Diagnosis and Management of

Congestive Heart Failure

David Putnam, MD

Albany Medical College

• Coronary heart disease mortality has declined steadily since 1972

• Hospitalizations rates for CHF have increased

Incidence of CHF

• Common medical condition that afflicts 4.8 million people in the US

• Approximately 2% of the US population has CHF

• 400,000 to 700,000 new cases per year

• Prevalence increases with age

• Up to 20 million people may have asymptomatic LV dysfunction

Congestive Heart Failure

• Pathophysiologic state in which cardiac output is inadequate to meet the metabolic needs of the body

• Complex clinical syndrome that can result from any cardiac disorder that impairs the ability of the ventricle to eject blood

Historical Perspective of CHF

• Dropsical condition

• Central cardiac pump problem

• Circulatory dysfunction

• Disorder of renal function

• Complicated milieu of pump dysfunction, remodeling, humoral perturbation and subsequent circulatory insufficiency

Syndrome of CHF in the 1990s in US

• CAD most common cause ( >70% )

• Systemic and/or pulmonary congestion infrequent

• Diastolic dysfunction common in the elderly

• Sudden death frequent ( > 50% )

CHF: Survival

• Average 5-year survival 50%

• Survival in women better than in men

• Risk of death is 5 to 10% annually in patients with mild symptoms

• Risk of death is 30 to 40% annually in patients with severe symptoms

CHF: Survival

Left Ventricular Failure

• Systolic Dysfunction

• Diastolic Dysfunction

• Systolic and Diastolic Dysfunction

CHF: Systolic Dysfunction

• Causative Factor

A. Loss of Muscle

B. Pressure Overload

C. Volume Overload

D. Decreased contractility

• Example

A. Myocardial Infarct

B. Hypertension

C. Valvular regurgitation

D. Dilated cardiomyopathy

CHF: Diastolic Dysfunction

• Causative Factor

A. Delayed relaxation

B. Restricted filling

C. Reduced filling time

(tachycardia)

• Example

A. Ischemia

B. Hypertrophic cardiomyopathy

C. Mitral stenosis

CHF: Diastolic Dysfunction

• Very common

• 20 to 40% of all new cases of CHF

• Incidence increases with age

CHF: Disease Process

CHF: Ventricular Dysfunction

CHF: Hemodynamic Abnormalities

CHF: Compensatory Mechanisms

CHF: Clinical PresentationCardinal Manifestations

• Dyspnea

• Fatigue

• Fluid retention ( pulmonary and peripheral edema )

CHF: Steps in Evaluation

• Rule out precipitating causes

• Determine LVEF

• Systolic vs. diastolic dysfunctin

• Rule out CAD/myocardial ischemia

• Rule out significant ventricular arrhythmias

• Functional capacity

CHF: Precipitating Causes

• Poor compliance with meds or diet

• Alcohol abuse

• Uncontrolled HTN

• Ischemia/MI

• Arrhythmias, e.g., atrial fibrillation

• Infection, anemia, thyrotoxicosis

• Renal dysfunction

• Medications

CHF: Physical Findings

• Pulsus alternans

• Elevated jugular venous pressure

• Displaced cardiac apical impulse

• Third heart sound

• Pulmonary rales

• Hepatomegaly

• Peripheral edema

CHF: Lab Tests

CHF: Lab Tests

Diagnosis of CHFRoutine Tests

• ECG

• Chest x-ray

• Echocardiogram

CHF: ECG

CHF: CXR

• Cardiomegaly

• Vascular redistribution

• Kerley B lines

• Interstitial edema

• Peri-bronchial “cuffing”

• Effusions

Congestive Heart Failure

CHF: Echocardiogram

• Chamber enlargement

• Wall motion abnormalities

• Diminished ejection fraction

• Possible LVH

• Possible valvular problems

• Assess diastolic dysfunction

Echocardiogram

Dilated Cardiomyopathy

Hypertrophic Cardiomyopathy

CHF: Additional Testing

• MUGA scan

• Exercise stress test

• Cardiac catheterization

• Holter monitor

CHF: Treatment Goals

• Improve symptoms

A. Enhance well-being and quality of life

B. Increase exercise tolerance

• Improve survival

A. Prevent progressive heart failure

B. Prevent sudden death

C. Prevent thromboembolic episodes

CHF: Medical Management

• Diuretics

• Digitalis

• ACE Inhibitors

• Beta Blockers

• Spironolactone

CHF: Diuretics

• Reduce volume overload

• Reduce sodium overload

• Preload reduction

CHF: Diuretics

Advantages

• Highly effective in most classes

• Essential with fluid retention

• Well tolerated, simple to use

Disadvantages

• Electrolyte abnormalities

• Hypovolemia, hypotension, renal dysfunction

• Activation of neurohormaonal system

CHF: Diuretics

• Elimination of symptoms and/or signs of congestion

• Avoid volume depletion

A. Postural hypotension

B. Increase in heart rate

C. Increase in BUN/Cr

D. Neuroendocrine activation

Diuretics

Thiazide Diuretics

• HCTZ

• Chlorthalidone

• Metolazone

Loop Diuretics

• Furosemide

• Torsemide

Potassium Sparing Diuretics

• Spironolactone

• Triamterene

• Amiloride

CHF: SpironolactoneRALES Study

• Spironolactone 25 mg/day in Class III or IV patients in addition to ACE and loop diuretics

• 30% reduction in mortality

• 31% reduction in cardiac mortality

• Anti-aldosterone effect

Pitt B. NEJM 1999;341:709-717

CHF: Digoxin

• Improves rest and exercise hemodynamics

• Attenuates neurohormal abnormalities

• Improves symptoms

• May result in fewer hospitalizations and ER visits

• Has unknown effects on mortality

CHF: Digoxin

• Useful in patients with CHF and supraventricular arrhythmias

• Useful in patients with systolic dysfunction

• Disadvantages include:

A. Narrow Rx range

B. Synergistic toxicity with hypokalemia

C. Drug interactions

D. Possible arrhythmogenesis

CHF: ACE Inhibitors

• Improve hemodynamic status

• Attenuate neurohumoral abnormalities

• Improve symptoms

• Reduce incidence of hospitization

• Slow progression

• Reduce mortality

CHF: ACE Inhibitors

Neurohormonal Changes

• Decreased angiotensin II

• Increased bradykinin

• Decreased or no change in aldosterone

• Decreased norepinephrine

CHF: ACE Inhibitors

Reduction in Sudden Death/Potential Mechanisms

• Increase in serum/total body potassium

• Decreased adrenergic stimulation

• Reduced heart size and decrease in ventricular hypertrophy

• Prevention of myocardial ischemia

• Prevention of progressive myocardial damage

CHF: FDA Approved ACE Inhibitors

• Captopril

• Enalapril

• Lisinopril

• Quinapril

• Trandolapril

• Fosinopril

CHF: ACE Inhibitor Doseages

Captopril

Enalapril

Lisinipril

Quinapril

• Start: 6.25 bid/tid

• Usual: 6.25-50 bid/tid

• Start: 2.5 qd/bid

• Usual: 2.5-10 bid

• Start: 2.5-5 qd

• Usual: 5-20 qd

• Start: 5 bid

• Usual 10-20 bid

ELITE IIELITE II Primary Endpoint: All-Cause MortalityPrimary Endpoint: All-Cause Mortality

00 100100 200200 300300 400400 500500 600600 700700

Days of Follow-upDays of Follow-up

0.00.0

0.20.2

0.40.4

0.60.6

0.80.8

1.01.0

Pro

babi

lity

of S

urvi

val

Pro

babi

lity

of S

urvi

val

LosartanLosartanCaptopril Captopril

Hazard Ratio (95-7% C.I.) = 1.13 (0.95-1.35) P = 0.16Hazard Ratio (95-7% C.I.) = 1.13 (0.95-1.35) P = 0.16

Lancet Lancet 2000;355:1582-872000;355:1582-87

ELITE IIELITE IIWithdrawal for Adverse Experience (Excluding Death)Withdrawal for Adverse Experience (Excluding Death)

0

5

10

15

20

Any AE Drug-RelatedAE

Cough HF

% o

f P

atie

nts

Losartan (N=1578)Captopril (N=1574)

******** p p0.001 between 0.001 between groupsgroups

****

****

Lancet Lancet 2000;355:1582-872000;355:1582-87

ELITE IIELITE IIDiscussionDiscussion

• Losartan was not superior to captopril in improving survival in elderly heart-failure patients, but was significantly better tolerated.

• Based on extensive randomized, placebo-controlled observations, ACE inhibitors should be the initial treatment for heart failure, although angiotensin II receptor antagonists may be useful to block the renin angiotensin aldosterone system when ACE inhibitors are not tolerated.

Lancet Lancet 2000;355:1582-872000;355:1582-87

CHF: Beta Blockers

• Acutely depresses myocardial function (pharmacological)

• Chronically improves myocardial function (biological)

CHF: Beta Blockers

• Primary mechanism is inhibition of down regulation of beta receptors

• Additional mechanismsA. Restore receptor densityB. Protect against cardiotoxicity of

catecholeaminesC. Improve systolic/diastolic function in

ischemic myocardium

Beta Blockers

• First Generation: Beta 1 and Beta 2

Propranolol/Timolol

• Second Generation: Beta 1

Metoprolol/Atenolol

• Third Generation: Vasodilating Properties

Carvedilol

CHF: Beta Blockers

Improve symptoms and clinical class

• Degree of benefit appears to relate to degree of disability before treatment

Reduce Mortality

• 5 trials with metoprolol/bisoprolol

• 5 trials with carvedilol

CHF: Metoprolol vs. Carvedilol

• Randomized, double-blind comparison

• 150 patients followed for 12 months

• Class II, III, IV

• LVEF <=35%

• Greater improvement in cardiac function with Carvedilol

Circulation 2000(AUG);102:546-551.

CHF: Beta Blockers

• Should be used in all stable Class II/III patients unless contraindicated

• Treatment should not be initiated in patients with acutely decompensated CHF

• Clinical response may take 2 to 3 months

CHF: Beta Blockers

Risks of Treatment

• Hypotension

• Fluid retention and worsening CHF

• Bradycardia and heart block

CHF: Beta Blockers

• Carvedilol

• Metoprolol

• Bisoprolol

• Start: 3.125 mg bid

• Usual: 25 mg bid

• Start: 12.5-25 mg qd

• Usual: 50-100 mg bid

• Start: 1.25 mg qd

• Usual: 5-10 mg qd

CHF: IV Dobutamine

• 80 patients with class III/IV CHF

• Continuous IV Dobutamine @ 9 mcg/kg/min for 14 days

• Adverse event rate in treatment group: 85%

• Adverse event rate in placebo group: 65%

AM HRT J 1999;138:78-86

CHF: IV Dobutamine

• Continuous IV Dobutamine has never been shown to improve survivorship

• Intermittent infusion has been called into question

Ewy GA. JACC 1999;33:572-74

CHF: Diastolic Dysfunction

• Difficult to treat

• Diuretics for volume overload. Avoid volume depletion

• Prevent tachycardia

• Rate-limiting calcium channel blockers first choice

• Beta 1 beta blockers second choice

Diastolic Time and Heart Rate

CHF: Diastolic Dysfunction

Benefits of Calcium Channel Blockers

• Slowing of heart rate

• Reduction of MVO2

• Control of BP

• Regression of LVH

• Dilation of coronary microcirculation

• Amelioration of intracellular calcium overload

CHF: Diastolic Dysfunction

Benefits of Beta Blockers

• Slowing of heart rate

• Reduction of MVO2

• Control of blood pressure

• Regression of LVH

CHF: Treatment Scheme

The End

Myocardial Oxygen Consumption

CHF: ACE Inhibitors

• 18 patients with SBP 60 to 100

• At four weeks 82% of patients were tolerating Lisinipril 40 mg/day