HEART FAILURE. Study day November 2017 Sarah Briggs and Janet Laing

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1 HEART FAILURE Study day November 2017 Sarah Briggs and Janet Laing

2 Overview and Introduction This course is an introduction and overview of heart failure. Normal heart function and basic pathophysiology of heart failure is explained. This will be then related to the diagnosis of heart failure and to the overall management of patients with heart failure. Device therapy will be explained, and also finally we will have discussion session about palliative care and heart failure.

3 Demographics of heart failure Heart failure is serious Heart failure is terminal Heart failure is unpredictable Heart failure causes severe symptoms Heart failure outcomes are directly linked to good management and self monitoring. You can make a profound difference to a patient s life

4 Plan of the Day The normal heart Pathophysiology of heart failure Clinical presentation: History, assessment and clinical examination Differential diagnosis, Investigations and Diagnosis Pharmacological Management Non medical Management Palliative care Device therapy

5 1. The Normal Heart

6 1. Normal Heart Function The Cardiac Circulation The Cardiac Valves The Coronary Circulation The Cardiac Electrical System

7 The Heart = A house!

8 Coronary circulation

9 Coronary circulation

10 2. Pathophysiology of Heart Failure

11 2. Pathophysiology of heart failure The two types of heart failure affecting the left ventricle. HFrEF can t pump HFPEF can t relax

12 2. Pathophysiology of heart failure Causes: Myocardial Infarction

13 Ischaemia

14 2. Pathophysiology of heart failure Causes: Hypertension and aortic stenosis

15 Hypertension

16 Hypertension

17 Aortic Stenosis

18 Left Ventricular Hypertrophy

19 Other causes include: Mitral regurgitation Atrial fibrillation Cardiomyopathies Chemotherapy.

20 Neurohormonal Activation Increased Sympathetic activation Reduction in renal perfusion results in activation of the RAAs Brain natriuretic peptide release

21 Neurohormonal Activation

22 The Natriuretic Peptide System

23

24 Heart failure is unpredictable!

25 3. History, Assessment and Clinical Examination

26 History Presenting Complaint: History of Presenting Complaint: Past Medical History:

27 Its Systemic Fatigue Cool extremities Pallor Heavy leaden legs Renal dysfunction Anaemia Acute/increasing breathlessness Presents/punctuated with unpredictable episodes of fluid retention..

28 3. Clinical Presentation Signs of Heart Failure - General Appearance distress, gait, mobility, colour, pallor, tachypnoea, breathlessness, audible breath sounds,habitus, Tachycardia/irregular Hypertension/hypotension Pallor/mallor flush Elevated JVP (>5cm) Heart Sounds third heart sound Added Breath Sounds Crepitations/wheeze Abdominal distension Oedema legs/sacral

29 Elevated JVP

30 Crepitations

31 Pulmonary Oedema

32 Ascites

33 Pitting Oedema

34 The Burden of Heart Failure

35 Warning Signs

36 Weight Gain!!

37 Lets Talk about it!!...

38 5. Differential Diagnoses

39 ??? Is it? Chest infection/pneumonia? Pulmonary Embolism? COPD? N/AFLD? Obesity? Reduced Venous Return? Lymphoedema? Or is it? Heart Failure?

40 6. Investigation

41 Investigations BNP ECHO ECG CXR Holter monitor 24hour BP Also Cardiac MR, MPS, Angiography

42 7. Diagnosis

43 Heart Failure?? Lets review the ECHO

44 8. Pharmacological Management

45 Neurohormonal deactivation 1. Adrenaline Beta Blockers Dose Side Effects Monitoring

46 Neurohormonal Deactivation 2. Angiotensin II ACE Inhibition Dose Side Effects Monitoring

47 ARNI Angiotensin receptor/neprilysn Inhibition

48 ARNI

49 Neurohormonal Deactivation 3. Aldosterone MRA Dose Side Effects Monitoring

50 Symptomatic management Diuretics Loop/thiazide Dose Side Effects Monitoring

51 Other Pharmacological agents and contraindications Digoxin Oral Anticoagulations NOACS Ivabradine Antianginals Antihypertensives Palliative Medications Contraindications

52 9. Non Pharmacological Management

53 Non Pharmacological Management Anxiety/stress management Depression/low mood Support Groups Telehealth Salt intake Fluid intake Dry mouth

54 Non Pharmacological Management Exercise General weight management Smoking, alcohol Fatigue management goal setting Sleep Caffeine intake Vaccinations Holidays

55 11. Palliative Care

56 10. Device Therapy

57 CRT and ICD NYHA class QRS interval I II III IV <120 milliseconds ICD if there is a high risk of sudden cardiac death ICD and CRT not clinically indicated milliseconds without LBBB ICD ICD ICD CRT-P milliseconds with LBBB ICD CRT-D CRT-P or CRT-D CRT-P 150 milliseconds with or without LBBB CRT-D CRT-D CRT-P or CRT-D CRT-P LBBB, left bundle branch block; NYHA, New York Heart Association

58

59 CRT

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