HEART FAILURE
Prevalence increasing in our ageing population
Incidence doubles with each decade between 40 and 80
At any age more common in men than women
One of the commonest causes of hospital admission
Heart Failure
1. A cardiac disorder that prohibits delivery of sufficient output to meet the perfusion requirements of metabolizing tissues
2. A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic and hormonal responses
Causes of heart failure
• Coronary artery disease
• Hypertension
• Cardiomyopathy
• Valvular heart disease
• Other causes
Heart failure: aggravating factors
• Cardiac arrhythmias (esp AF)
• Hypertension
• Anaemia
• Chest infection
Sympatho-adrenalactivation
Renin-angiotensinactivation
Redistribution ofvenous flow
Salt and waterretention
Ventricular dilatation
Inotropic state
Myocardial mass
Contractile Function
Compensatory Physiology in Heart failure
Heart failure: symptoms and signs
Symptoms Signscardiac output fatigue cool skin
(peripheral hypoperfusion) peripheral cyanosis
Fluid retention dyspnoea basal crackles
(congestion) oedema JVP ankle swelling, ascites
sympathetic activity - tachycardiasweating
Other findings - S3, alternating pulse
S3
Heart failure: S3, alternating pulse
Heart failure: ECG (never normal)
Inferior Q waves
Anterior T wave + ectopics
Left bundle branch block
Heart failure: CXR
Pulmonary congestion Pulmonary oedema
Heart failure: m-mode echo
Cardiomyopathy:global LV dysfunction
Coronary heart disease:regional LV dysfunction
S3
Heart failure: 2D echo
LV
LV
LA
LARA
RVRV
4 chamber view
Long axis view
Heart failure: brain natriuretic peptide (BNP)
Secreted by myocardial cells in response to raised left atrial pressure
• Promote natriuresis, vasodilatation
• Inhibit ADH and aldosterone release
• Levels >50pg/ml indicate heart disease as cause of dyspnoea and fluid retention
Heart failure: Complications
• Intravascular thrombosis
– pulmonary embolism– systemic embolism
• Infection– chest infection– ulcerated cellulitic legs
• Functional valvular dysfunction– MR, TR
• Multi-organ failure– renal failure– liver failure
• Cardiac Arrhythmias– AF– VT VF
• Sudden death
Heart failure: non-drug treatment
• Severely oedematous patient– bed rest– nurse in head up position– oxygen therapy– aspiration of large pleural effusions– salt restriction
• Ambulant patient– no added salt– regular walking exercise
Heart failure: treat aggravating factors
• Atrial fibrillation
– rate control + warfarin
– DC cardioversion
• Hypertension
– ACE-Is + beta blockers + diuretics
• Anaemia
– haematinics
– erythropoetin (?)
– blood transfusion (?)
• Chest infection
– physiotherapy
– antibiotics
Sympatho-adrenalactivation
Renin-angiotensinactivation
Redistribution ofvenous flow
Salt and waterretention
Ventricular dilatation
Inotropic state
Myocardial mass
Contractile Function
Treatment of Heart failure
Beta-blockers ACE-Is, ARBsSpironolactone
Beta-blockers
Carvedilol in theCOPERNICUS trial
Circulation 2002
ACE-Inhibitors
Meta-analysis of allrandomized trials
Lancet 2000
Spironolactone
RALES trialNEJM 1999
ARBs Losartan in ELITE II
Lancet 2000
Treatment of Heart failure: Evidence base
ACE-I
Placebo
Losartan
Captopril
Heart failure: treatment
• Fluid retention– diuretics
• Symptoms and prognosis in systolic heart failure•Drugs– ACE-Is (all grades of heart failure)– ARBs (if ACE-Is cannot be tolerated)– beta-blockers (all grades of heart failure)– spironolactone (NYHA grade III and IV only)
•Devices– Cardiac resynchronization therapy (CRT)
Heart failure: treatment ofcomplications
•Atrial fibrillation– cardioversion (often not possible) – rate control (beta-blockers ± digoxin)– warfarin
•Ventricular arrhythmias– implantable defibrillator
Canadian Implantable Defibrillator Study
Circulation 2004
Heart Transplantation
• Indications: resistant ccf without:
– major organ failure– major co-morbidity– psychological disability– severe pulmonary hypertension
• Procedure– orthotopic transplant
• Prognosis– 80% 1 year survival
Prognosis of Heart Failure
The End
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