Heart FailureDefinitionHeart 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

Myocardial failure, a term used to denote abnormal systolic or diastolic function, may be asymptomatic or progress to heart failure

Circulatory failure is not synonymous with heart failure because a variety of noncardiac conditions can lead to circulatory collapse while cardiac function is preserved

The Heart Failure MilieuFrom Molecular Biodynamic to a Clinical Syndrome

Treatment

NecrosisToxins

Volume overload/Pressure overloadHormone signal transduction

Heritable disorders

Compensation

Physiologic milieu

Pump

Contraction

Contractile proteins

DNA

De-compensation

Compensatory responses

Remodeling

Prevention

Remodeling

MOLECULAR,GENETIC

CELLULAR,ORGANELLE

INTEGRATEDORGANISM:

MAN

HEART

CELL

The Heart Failure MilieuDisease Process

Mechanical DysfunctionPressure overload Hypertension Aortic / pulmonic valve stenosis Pulmonary HypertensionVolume overload Aortic, mitral, tricuspid valve insufficiency Impaired Heart Filling

Pericardial diseaseVentricular hypertrophyMyocardial restrictionMitral / tricuspid stenosis

Direct Cell InjuryMyocardial infacrtionCardiomyopathyMyocarditisDrug / toxin-inducedSystemic disease effects

DiseaseProcess

The Heart Failure MilieuVentricular Dysfunction

DiseaseProcess

VentricularDysfunction

Diastolic dysfunctionImpaired ventricular filling

Systolic dysfunctionImpaired myocardial contractility

The Heart Failure MilieuHemodynamic Abnormalities

Diseaseprocess

Ventriculardysfunction

IncreasedLVEDP,PCWP,RAP (preload)Pulmonary artery pressurePulmonary blood volume(afterload)

DecreasedStroke volumeCardiac output

Regional blood flow

Hemodynamicabnormalities

The Heart Failure MilieuCompensatory Mechanisms

Diseaseprocess

RenalRenin-angiotensin-aldosterone

Salt / water retentionVentricular

DilationHypertrophy

SympatheticIncreased contractilityTachycardiaIncreased venous toneIncreased arterial tone

Ventriculardysfunction

Hemodynamicabnormalities

Compensatorymechanism

Diseaseprocess

Ventriculardysfunction

Hemodynamicabnormalities

Metabolicchanges

Symptoms andPhysical findings

The Heart Failure MilieuClinical Presentation

Physical findingsPeripheral edemaAscitesVascular congestionJugular venous distentionRalesTachycardiaHypotensionCachexiaDisease-spesific findings

Metabolic changesAzotemia

HyponatremiaHypocalcemia

HypomagnesemiaHyperuricemia

Acidosis/alkalosisHypoxia/O2 desaturation

Decreased MVO2

SymptomsFatique and weaknessDyspnea and fluid retention syndromesNocturiaGastrointestinal symptomsDiminished mentation

Compensatorymechanism

Diseaseprocess

Ventriculardysfunction

Hemodynamicabnormalities

Metabolicchanges

Symptoms andPhysical findings

The Heart Failure MilieuEnd-Organ Failure and Death

Compensatorymechanism End-Organ

Failure

SUDDENDEATH

DEATH

Lethal arrhythmiaElectrolyte abnormalitiesElevated cathecolamine levelsIschemiaDrug-proarrhythmia

Systemic organ failureRenal failureHepatic failure Respiratoric failureMulti-organ failurePulmonary embolismPeripheral (cerebral) embolism,

The Evaluation of Heart Failure Patients Recognize the milieu Clarify precipitating disease Define syndrome severity Establish patient prognosis Create therapeutic protocol

PHYSICALEXAMINATION

DIAGNOSTICSTUDIES

LABORATORYTESTS

HISTORY

Pulmonary

Neuro-psychiatric Systemic

Gastro-intestinal

Patient history

Neurologic

Abdominal

Physical examinationCardiac Cardiac

Pulmonary

Diagnostic studiesLaboratory

tests

Echo-cardiography

RadionuclidestudiesCardiac

catheterization

Chestroentenogtam

Exercisetesting

Electro-cardiography

Renal

Assessment of Heart Failure

Framingham criteria for Congestive Heart Failure

Definite : - 2 major - 1 major + 2 minor

Major Criteria Minor CriteriaParoxysmal nocturnal dyspneaNeck-vein distensionRalesAcute pulmonary edemaS3 gallopIncreased venous pressure > 16 cm H2OCirculation time > 25 secHepatojugular reflux

Ankle edemaNight coughDyspnea on exertionHepatomegalyPleural effusionVital capacity increased 1/3 from maximunTachycardia ( rate > 120/min)

Major or Minor CriteriaWeight loss > 4.5 kg in 5 days in response to treatment

New York Heart Association Functional Classification

Class I : No symptoms with ordinary activity Class II : Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginaClass III : Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal painClass IV : Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest

NORMALAsymptomatic LV Dysfunction

CompensatedCHF

DecompensatedCHF

No symptomsNormal exerciseNormal LV fx

No symptomsNormal exerciseAbnormal LV fx

No symptoms ExerciseAbnormal LV fx

Symptoms ExerciseAbnormal LV fx

RefractoryCHF

Symptoms not controlled with treatment

Chronic Congestive Heart Failure

Evolution of Clinical Stages

Stages of Heart Failure and Treatment Options for Systolic Heart Failure

HTCADDM

Tx CardiotxicAlc abuse

FH cardiomyopathy

LVHAsymp.RHDPrevious MI

FatiqueDOE

Prior symp. HF

Frequent HF hosp.Awaiting for transplant

Cont.inotropic or mec.support

Assess LV Function (echo, gated RNA)• EF < 40%-systolic dysfunction

• EF 40-55%-systolic/diastolic dysfunction

• EF >55%-diastolic dysfunction

Assess Volume Status

Signs and Symptoms of Fluid Retention

No Signs and Symptoms of Fluid Retention

Loop Diuretic± Thiazide

(titrate to euvolemic state)

ACE inhibitor/ARB if ACE intolerantCombination Rx if HF, hospitalization or -blocker

intolerant

Spironolactone (NYHA Class III-IV CHF/EF<35%/Cr<200/K<5)

Add Digoxin for symptom control

Symptoms Prognosis & Symptoms

-blocker (NYHA II-IV)

Inotropes, mitral repair, VAD, Tx

General Rx Strategies in HF

Angiotensin Converting Enzyme Inhibitors

Carvedilol/ -Blockers

Diuretics (Spironolactone)

Digoxin

No Added Salt 2 gm NaActivity as Tolerated Customized Ex Training

Tailored RxCorrect Cause:ArrhythmiasIschemiaPressure Load

Asymptomatic Mild/Mod Severe Refractory

Modified from Warner-Stevenson, ACC HF Summit

Management of Heart FailurePrimary Targets of Treatment in Heart Failure.

The Donkey Analogy

Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

Digitalis CompoundsLike the carrot placed in front of the donkey

Diuretics, ACE Inhibitors

Reduce the number of sacks on the wagon

ß-BlockersLimit the donkey’s speed, thus saving energy

Treatment Approach for the Patient with Heart Failure

Stage A

At high risk, no structural disease

Stage B

Structural heart disease,

asymptomatic

Stage D

Refractory HF requiring

specialized interventions

Therapy

• Treat Hypertension

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake

• ACE inhibition

Therapy

• All measures under stage A

• ACE inhibitors in appropriate patients

• Beta-blockers in appropriate patients

Therapy

• All measures under stage A

Drugs:

• Diuretics

• ACE inhibitors

• Beta-blockers

• Digitalis

• Dietary salt restriction

Therapy

• All measures under stages A,B, and C

• Mechanical assist devices

• Heart transplantation

• Continuous (not intermittent) IV inotropic infusions for palliation

• Hospice care

Stage C

Structural heart disease with prior/current

symptoms of HF

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

Cardiac Resynchronization Therapy

Increase the donkey’s (heart) efficiency

Summary• Heart failure is a chronic, progressive disease

that is generally not curable, but treatable

• Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors, beta blockers, digoxin, and diuretics

• It is estimated 15% of all heart failure patients may be candidates for cardiac resynchronization therapy (see later section for details)

• Close follow-up of the heart failure patient is essential, with necessary adjustments in medical management