MODERN METHODS FOR TREATMENT OF HEART FAILURE

TREATMENT OF HEART FAILURE

BY ROD PRASAD

Classification (NYHA)Functional CapacityObjective AssessmentClass INo limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation (feeling heart beats), or dyspnea (shortness of breath).Class IISlight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.Class IIIMarked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.Class IVUnable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Stages of HFStage Definition Stage APresence of heart failure risk factors but no heart disease and no symptomsStage BHeart disease is present but there are no symptoms(structural changes in heart before symptoms occur)Stage CStructural heart disease is present AND symptoms have occurredStage DPresence of advanced heart disease with continued heart failuresymptoms requiring aggressive medical therapy

Stage A: Recommendations

Class I

Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF. Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardio toxic agents (chemotherapy regimens which are anthracycline based), should be controlled or avoided.

Stage BClass IIn all patients with a recent or remote history of MI or ACS and reduced EF, ACE inhibitors should be used to prevent symptomatic HF and reduce mortality. In patients intolerant of ACE inhibitors, ARBs are appropriate unless contraindicated.In all patients with a recent or remote history of MI or ACS and reduced EF, evidence-based beta blockers should be used to reduce mortality.In all patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and cardiovascular events.In patients with structural cardiac abnormalities, including LV hypertrophy, in the absence of a history of MI or ACS, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF.ACE inhibitors should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.

Stage BClass IITo prevent sudden death, placement of an ICD is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are on appropriate medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year.Class III: HarmNondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI.

Stage C (nonpharmalogical)Class IPatients with HF should receive specific education to facilitate HF self-careClass IIaSodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptomsContinuous positive airway pressure can be beneficial to increase LVEF and improve functional status in patients with HF and sleep apnea.

Stage C (Pharmacological)ACE inhibitorsAngiotensin II receptor blockersAldosterone antagonistsDiureticsBeta blockersVasodilators Digoxinanticoagulants

ACE InhibitorsAll patients with symptomatic or asymptomatic left ventricular (LV) dysfunction (LV ejection fraction 40 percent), regardless of etiology, should be started on an angiotensin converting enzyme (ACE) inhibitor, unless there is a contraindicationAction: Inhibits ACE, reduces AII formation by inhibiting conversion of AI to AIIEffects: Arteriolar and venous dilation, reduces aldosterone secretion, reduces cardiac remodellingSide effects: Cough, hyperkalemia, angioneurotic edema, allergy, rash.Contraindications: Previousangioedemaassociated with ACE inhibitor therapy, hypersensitivity to ACE inhibitors, high potassium levels, pregnancyExamples: Captopril, Enalapril, Fosinopril, Lisinopril

Angiotensin II Receptor BlockersThese drugs work similarly to ACE inhibitors to relax the blood vessels and are frequently used to replace ACE inhibitors that cause coughing.Action: provide selective blockade of AT1 receptors.Effects: similar to ACE inhibitors.Side effects: Hyperkalemia, angioneurotic edema, dizziness, stomach problems.Contraindications: hypersensitivity, certain renal disease and pregnancy.Examples: Candesartan, Eprosartan, Irbesartan Losartan, Olmesartan, Valsartan

Aldosterone Antagonists Aldosterone receptor antagonists may be used if you have heart failure and you are already taking other type of diuretic, ACE inhibitor, or a beta-blocker. Action: Blocks cytoplasmic aldosterone receptors in collecting tubules of nephron, possible membrane effect.Effects: Increased salt and water excretion, reduces remodelling, reduces mortality.Side effects: gynecomastia, impotence, menstrual abnormalities. (only spironolactone)Contraindications: Anuria, Acute kidney failure, Hyperkalema, Addison's diseaseExamples: spironolactone, eplerenone

Diuretics Neurohormonal activation results in avid salt and water retention. Loop diuretic agents are often required because of their increased potency.Action: Decreases NaCl and KCl reabsorption in thick ascending limb of the loop of HenleEffects: Increased excretion of salt and water, reduces cardiac preload and afterload, reduces pulmonary and peripheral edema.Adverse effects: electrolyte and fluid loss, hypotensionContraindications: Hypovolemia, hypokalemia, orthostatic hypotension, ototoxicity.Example: Furosemide, Bumetanide, Torsemide, Chlorothiazide, Amiloride.

Beta BlockersBeta blockers should be prescribed to all patients with stable HFrEF unless they have a contraindication to their use or are intolerant of these drugs.Action: Blockade of Beta-1 receptors, primarily located in cardiac tissue Effects: results in decreased heart rate, decreased contractility, slowed AV conduction, and suppression of automaticity.Adverse effects: fluid retention and worsening HF; fatigue; bradycardia or heart block; and hypotension.Contraindications: Hypersensitivity to the particular beta blocker agent, cardiogenic shock, severe sinus bradycardia, bronchial asthma or chronic obstructive pulmonary disease.

VasodilatorsVasodilators may be used to relax the blood vessels and decrease the workload on the heart. Used when there is ACEIs resistance or hypersensitivity.Action: Releases nitric oxide (NO)Effect: reduces preload and afterload, ventricular stretch, reduces blood pressure.Adverse effects: headache, dizziness, and gastrointestinal complaintsContraindications: avoid 5 phosphodiesterase inhibitor, excessive hypotension.Examples: Isosorbide dinitrate, Hydralazine, Nitroprusside

Digoxin Digoxin is occasionally used in the treatment of variousheart conditions, namelyatrial fibrillation,atrial flutterand sometimesheart failure.Action: Na+/K+-ATPase inhibition results in reduced Ca2+ expulsion and increased Ca2+ stored in sarcoplasmic reticulumEffect: Increases cardiac contractility, cardiac parasympathomimetic effect (slowed sinus heart rate, slowed atrioventricular conduction)Adverse effects: Nausea, vomiting, diarrhea, cardiac arrhythmiasContraindications: hypersensitivity and ventricular fibrillation.

Anticoagulant Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke.Action: activating antithrombin and accelerating the rate at which antithrombin inhibits clotting enzyme, particularly thrombin and factor Xa.Side Effects: bleeding, thrombocytopenia, osteoporosis and elevated levels of transaminases. Contraindications: patients with chronic HFrEF without AF, a prior thromboembolic event, or a cardioembolic source.Example: UHF, LMWH, bivalirudin, fondaparinux

Stage C (Invasive)

Implantable Cardioverter Defibrillators (ICD)

Cardio Resynchronization Therapy (CRT)

Implantable Cardioverter-DefibrillatorAn ICD is a battery-powered device placed under the skin that keeps track of the heart rate. Thin wires connect the ICD to the heart. If an abnormal heart rhythm is detected the device will deliver an electric shock to restore a normal.ICDs have been very useful in preventing sudden death in patients with known, sustained ventricular tachycardia or fibrillation. Studies have shown that they may have a role in preventing cardiac arrest in high-risk patients who haven't had, but are at risk for, life-threatening ventricular arrhythmias.Patients with mild to moderate symptoms of HF with LVEF 35% due either to ischemic or non ischemic etiology, there was a 23% decrease in mortality over a 5-year period.

Types of ICD

How it works?

Indications ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF of 35% or less and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for more than 1 year.Contraindications ICD is contraindicated for patients experiencing tachyarrhythmias with transient or reversible causes including, but not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance, hypoxia, or sepsis; patients who have a unipolar pacemaker implanted, patients with incessant VT or VF, and patients whose primary disorder is atrial tachyarrhythmia.

Potential ComplicationsRejection phenomenaErosion through the skinMuscle or nerve stimulationOversensingFailure to detect and/or terminate tachyarrhythmia episodesAcceleration of ventricular tachycardiaSurgical complications such as hematoma, infection, inflammation, and thrombosis.

Cardiac Resynchronization Therapy (CRT)CRT, or biventricular pacing, is used to help improve the hearts rhythm and the symptoms associated with the arrhythmia.CRT can improve ventricular contractile function, diminish secondary mitral regurgitation, reverse ventricular remodelling, and sustain improvement in LVEF.Benefits are seen in patients with NYHA class III HF symptoms and QRS duration of 120 to 130 ms. These results have included a decrease of approximately 30% in rehospitalization and reductions in all-cause mortality in the range of 24% to 36%

During a left bundle branch block, arrhythmia occurs which causes the ventricles to contract out of sync.CRT devices are able to recognizes the arrhythmia.

After sensing the arrhythmia the CRT device sends impulses through the leads to resynchronize the contraction of the ventricles.

Indications CRT can be useful for patients who have LVEF of 35% or less Life-threatening ventricular arrhythmiasAtrial tachyarrhythmiasLBBB with a QRS duration of 120 to 149 ms, and NYHA class II, III.ContraindicationsCRT is not recommended for patients with NYHA class I or II symptomsNon-LBBB pattern with QRS duration less than 150 ms.Patients with incessant VT or VF.

Potential ComplicationsMostly similar to that of ICDLead dislodgement Lead conductor fractureInsulation failureThreshold elevationExit block.

Stage DIntravenous inotropic support is a reasonable bridge therapy in patients with stage D HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation.Mechanical Circulatory Support (MCS) is beneficial in carefully selected patients with stage D HFrEF in whom definitive management (eg, cardiac transplantation) or cardiac recovery is anticipated or planned.Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management.

Inotropes Inotropes may be a necessary evil in a subset of acute heart failure patients.Mechanism of action: inhibition of phosphodiesterase, stimulation of adrenergic or dopaminergic receptors, calcium sensitization.Effect: positive inotropes increase cardiac contractilityIndication: Inotropes should be considered only in such patients with systolic dysfunction who have low cardiac index and evidence of systemic hypoperfusion and/or congestion.Contraindication: increased myocardial oxygen demand, cardiac arrhythmias, and mortality in a variety of clinical settingsTo minimize adverse effects, lower doses are preferredExamples: oral milrinone, calcium-sensitizing levosimendan

Mechanical Circulatory SupportAlso known as Ventricular Assist Devices (VAD)MCS has emerged as a viable therapeutic option for patients with advanced stage D HFrEF refractory to optimal GDMT and cardiac device intervention.VADs are effective in both the short-term (hours to days) management of acute decompensated unstable HFrEF and long term (months to years) management of stage D chronic HFrEF.Long-term strategies: bridge to transplantation,bridge to candidacydestination therapy

Total Artificial Heart Artificial hearts are typically used to bridge the time toheart transplantation, or to permanently replace the heart in case heart transplantation is impossible. It is a pneumatic, biventricular, orthotopically implanted ventricular assist device with an externalized driveline connecting it to its console. The control console can be a large box on wheels that stays beside the patient. It can also be much smaller, with attachable batteries, and worn on a belt or vest. It is powered by either compressed air or electricity.

Heartmate IIThe Heartmate II is a left ventricular assist device (LVAD) that is implanted alongside the patients native heart with the purpose of pumping for the hearts left ventricle.It is surgically implanted just below the diaphragm in the abdomen. It acts as a conduit by attaching to the left ventricle and then to the aorta.Contraindicated in people who cannot tolerate or are allergic to anticoagulation therapy.

HeartWare Ventricular Assist System with the HVAD pump

The HVAD Pump, which is implanted in the pericardial space with left ventricular apex to ascending aortic cannulation for left ventricular support.

A percutaneous driveline connects the pump to an external controller. The controller, powered by two batteries and electricity from the wall or car outlet, regulates pump function and monitors the system.Utilizes a centrifugal blood pump,

C Pulse SystemC-Pulse Heart Assist System is an extra-vascular, mechanical, implantable device. The system is designed to provide partial circulatory support for moderate to severe heart failure patients.The C-Pulse includes a non-blood-contacting cuff, ECG sensing leads, and an extracorporeal wearable battery-powered or mobile AC-powered controller/drive unit.The C-Pulse cuff pumps in rhythm with the natural heartbeat, which is monitored using the ECG sensing leads placed on the left ventricle. The C-Pulse cuff is timed to inflates during diastole and deflates before systole.

Heart Transplantation

Cardiac transplantation is considered the gold standard for the treatment of refractory end-stage HF.First successful cardiac transplantation in 1967.The most common procedure is to take a functioningheartfrom a recently deceasedorgan donor(allograft) and implant it into the patient. The patient's own heart is either removed and replaced with the donor heart (orthotopic procedure) or, less commonly, left in place to support the donor heart (heterotopic procedure).Advances in immunosuppressive therapy have vastly improved the long-term survival of transplant recipients with a 5-year post transplant survival rate of 71.7%

Absolute Contraindications Advancedkidney,lung, orliverdiseaseActive cancer if it is likely to impact the survival of the patientLife-threatening diseases unrelated toheart failureincluding acute infection or systemic disease such assystemic lupus erythematosus,sarcoidosis oramyloidosisVascular diseaseof the neck and leg arteries.High pulmonary vascular resistance

Relative contraindicationsInsulin-dependentdiabeteswith severe organ dysfunctionRecentthromboembolismsuch asstrokeSevere obesityAge over 65 years (some variation between centres) - older patients are usually evaluated on an individual basis.Active substance abuse, such as alcohol, recreational drugs ortobacco smoking (which increases the chance of lung disease)

Complications Infection,Sepsis,Organ rejection, Side-effects of the immunosuppressive medication.Recipients can acquire kidney disease from a heart transplant due to side effects of immunosuppressant medication

Case Study

A 72-year-old woman presented with shortness of breath. Three months earlier, she had begun to notice dyspnea on exertion. This dyspnea progressed to the point that she noted dyspnea at rest in the 24 hours before presentation. She had a history of long-standing mild hypertension, treated with a calcium-channel antagonist, and type 2 diabetes. She denied chest pain, lightheadedness, and abdominal or ankle swelling, although she believed that she had gained between 5 and 10 pounds in recent weeks.

What is the cause and determine the treatment ?

On examination, she had a blood pressure of 150/90 mm Hg, a regular pulse at a rate of 90 min1, jugular venous pressure of about 8 cm water, faint bibasilar crackles, a prominent and displaced apical impulse, and a summation gallop, with no murmurs, no organomegaly, or ascites, but with 1+ ankle edema.Laboratory findings were notable for a creatinine level of 2.0 mg/dL, a random blood sugar level of 220 mg/dL, and proteinuria (protein: creatinine=400 mg/g). Her ECG showed sinus rhythm, left atrial enlargement, left ventricular hypertrophy (LVH), Q waves in the inferior leads, and inferolateral ST- and T-wave changes. The ECG findings were unchanged, except for a heart rate that had increased from a tracing taken 6 months earlier. Her chest x-ray showed a mildly enlarged cardiac silhouette and questionable evidence of pulmonary venous congestion. An echocardiogram showed a moderately dilated left ventricle with increased wall thickness, inferobasilar akinesis, and an ejection fraction estimated between 30% and 35%. NT-proBNP >900 pg/mL

ECG findings

Echocardiogram Fig. 1

Fig. 2

EchocardiogramFig. 3

Fig. 4

Diagnosis

Heart Failure With Preserved Ejection Fraction (Nondilated Left Ventricle)

Treatment

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