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Systolic Heart Systolic Heart FailureFailure

Eugene Yevstratov MDEugene Yevstratov MD

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DefinitionDefinition Inability to pump an adequate

volume of blood and/or to do so only from an abnormally elevated filling pressure,is that heart failure, can be caused by an abnormality in systolic function leading to a defect in the expulsion of blood i.e.

Systolic Heart Failure

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CausesCauses

•Coronary artery diseaseCoronary artery disease•Valvular heart diseaseValvular heart disease•Hypertension and agingHypertension and aging•DiabetesDiabetes•Dilated cardiomyopathyDilated cardiomyopathy

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NYHA classification of heart failure symptoms

• Class 1Class 1: No limitations, ordinary physical : No limitations, ordinary physical activity does not cause undue fatige, activity does not cause undue fatige, dyspnoea or palpitation (asymptomatic dyspnoea or palpitation (asymptomatic LVD)LVD)

• Class 2Class 2: Slight limitation of physical : Slight limitation of physical activity, such patients are comfortable at activity, such patients are comfortable at rest (symptomatically ¨mild¨heart failure)rest (symptomatically ¨mild¨heart failure)

• Class 3Class 3: Marked limitation od physical : Marked limitation od physical activityactivity,, less then ordinary physical less then ordinary physical activity will lead to symptoms activity will lead to symptoms

(symptomatilcally ¨moderade¨heart (symptomatilcally ¨moderade¨heart failure)failure)

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Echo Morphological ClassificationEcho Morphological Classification•Segmental dysfunctionSegmental dysfunction Focal scarring/dyskinesis most

likely ischemic origin,but significant regional asymmetry (even without LBBB) often seen in DCM

•Global dysfunctionGlobal dysfunction May be due to any of the causes of

systolic dysfunction, including CAD

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SHF vs Normal Heart SHF vs Normal Heart ValueValue• End diastolic volume 135 End diastolic volume 135

mVm2 (N80)mVm2 (N80)• End Systolic volume 105 End Systolic volume 105

ml/m2 (N40)ml/m2 (N40)• Stroke volume 30 ml/m2 (N40)Stroke volume 30 ml/m2 (N40)• Ejection fraction 20 % (N50)Ejection fraction 20 % (N50)• End diastolic pressure 25 End diastolic pressure 25

mmHg (N10)mmHg (N10)

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Left ventricular Left ventricular systolic systolic dysfunction is dysfunction is defined as an defined as an ejection fraction ejection fraction of less than 40%of less than 40%

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Clinical SymptomsClinical Symptoms

• DyspnoeaDyspnoea• FatigueFatigue• Periferal oedemaPeriferal oedema• OrthopnoeaOrthopnoea• Paroxysmal nocturnal dyspnoeaParoxysmal nocturnal dyspnoea

Hallmark symptoms

Spesific symptoms

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Nearly 50% of patients Nearly 50% of patients with heart failure die with heart failure die within five years of within five years of the onest of the onest of symptomssymptoms

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Identification of SHFIdentification of SHF

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CAD producing CAD producing ischemic ischemic cardiomyopathy is cardiomyopathy is the most common the most common cause of left cause of left ventricular systolic ventricular systolic dysfunctiondysfunction

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PhysiologyPhysiology

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PreloadPreload

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AfterloadAfterload

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Pressure overload Volume overload

Increased SP Increased DP

Icreased Sσ Icreased Dσ

Parallel addition of new myofibrils

Series addition of new safcomeres

Wall thickening Chamber enlargement

Concentric hypertrophy Eccentric hypertophy

+

-

-

normal

LV LV remodelingremodeling

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Ventricular HypertrophyVentricular Hypertrophy3

1

435

2

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Systolic vs Diastolic DysfunctionSystolic vs Diastolic Dysfunction

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•DiureticsDiuretics•Positive Inotropics DrugsPositive Inotropics Drugs•Direct-Acting VasodilatorsDirect-Acting Vasodilators•Neurohormonal Neurohormonal

AntagonistsAntagonists

Treatment of SHFTreatment of SHF

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Treatment of SHFTreatment of SHF

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Tailored Therapy for Tailored Therapy for Advanced Heart Advanced Heart FailureFailure•IV nitroprusside and diuretics

tailored to hemodynamics goals

PCW <15mmHg

•Measurment of baseline hemodynamics

SVR< 1200 dynes/s/cm-5

RA < 8mmHg

SBP > 80 mmHg

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•Definition of optional hemodynamics by 23 – 48 hours

•Titration of high-dose oral vasodilators as nitroprusside weaned

(combination of captopril, ISDN, hydralazine as needed as alternative or addition)

•Monitored ambulation and diuretic adjustment for 24 – 48 hours

•Maintain digoxin levels 1.0 – 2.0 ng/dl if no contraindication

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Eugene Yevstratov MDEugene Yevstratov MD