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Heart Failure PowerPoint Presentation

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Description : Check out this medical presentation on Congestive Heart Failure, which is titled "Heart Failure", to know the definition of heart failure and clinical presentation of heart failure, types of heart failure based on ejection fraction, and the guideline-based management of patients with heart failure.

Tags : Congestive Heart Failure, clinical presentation

Published on : Jul 01, 2021 | Views : 3313 | Downloads : 23

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Heart Failure Anita Deswal, M.D., M.P.H. Professor of Medicine Chief of Cardiology Michael E. DeBakey VAMC & Baylor College of Medicine, Houston
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Speaker Disclosures None
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Objectives To discuss the definition of heart failure and clinical presentation of heart failure To discuss types of heart failure based on ejection fraction To discuss the guideline-based management of patients with heart failure
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Definition of Heart Failure “Heart failure is a 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” ACC/AHA Guidelines 2013
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ACC/AHA Guidelines 2013 Left Heart Failure: Dyspnea on exertion Dyspnea at rest Orthpnea Paroxysmal nocturnal dyspnea (PND) Fatigue, inability to exercise Right Heart Failure: Swelling of feet, hands Abdominal distention/fullness Right upper quadrant pain Early satiety Weight loss (cardiac cachexia) Clinical: Symptoms of HF
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ACC/AHA Guidelines 2013 Left Heart Failure: Rales Pleural effusions CM: Displaced apical impulse Tachycardia, LVS3, murmur of MR Narrow pulse pressure Right Heart Failure: Edema of lower extremities Elevated JVP/+ HJR RVS3, murmur of TR Hepatomegaly, RUQ tenderness Ascites Pleural effusions Clinical: Signs of HF
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ACC/AHA Guidelines 2013 Asymptomatic Symptomatic A At high risk for HF but without structural heart disease or symptoms of HF (e.g., patients with HTN or CAD) B Structural heart disease but without symptoms of HF C Structural heart disease with prior or current symptoms of HF D Refractory/advanced HF requiring specialized interventions Class I Asymptomatic: No limitation of physical activity. Ordinary activity does not cause sxs. II Symptomatic with moderate exertion. Ordinary physical activity causes SOB, fatigue IV Symptomatic at rest. Unable to carry on any activity without discomfort. III Symptomatic with minimal exertion. Less than usual activity causes sxs NYHA Class Stages of Heart Failure
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ACC/AHA Guidelines 2013 Class I Asymptomatic: No limitation of physical activity. Ordinary activity does not cause sxs. II Symptomatic with moderate exertion. Ordinary physical activity causes SOB, fatigue IV Symptomatic at rest. Unable to carry on any activity without discomfort. III Symptomatic with minimal exertion. Less than usual activity causes sxs NYHA Class 1-Yr Mortality NYHA Class and Mortality
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ACC/AHA Guidelines 2013 Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327. HF groups: 2013 ACC/AHA Guidelines The current definition of HF based on left ventricular ejection fraction (EF): HF with reduced EF (HFrEF, EF ≤40%) HF failure with preserved EF (HFpEF, EF ≥50%) HFpEF, borderline (EF 41-49%) HFpEF, improved (EF >40%)
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Management of Patients with Heart Failure
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2013 ACCF/AHA Guideline for the Management of Heart Failure
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After detailed history; Initial laboratory evaluation: CBC, urinalysis, CMP (including calcium and magnesium), fasting lipid profile, TSH, iron panel Serial monitoring, when indicated, should include serum electrolytes and renal function. A 12-lead ECG should be performed initially on all patients presenting with HF. Chest X-ray is all patients with new onset HF. Echocardiogram in all patients with new dx of HF (MUGA in some) Repeat echo usually for a significant change in clinical status or for consideration of changes after therapy or to evaluate for device therapy. Noninvasive stress imaging or cardiac cath is reasonable in HF and suspected CAD Initial Workup of Stage C HF
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BNP (NT-proBNP) in HF BNP or B-type natriuretic peptide is produced mostly by cardiac ventricles in response to stress/strain/stretch on the myocardium BNP has beneficial effects in heart failure: promotes vasodilation, diuresis and natriuresis Levels increased in patients with HF; levels correlate with wedge pressures and prognosis BNP < 100 pg/ml usually will r/o significant HF in acute dyspnea
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BNP (NT-proBNP) in HF (2) Patients discharged with BNP > 400-500 pg/ml at discharge are at a higher risk for HF readmissions and mortality However, patients with low LVEF can have normal levels if diuresed well (20-25% chronic HF) Levels ↑ with age, especially in older women, and with renal dysfunction ↑ in HFrEF & HFpEF (overall higher in HFrEF) ↓ ↓ in obesity Elevated BNP also seen with RV dysfunction, PE Although prognostic- no definitive data to recommend titrating diuretics or meds to BNP levels- outside of structured HF programs.
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Stage C (HFrEF & HFpEF) Non-pharmacologic interventions Education to facilitate self care Regular physical activity; cardiac rehabilitation Sodium restriction Treat comorbidities: Hypertension, diabetes, CAD, sleep apnea, anemia Influenza and pneumococcal immunization Decrease/stop alcohol, smoking, other drug abuse Close outpatient follow-up Avoid certain drug classes: NSAIDs Ca channel blockers except amlodipine (in HFrEF) Antiarrhythmics except amiodarone, dofetalide Thiazolidinediones (TZDs)
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Pathophysiology of HFrEF & Therapeutic Targets Adapted from Langenickel TH, Dole WP. Drug Discovery Today 2012;9:131–9. LV remodeling SNS SNS= sympathetic nervous system RAAS= Renin angiotensin aldosterone system
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HFrEF: Medications & Devices
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Commonly Used Diuretics
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Medical Therapy for Stage C HFrEF: Magnitude of Benefit in RCTs
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2013 ACCF/AHA Guideline for the Management of Heart Failure
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ACC/AHA Guidelines 2013 Indicated for symptomatic or asymptomatic EF ≤40%. Use agents and target doses used in clinical trials. Initiate when relatively euvolemic, off IV vasoactive agents and prior to hospital d/c. Titrate upward every 2 to 4 weeks as long as stable. Most trials held titration for HR <60 or SBP <90. Adjust other agents if dyspnea, BP, or weight gain occur in order to titrate to target doses. Use of Beta Blockers in HFrEF
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2013 ACCF/AHA Guideline for the Management of Heart Failure Which Beta Blocker; How Much?
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2013 ACCF/AHA Guideline for the Management of Heart Failure Which ACE I; How Much?
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ACC/AHA Guidelines 2013 ARBs are recommended in patients with HFrEF who are ACE inhibitor-intolerant (cough +/- angioedema), unless contraindicated, to reduce morbidity and mortality. ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. ACE I or ARB or Both?
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ACC/AHA Guidelines 2013 Which ARB; How Much?
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Aldosterone receptor antagonists [or mineralocorticoid receptor antagonists (MRA)] are recommended in patients with NYHA class II-IV and who have LVEF of < 35%. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine should be < 2.5 mg/dL or less in men or < 2.0 mg/dL in women (or eGFR >30 mL/min/1.73m2) and potassium < 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation, within 7-10 days after initiation and followed thereafter to minimize risk of hyperkalemia and renal insufficiency. Aldosterone Antagonists
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Eplerenone is a more specific aldosterone receptor antagonist; it can be used if spironolactone causes gynecomastia or breast pain. It causes the same effects on potassium and renal function as spironolactone. Aldosterone Antagonists
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HDZ/ISDN combincation is recommended for African Americans with NYHA class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers. HDZ/ISDN can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated. Nitrate/Hydralazine (ISDN/HDZ)
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Digoxin can be beneficial in patients with HFrEF and sinus rhythm to decrease hospitalizations for HF: consider adding if on other therapy and still symptomatic Digoxin can be used in HF patients with atrial fibrillation to help rate control **Dose: 0.125 -0.25 mg qd depending on renal function (levels not for dosing but for toxicity) **Interaction with amiodarone, which ↑ Digoxin levels Digitalis
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Neprilysin as a Therapeutic Target Inactive fragments Neprilysin Natriuretic peptides Adrenomedullin Bradykinin Substance P (angiotensin II) Neprilysin breaks down endogenous vasoactive peptides, including the natriuretic peptides Inhibition of neprilysin potentiates the action of those peptides Because angiotensin II is also a substrate for neprilysin, neprilysin inhibitors must be co-administered with a RAAS blocker The combination of a neprilysin inhibitor and an ACEI is associated with unacceptably high rates of angioedema Corti R et al. Circulation. 2001;104:1856-1862. Sacubitril/Valsartan (LCZ696): Angiotensin Receptor–Neprilysin Inhibitor (ARNI)
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1. McMurray JJ et al. N Engl J Med. 2014;371:993-1004 PARADIGM-HF: CV Death or HF Hospitalization (Primary Endpoint)
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SHIFT Trial Primary Composite Endpoint: CV Death or Hospitalization for Worsening HF Swedberg K et al. Lancet. 2010;376:875-885.
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1. Yancy CW et al. J Am Coll Cardiol. 2016;68:1476-1488. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
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Implantable Cardiac Defibrillators (ICD)
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Indications for ICD Therapy 2013 ACCF/AHA Guideline for the Management of Heart Failure
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Cardiac Resynchronization Pacing: Consequences of a Prolonged QRS Delayed Ventricular Activation Delayed lateral wall contraction Disorganized ventricular contraction Decreased pumping efficiency Reduction in diastolic filling times Prolongation of the duration of mitral regurgitation
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Intraventricular Activation Organized ventricular activation sequence Coordinated septal and freewall contraction Improved pumping efficiency Mechanism: Ventricular Resynchronization Conduction block
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Cardiac Resynchonization Rx (CRT) 2013 ACCF/AHA Guideline for the Management of Heart Failure
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Trials have not shown significant mortality or morbidity benefit with use of ACEI/ARB specifically in HFpEF No trials showing definite benefit of Beta blockers, sildenafil TOPCAT trial: Randomized-double blind trial of spironolactone (15-45 mg) vs. placebo in HFpEF patients (LVEF >45%) with Prior HF hospitalization or BNP > 100 pg/ml HFpEF
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? Spironolactone in select pts
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Stage D Refractory HF Marked HF symptoms at rest Recurrent hospitalizations despite GDMT
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Definition of HF Magnitude of the problem Symptoms & Signs of HF Types of HF: HFpEF & HFrEF Stages of HF and NYHA Functional Classification of HF Management of Patients with HF: Initial work up Medical therapy Device Therapy Summary
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Burden of Heart Failure Lifetime risk > 20% for Americans >40 years of age 870,000 new cases diagnosed annually Prevalence in US: 5.7 million