Thank Youdrtoufiq19711@yahoo.com Asia Pacific Congress of Hypertension, 2014, February Cebu city, Phillipines Seminar on Management of Hypertension, Gulshan, Dhaka