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CHRONIC CONGESTIVE
HEART FAILURE
2004 - 2005
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BACKGROUND:
HF PREVALENCE o from 3 - 20 at 45 years
to 80-160 over75 years
N.Sharpe, 1998
MORTALITY o with aging
5% deaths throughHF
below 45 years1/3 deaths through HF to 75 years
2/3 deaths through HF above 75 years
Chignon J, 1998
PHARMACOLOGICAL APPROACH
a. medication: intake / abuse / drug associations
b. changes in: - pharmacokinetics- pharmacodinamics
- social, economic, mental context.
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DEFINITION
(after ESC)
SUBJECTIVE:
HF symptoms:
dyspnea/ortopnea/ nocturnal paroxysmal d.
edema
tachycardia
rales
LV gallop
distended neck veins
OBJECTIVE: systolic/diastolic dysfunction
RETROSPECTIVE: response to correct HF treatment
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HF DIAGNOSIS: STEPS
Recognize HFpicture
Etiology
Pathogenesis: systolic/diastolic dysfunction
Recognize decompensation: edema, dyspnea
Assess morbidity/mortality predictive factors
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LV FAILURE
LV FAILURE: asymptomatic at rest, symptomatic at effort
edema
Cardiac asthma
Rest symptomatic LV failure
RV FAILURE
1. RECOGNIZE HF
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2. ETIOLOGY
CORONARY ARTERY DISEASE
- MYOCARDIAL INFARCTION
- CHRONIC ISCHEMIA
Systemic HYPERTENSION
CARDIOMYOPATHIES
- DILATIVE, HYPERTROPHIC, RESTRICTIVE- ACUTE MYOCARDITIS
- OTHER: METABOLIC, ENDOCRINE, NEUROMUSCULARE, TOXIC, etc.
VALVE DISEASES
- SEVERE AORTIC STENOSIS
- MITRALREGURGITATION
- AORTIC REGURGITATION
- MITRALSTENOSIS
OTHER
- ARRHYTHMIAS / BLOCKS
- INCREASED CARDIAC OUTPUT
- CONGENITAL CARDIAC DISEASES
- COR PULMONALE
- CONSTRICTIVE PERICARDITIS
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adapted LV insufficient LV
* dilation
* remodelling
* hemodynamic factors;
neurohumoral factors
3. LV DYSFUNCTION
* POPULATION AT RISK
* CAD
* Hypertension* valvular disease
* cardiomyopathies at onsetLV DYSFUNCTION
DIASTOLIC
-LVHc + EFn
-distensibility
-relaxation
-E/A
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DIASTOLIC DYSFUNCTION
= LV can not be filled at low pressure
Consequences * congestive syndrome pulmonary
peripheral
* EndD LV P > 12 mmHg
CLINIC signsofcongestive HF
cardiac silhouette normal
normal EF
Asymptomatic diastolic dysfunction ECHO
angiography/scintigraphy
Symptomatic: LV failure pulmonary HT right HF congestive syndrome chronic
low cardiac output
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DIASTOLIC DYSFUNCTION
ETIOLOGY:
* PERICARDITIS
* ENDOMYOCARDIALF
IBROSIS* Relaxation and ventricularcompliance deterioration:
concentric LV hypertrophy
CAD
RESTRICTIVE CARDIOPATHIES
* Pulmonary venousreturn decrease: HYPOVOLEMIA
* Secondary tosystolic dysfunction: MITRAL STENOSIS
AGGRAVATING FACTOR: ATRIAL FIBRILLATION
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DYSFUNCTION
SYSTOLIC DIASTOLIC
HISTORY OF
* MI ++ +/-* HTN + + +
ANAMNESIS
* BRUTAL ONSET +/- ++
X-RAY
* CARDIOMEGALY + + -
ECG* Q WAVE ++ +/-
* LV H +/- + +
ECHO EF q EF n
E/A < 1
DIASTOLIC DYSFUNCTION
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4. INVESTIGATIONS
1. HF detection
- Chest X-ray: cardio-thoracic index, pulmonary stasis
- Echocardiography: LV dysfunction- Ergospirometry: VO2 max
2. HF etiology
- ECG: ischemia / infarction, hypertrophy, arrhythmia
- Echocardiography: valve disease, systolic / diastolic dysfunction
- Rare causes: - thyroid dysfunction
- anemias- amiloidosis, sarcoidosis
- Cardiac catheterization
- PBM (myocardial biopsy)
3. HFseverity
- Isotopic ventriculography
- Myocardial scintigraphy- Ergospirometry
4. HFprognosis
- Holtermonitoring
- Assess - renal function
- liverfunction
- hydro-electrolitic equilibrium
- plasma NA peptide (> 900ng/ml)
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Establish diagnosis
Assessments in all cases
Necessary Supports Opposes
History with symptoms +++ Ifabsent
Objective evidence +++ Ifabsent
Response to treatment ++
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Testsfordiagnosis
Test
Necessary Supports Opposes
Electrocardiogram ++ Ifnormal
Echocardiography +++ Ifnormal
Chest x-ray Ifcongestion Ifnormal
Blood count Ifnormal
Blood chemistry Ifnormal
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Aditional tests
Test
Necessary Supports Opposes
Exercise test Ifnormal
Natriuretic peptide Ifelevated Ifnormal
Cardiac cath. Ifnormal
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CLASS I: no activity limitation patients have cardiac
dysfunction, had before HF symptoms and are under medication
for HF
CLASS II: moderate limitation of physical activity:
asymptomatic in resting, but usual effort leads to dyspnoea,
fatigue, palpitations or angina
CLASS III: important limitation of physical activity :
asymptomatic at rest, but an effort below the usual intensity
leads to symptoms.
CLASS IV: HF symptoms are present at rest and aggravated at
minimal effort. The patient is not able to perform any physical
activity without symptoms.
NYHA Classification
( New York Heart Association) 1964
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CLASA A VO2 max > 20 ml/min/kg
CLASA B VO2 max = 16-20 ml/min/kgCLASA C VO2 max = 10-15 ml/min/kg
CLASA D VO2 max < 10 ml/min/kg
CLASA E VO2 max < 6 ml/min/kg
Weber andJanicki Classification 1985
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* HYPERVOLEMIA
* PRIMARY CARDIOMYOPATHY
* CAD + ATRIAL ARRHYTHMIA
* DYSELECTROLYTEMIAS
- alcalosis with hypo-K+
- hypo-Na+
*ALCOHOL
* INADEQUATE TREATMENT
-digitalic toxicity-dysfunction -systolic
-diastolic - diuretics !!!
- antiarrhythmics
5. POTENTIAL REVERSIBLE CONDITIONS
THAT AGGRAVATE HF
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1. ACE inhibitors
- first-line therapy in patients with reduced EF < 45%, with orwithoutsymptoms
- in all HFstages.- fluid retention: ACE-i + Diuretic.
Recommendations:
- avoid excessive diuresis before treatment
- start with a low dose and build up tomaintenance dosage with
weekly monitoring creatinine and plasma ions- avoid potassium-sparing diuretics during therapy initiation
- avoid NSAIDs
If no satisfying response:
- change with anotherACE-i or
- Choose an AT1-receptorinhibitor
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2. Beta-blockade in HF
Indications
-stable mild, moderate and severe HFof ischemic and non-ischemicorigin (ifno contraindications)
-patients with LV dysfunction with/without HFpost-MI forsurvivalbenefit
Initiation and uptitration ofbeta-blockade in HF:
- stable patient on a background therapy with ACE-i + DiureticDigoxin
- nofluid retention
- no hypotension ( SBP < 90 mmHg)
- no bradycardia (HR < 55 / min)
- titrate slowly and carefully from low initial dose to target doses
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BETA-BLOCKERS in HF
-BLOCKER INITIAL DOSE (mg) TITRATION (mg) MAX DAILY DOSE(mg)
BISOPROLOL 1,25 2,5/3,75/5/7,5/10 10CARVEDILOL 3,125 6,25/12,5/25/50 50
METOPROLOL
Succinate CR 12,5/25 25/50/100/200 200
Tartrate 5 10/15/30/50/75/100 150
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Patientsshould be addressed to a specialist if:
Severe HF class III/IV Unknown etiology
Relative CI: bradicardia, low blood pressure
Low dose intolerance
Previous beta-blockeruse with treatment cessation because of
symptoms Suspicion ofasthma orCAD
Beta-blockers: contraindications in HF
Asthma
Severe bronchitis
Symptomatic bradicardia orhypotension
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3. DIURETICS
Loop-diuretics or thiazides
Always togetherwith an ACE-i
If GFR < 30 ml/min (glomerular filtration rate) then nothiazides (exception: if thiazides are adjuvant to loop-diuretics)
Insufficient response:
1. Increase diuretic dose2. Associate loop-diuretics and thiazides
3. Persistent fluid retention: loop-diuretics twice a day
4. Severe HF: monitorcreatinine and electrolytes
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Potassium-sparing diuretics: triamteren, amiloride,
spironolactone
Only if hypo-K+ persists after therapy initiation with ACE-I
and diuretics
Initiate with low dose for 1 week, then assess plasma K+
and creatinine after 5 - 7 days and increase correctly the
dose. Monitor K+ and creatinine every 5 7 days till K+ is
constant.
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MEDICATION INITIAL
DOSE
(mg)
MAX
DOSE
(mg)
SIDE EFFECTS
l.POTASSIUM-SPARING D.
* SPIRONOLACTONE 25 100
* AMILORID 5 40 HYPER-K +
* TRIAMTEREN 50 100
2.THIAZIDES
* HYDROCHLOROTHIAZID 25 50 DYSELECTROLYTEMIA
* METOLAZONE 2,5 10 THIAZIDIC DIABETES
METABOLIC
DISORDERS
3.LOOP-DIURETICS
* FUROSEMID 10 240
* BUMETANID 0,5 10 DYSELECTROLYTEMIA
* TORASEMID 5 100 METABOLIC
DISORDERS
* ETACRINIC ACID 50 200
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4. DIGITALIS GLYCOSIDES are indicated in:
-atrial fibrillation
-any symptomatic HFstage
-sinusrhythm, ifpersistent HF (systolic LVdysfunction) even if treated with ACE-i + Diuretic
Digoxin + Beta-blocker: superiorassociation vs. monotherapy
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5. Vasodilators
May be used as adjunctive therapy in HFforthe reliefof
angina oracute dyspnea (nitrates) orconcomitant
hypertension (DHP calcium antagonists) AT1 bl betterchoice than nitrates /hydralazine when
intolerance to ACE-I
Alpha-blockers are not recommended in HF
DHP calcium antagonists have no effect on survival inHF due to LV systolic dysfunction
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HF WORSENING imposesfollowing associations:
-Spironolactone and / or-Loop-diuretic + thiazide
HF class IV NYHA despite ofoptimal therapy and correct diagnosis
-Continue with mentioned measures
-Add palliative therapy in final stages (opioids)
LV DIASTOLIC DYSFUNCTION
Recommendations
-Beta-blockers
-Calcium antagonists (Verapamil)
-ACE-i
-Diuretics (caution!)-Arrhythmias control sustained VT Amiodarone
Symptomatic A.F. Digitalis
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