Post on 07-Jul-2020
HEART FAILURE: Current Concepts, Diagnosis and Management
Geetha Pinto, MD, FACC
Medical Director, Heart Failure Program
Roper St. Francis HealthCare
Coastal Cardiology, PA
Objectives● Etiology and Diagnosis of Heart Failure● Pathophysiology of Heart Failure ● Pharmacological Considerations ● Current Guidelines about Treatment of
Comorbidities (2017 Focused Update)● Cardio-Onclogy
Facts About Heart Failure ● About 5.7 million U.S. adults have heart failure
● 50% of those patients will die in the next 5 years
● Heart failure costs about $30.7 BILLION EACH YEAR
● About 50% of these patient costs are related to HFpEF
● The prevalence of HFpEF is increasing over that of HFrEF due to aging population with accumulation of risk factors
Definition of Heart Failure
● Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder causing systemic perfusion inadequate to meet the body’s metabolic demands without excessively increasing left ventricular filling pressures.
● It is characterized by symptoms, such as dyspnea and fatigue, and signs, such as fluid retention.
● There are many ways to assess cardiac function. However, there is no diagnostic test for HF, since it is largely a clinical diagnosis that is based upon a careful history and physical examination.
Heart Failure can exist along the ENTIRE SPECTRUM of Ejection Fractions
Elevated Cardiac Filling Pressures is the issue at heart
Classification and Types of Heart Failure
● Based on Ejection Fraction/Ventricle ○ Ejection Fraction
■ Systolic, diastolic, mid-range (EF 41-49%)○ High-Output Heart failure
■ Anemia, hyperthyroidism, AV fistula, sepsis, Paget’s
○ Right-sided, left-sided, combined ○ Classes of HF (NYHA 1-4) = symptoms ○ Stages of HF (A-D)
Etiologies of Heart Failure
VALVULAR DISEASE● Stenosis and Regurgitation ● Diastolic and systolic
HEART FAILURE
HIGH OUTPUT STATES● Anaemia● Sepsis● Thyrotoxicosis● Paget‘s disease● Arteriovenous fistula
VOLUME OVERLOAD● Renal failure● Iatrogenic (e.g. post-
operative fluid infusion
CONGENITAL HEART DISEASE
ARRHYTHMIA● Tachyarrhythmia● Atrial● Ventricular● Bradyarrhythmia● Sinus node dysfunction
CONDUCTION DISORDERS● Atrioventricular block
MYOCARDIAL DISEASE● Coronary artery disease● Hypertension● Cardiomyopathy
ENDOCARDIAL DISEASE● With/without
hypereosinophilia● Endocardial fibroelastosis
PERICARDIAL DISEASE● Constrictive pericarditis● Pericardial effusion
HEART FAILURE WITH PRESERVED EJECTION FRACTION
Goel S, Miller A, Sharma A, Gidwani U, Shani J (2015) Treatment Modalities for Heart Failure with Preserved Ejection Fraction (HFpEF) - Current State of Evidence and Future Perspective. J Clin Exp Cardiolog 6:383. doi:10.4172/2155-9880.1000383
DIAGNOSIS OF HEART FAILURE
● Signs and symptoms ● Cardiac Biomarkers ○ BNP/NT-BNP ○ Troponin
● Evidence of elevated LV filling pressures○ Echo/Stress Echo○ Right heart cath
Signs and Symptoms of Heart Failure
Pathophysiology of Heart Failure- Neurohormonal Activation
June 2016Br J Cardiol 2016;23(suppl 1):S1–S16doi:10.5837/bjc.2016.s01
↑ Sympathetic Tone/SNS activation
↑ RAAS Activity
Counterbalanced by:
↑ but weaker Natriuretic peptide system (NPS)
=Increased inflammation
Increased Oxidative StressIncreased cardiac tissue fibrosis
Goal of Management Strategies
● Prevention ● Improve symptoms/hospitalization/complications/quality of
life (Morbidity)
AND
● Improve Life Span (Mortality)
Management of Acute SYSTOLIC Heart Failure
Pharmacological Management of Chronic SYSTOLIC Heart Failure
Inhibit Sympathetic Tone
Inhibit RAAS Activation
Augment Natriuretic Peptide System Activity and Other Mechanisms
Volume Removal
● BETA BLOCKERS- Carvedilol
- Metoprolol Succinate
- Bisoprolol
- Nebivolol
● ACEi- Enalapril et. al
● ARB - Candesartan/Valsar
tan/losartan
● MRA- Spironolactone- Eplerenone
● Furosemide
● Torsemide
● Bumetanide
● Ethacrynic Acid
● Metolazone/HCTZ
● ARNI (sacubitril-valsartan)
● SGLT2 inhibitors (gliflozins)
AFTERLOAD REDUCERISDN/Hydralazine
(Bidil)
WHAT ABOUT HFpEF?
HFpEF Therapeutic Strategies
Heart failure with preserved ejection fraction: A systemic disease linked to multiple comorbidities, targeting new therapeutic options - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Cardiac-and-extracardiac-factors-involved-in-the-pathophysiology-of-heart-failure-with_fig1_326036459
TOPCAT Trial (2014) Spironolactone vs. Placebo in HFpEF
Heart Failure and Glycemic Control Medications (SGLT-2 Inhibitors)
SGLT-2 INHIBITORS
● Empagliflozin ● Canagliflozin ● Dapagliflozin
2017 Focused Update on HF Guidelines(Management of Comorbidities)
● Sacubitril-valsartan (Class I indication over ACEi, ARB in HFrEF)● Ivabradine (Class IIa indication in HFrEF)● Spironolactone in HFpEF● Anemia /iron deficiency without anemia ● Hypertension ● Sleep disordered breathing
CARDIO-ONCOLOGY
Dr. W. Blount Ellison