Heart failure (what a family physician need to know)

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Transcript of Heart failure (what a family physician need to know)

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Heart FailureWhat a Family Physician need to knowPrepared by : Dr. Ahmed Ibrahim Eldesouky AbouelelaFamily Medicine RegistrarMBBch, Msc, MRCGP.int

What a Family Physician need to knowTerrifying informations.Basic informations.Role of family physician.

Terrifying InformationsHeart failure is the leading cause of hospitalization of patients > 65 years in age.> 15million new cases of HF estimated each year worldwide.Approximately 50% of patients with HF die within 5 years of diagnosis.Symptomatic HF has worse prognosis than majority of cancers.The most common cause of complications of heart failure is poor compliance to treatment.

Basic DefinitionFailure of the heart to provide the body tissue by its need of blood and subsequently oxygen and nutrients

Heart Failure ClassificationAcute vs. ChronicSystolic vs. DiastolicRight sided vs. Left sidedRight ventricular vs. Left ventricular vs. BiventricularPreload vs. AfterloadLow cardiac output vs. High cardiac out putLow ejection fraction vs. Normal ejection fraction

Acute versus Chronic Acute heart failure develops rapidlycan be immediately life threatening due to lack of time to undergo compensatory adaptations.may result from cardiopulmonary by-pass surgery, acute infection (sepsis), acute myocardial infarction, valve dysfunction, severe arrhythmias, etc. can often be managed successfully by pharmacological or surgical interventions.Chronic heart failurea long-term condition (months/years) that is associated with the heart undergoing adaptive responses (e.g., dilation, hypertrophy) to a precipitating cause.These adaptive responses, however, can be deleterious in the long-term and lead to a worsening condition.

Systolic versus DiastolicSystolic cant pumpAortic StenosisHTNAortic InsufficiencyMitral RegurgitationMuscle LossIschemiaFibrosisInfiltrationDiastolic- cant fillMitral StenosisTamponadeHypertrophyInfiltrationFibrosis

Left versus Right FailureLeft Heart FailureDyspnea Decrease exercise toleranceCough OrthopneaPink, frothy sputumRight Heart FailureDecrease exercise toleranceEdema HepatomegalyAscites

Functional classification

NYHA Classification of heart failureClass I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.Class III: marked limitation of any activity; the patient is comfortable only at rest.Class IV: any physical activity brings on discomfort and symptoms occur at rest.

New classification of heart failureStage A: Asymptomatic with no heart damage but have risk factors for heart failureStage B: Asymptomatic but have signs of structural heart damageStage C: Have symptoms and heart damageStage D: End stage disease

ACC/AHA guidelines, 2001

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class1Hunt SA et al. J Am Coll Cardiol. 2001;38:21012113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890897.ACC/AHA HF Stage1NYHA Functional Class2AAt high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)BStructural heart disease but withoutsymptoms of heart failureCStructural heart disease with prior orcurrent symptoms of heart failureDRefractory heart failure requiringspecialized interventionsI AsymptomaticII Symptomatic with moderate exertionIV Symptomatic at restIII Symptomatic with minimal exertionNone

12The New York Heart Association (NYHA) classification system is based largely on the assessment of symptoms.1The new American College of Cardiology and American Heart Association (ACC/AHA) classification guidelines were designed to compliment the NYHA classification system. These new guidelines focus more on underlying disease and the need to treat early in the disease process, even before overt symptoms of heart failure are present.21The Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis. 6th ed. Boston, Mass: Little Brown; 1964.2Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001;38:2101-2113.

Causes HypertensionCongenital heart defectsValvular heart diseasesHeart attackSevere lung diseaseDiabetesSevere anemiaOveractive thyroid gland (hyperthyroidism)Abnormal heart rhythms(Arrhythmias)

Pathophysiology

Symptoms and SignsFatigue, effort intolerance Dyspnea on exertion or at restDifficulty breathing when lying flat (Orthopnea)Swelling in feet, ankles, legs or abdomenhepatomegalyWeight gainHeart palpitationsMay feel like the heart is racing or throbbingCoughing that produces white or pink blood-tinged sputumFeeling of being full or sick to your stomachMemory loss or feeling of disorientationRelative or caregiver may notice this first

Symptoms and Signs

Complication Kidney damage or failure.Heart valve problems.Heart rhythm problems.Liver damage.

Diagnosis Brain Natriuretic Peptide ( BNP test )EchoChest X rayECGLab

BNP(Brain Natriuretic Peptide) TestBNP(Brain Natriuretic Peptide) TestUsed in ER departmentsGood negative correlationNeed baseline for positivityDiagnostic of CHF withSensitivity 90%Specificity 76%Predictive accuracy 83%BNP < 100 pg/L 98% negative predictive accuracy

Treatment ACE InhibitorsARBsDiureticsAldosterone blockadePotassiumBeta-blockersVasodilatorsDigitalis preparationsDevice therapy ( Biventricular (BiV) pacers / Intracardiac defibrillators (ICDs)Surgery and other Medical Procedures

Heart Failure Treatments: Medication TypesACE inhibitor (angiotensin-converting enzyme) ARB (angiotensin receptor blockers)Beta-blockerDigoxinDiuretic

Aldosterone blockadeType What it doesExpands blood vessels which lowers blood pressure, neurohormonal blockadeSimilar to ACE inhibitorlowers blood pressureReduces the action of stress hormones and slows the heart rateSlows the heart rate and improves the hearts pumping function (EF)Filters sodium and excess fluid from the blood to reduce the hearts workloadBlocks neurohormal activation and controls volume

Heart Failure Treatments:Types and MechanismsDiuretics and ACEiReduce load

B blockersLimit speed and Thus save energy

Heart Failure Treatments: Types and MechanismsDigitalisMotivate heart

DevicesIncrease efficiency

Role of Family Physician

Prevention

New classification of heart failureStage A: Asymptomatic with no heart damage but have risk factors for heart failureStage B: Asymptomatic but have signs of structural heart damageStage C: Have symptoms and heart damageStage D: End stage disease

ACC/AHA guidelines, 2001

Prevention 1ry prevention2ry prevention3ry prevention

1ry preventionHeart failure cant be primarily prevented but still life style modification is recommended to those who has more than one risk factor

Risk factorsHigh blood pressure.Coronary artery disease.Heart attack.Diabetes and Some diabetes medications.COPD.Sleep apnea.Obesity. Alcohol use.Tobacco use.Congenital heart defects.Valvular heart disease.Irregular heartbeats.

Life style modificationStop smoking.Stop alcohol.Check legs, ankles and feet for swelling daily.Eat a healthy diet, Restrict salt in diet.Maintain a healthy weight.Consider getting vaccinations.Control fats and cholesterol.Be active.Reduce stress.Sleep well.

2ry preventionAssessing risk factorsApplying Modified Framingham Criteria for Heart Failure diagnosisGo to specific diagnosis investigation (BNP or echo ) for definite diagnosis.

Risk factorsHigh blood pressure.Coronary artery disease.Heart attack.Diabetes and Some diabetes medications.COPD.Sleep apnea.Congenital heart defects.Valvular heart disease.Alcohol use.Tobacco use.Obesity.Irregular heartbeats.

Modified Framingham Criteria Diagnosis for Heart FailureMajor criteriaMinor criteriaNeck vein distensionPND or OrthopneaCardiomegaly on CXRAcute pulmonary edemaPulmonary ralesPositive abdominojugular test (Hepatojugular reflux)Third heart sound (S3 Gallop rhythm)

Bilateral ankle edemaNight coughDyspnea on exertionHepatomegalyPleural effusionTachycardia (> 120 beats/min)

Modified Framingham Criteria Diagnosis for Heart FailureInterpretation: heart failure diagnosis requires 1 major criteria and 2 minor criteriaEfficacy: Sensitive but not specific Test sensitivity: 97%Test specificity: 79%

Life style modificationStop smoking.Stop alcohol.Check your legs, ankles and feet for swelling daily.Eat a healthy diet, Restrict salt in your diet.Maintain a healthy weight.Consider getting vaccinations.Control fats and cholesterol.Be active.Reduce stress.Sleep well.

3ry preventionInsure good compliance to treatment.Life style modification.Appropriate timing of surgery or angioplasty for ischemic or valvular heart disease.

Home massages

Heart failure is one of the professional killer diseases.Heart failure is malignant than malignancy.The most common cause of heart failure complication is poor compliance to treatment.Asymptomatic patient with no heart damage but have risk factors for heart failure is consider to be Stage A.Main role of family physician is prevention.

REFERENCESUp To DateMayo ClinicJ M 6th editionMedscapePubmed

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