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1 Heart Failure Heart Failure Introduction and History AHA 2015 Statistics About 6 million Americans 870,000 new cases each year 1 in 9 deaths related to HF Almost 1 million hospitalizations each year (cost of approx. $15.6 Billion) 50% die within 5 years of HF diagnosis Current mortality rate >57,000 / year Prevalence: men>women (all ages); Almost 20% of population >75 Most common DRG for patient > age 65 Etiology and Diagnosis Heart failure is a set of clinical signs and symptoms that follow injury to or dysfunction of the myocardium Symptoms: Shortness of breath Crackles Edema Fatigue or poor exercise tolerance Contributing Factors Most common contributing factors for the development of HF are: coronary artery disease hypertension 1

2 Contributing Factors Conditions that accelerate atherosclerosis Smoking Diabetes Other conditions are: hyperthyroidism, anemia, alcohol abuse, cocaine use, valvular abnormalities, rapid fluid infusion, and infectious or inflammatory processes New York Heart Assn Classification Functional Capacity Class I: No symptoms with normal activity Class II: Symptoms with ordinary activity Class III: Symptoms with less than ordinary activity Class IV: Symptoms at rest Objective Assessment No objective evidence of cardiovascular disease Evidence of minimal cardiovascular disease Objective evidence of moderately severe cardiovascular disease Evidence of severe cardiovascular disease. Two common ways of describing heart failure: Left sided heart failure vs right sided heart failure 1.Left sided heart failure versus right sided heart failure 2.Systolic versus diastolic Left sided heart failure Cardiac output decreases Pressure in the LV, left atrium and pulmonary rises Leads to pulmonary congestion, Demonstrated as dyspnea and fatigue. Left sided heart failure vs right sided heart failure Right sided heart failure leads to similar problems in the systemic venous circulation neck distension peripheral edema (and consequent weight gain) engorgement of the hepatic and gastric vessels Systolic versus diastolic * Systolic Systolic most common type occurs in about 2/3 of patients with HF Chronic volume overload Distended left ventricle Elevated LV end diastolic volume Decreased cardiac output Decreased ejection fraction; EFs less than 40%, sometimes as low as 15 20% 2

3 Systolic versus diastolic * Diastolic Stiff left ventricle that cannot fill adequately with normal filling pressures Decreased LV end diastolic volume Normal to elevated ejection fraction Systolic versus Diastolic Systolic Diastolic S3 gallop S4 Gallop Solid Tx guidelines Tx guidelines lacking Poor prognosis Better prognosis Large dilated heart Small or normal size heart, thicken left ventricle BP low to normal BP Elevated EF < 40% EF Normal or > 40% Less common in women More common in women Pathophysiology Three neurohormonal responses occur to help body try to compensate. 1. Sympathetic nervous system stimulation 2. Renin angiotensin aldosterone activation 3. Ventricular remodeling Sympathetic nervous system stimulation Baroreceptors stimulate the medulla Catecholamines are released causing vasoconstriction and increased heart rate Sympathetic nervous system stimulation can trigger arrhythmias and sudden death Sinus tachycardia is a compensatory mechanism, used to increase cardiac output Renin angiotensin aldosterone activation Ventricular Hypertrophy Promotes fluid retention. Angiotensin II is a potent vasoconstrictor which increases BP and afterload. Aldosterone causes sodium and water retention. 3

4 Ventricular remodeling Cardiac cells (myocytes) change configuration Hypertrophy yields large abnormal cells that do not contract as efficiently Shape of the ventricle changes, increases muscle mass and impairs contractility Myocardial oxygen demand increases with increased size Ventricular Remodeling Heart Failure Progression Normal Heart Injury Neurohormonal Chemicals are activated Heart Ventricular enlarging Wall stress heart wall overstretch Apoptosis Preprogrammed cell death without inflammation or scarring Certain neurohormones such as angiotensin II and catecholamines promote apoptosis Neurohormones Atrial natriuretic peptide (ANP) Brain natriuretic peptide (BNP) Neurohormones Both ANP and BNP promote vasodilatation, reduce sodium and water retention, and inhibit sympathetic tones Limit cardiac hypertrophy and remodeling Neurohormones Nesiritide is a commercially prepared form of BNP Given IV for severe decompensated HF 4

5 Neurohormones BNP Test is used for patients that present to Emergency Room with shortness of breath Test helps differentiate between HF and respiratory problems such as COPD or pneumonia Results in 15 minutes BNP Results BNP< 100 pg/ml, not heart failure BNP pg/ml. probably heart failure, compensated BNP > 500 decompensated heart failure BNP > 1000, only due to heart failure N Terminal probnp (NT probnp) Age related Diuretics given to reduce fluid overload Age < 50 Age Age > pg/ml 900 pg/ml 1800 pg/ml Loop diuretics furosemide, bumetanide Continuous infusion vs. intermittent dosing On average a 5 10 fold increase over previous measures. spironolactone reserved for NY class III or IV Angiotensin Converting Enzyme (ACE) Inhibitors often given in conjunction with the diuretics. captopril, enalapril, lisinopril Beta Adrenergic Blockers use in combination with diuretics and ACE Inhibitors For NYHA class I through III heart failure Do not use with class IV heart failure, asthma or other pulmonary disease, or severe bradycardia or conduction problem Carvedilol, metoprolol only two FDA approved for HF 5

6 Cardiac Glycosides Digoxin Used to treat sinus tachycardia Angiotensin II Blockers usually used if patient cannot take ACE Inhibitors Losartan, valsartan Vasodilators isosorbide Positive inotropic agents Dobutamine, usually used for short term therapy Milrinone (a phosphodiesterase inhibitor Nesiritide acute only, not long term Calcium Channel Blockers Amlodipine, felodipine Anticoagulants warfarin 6

7 Other agents Lipid agents Thiamine Coenzyme Q Vitamin E Vitamin C Magnesium Treatments: Ultrafiltration Therapy to remove excess salt and water from patients with fluid overload. Adjunct to diuretics or when diuretics fail to work effectively. (Hold diuretics during the procedure.) Removes isotonic fluid therefore removes more sodium than diuretics. Treatments: Ultrafiltration Left sided failure Typically pull 250 cc/hr for 24 hours (6 Liters) Right side failure Typically pull 100 cc/hr Treatments: Mechanical Pacers Dual chamber, biventricular VADs Ventricular assist device Bridge to transplant or destination therapy Examples: Jarvik 2000, Heartmate 2 Treatments: Mechanical Jarvik 2000 Heartmate 2 Device in body Heartmate and Jarvik 2000 Battery Pack 7

8 CABG Transplantation Treatment: Surgical CorCap Cardiac Support Device (CSD) A unique fabric device, surgically positioned around the heart Intended for patients with enlarged hearts Paracor Device C Pulse Experimental Treatment Angiogenesis the growth of new blood vessels Stem cell research Patient Education Primary Prevention Prevent coronary artery disease Manage lifestyle risk factors 8

9 Patient Education Secondary Prevention Support MI patients aggressive treatment to limit infarct size Patient Education Tertiary Care Prevent HF progression Prevent recurrent MI Recurrent MI pts have more LV dysfunction, HF & increased mortality Prevent post MI CHF (Use of ACE I in therapeutic ranges) Patient Education Goal prevent fluid retention so your heart does not have to work so hard Take medications every day Eat less salt Drink less fluid if your doctor recommends it Weigh yourself everyday Patient Education continued Follow a heart healthy lifestyle Stop smoking If overweight, limit your caloric intake Avoid or reduce alcohol Increase your physical activity If you are diabetic or have other health problems, try to keep them under control Keep all doctor appointments Patient Education continued Call your health care provider when problems occur Unexplained weight gain of three pounds in a day or 5 pounds in a week Swelling in ankles, feet, legs, or abdomen has worsened Shortness of breath has worsened, especially when lying flat Fast heart rate (over 120) Constant dizziness or lightheadedness Respiratory infection or cough that has worsened Cardiomyopathy Definition Any heart muscle disease of unknown origin Structural or functional abnormality Primary or secondary 9

10 Primary Secondary Unknown cause Only myocardium is affected Caused by another condition Examples: Ischemia, ETOH, AIDS, pregnancy Types of Cardiomyopathies Dilated Hypertrophic Restrictive Dilated Cardiomyopathies Most common type Problem with contraction Progressive deterioration Normal Heart Dilated Heart 10

11 Dilated 4 Dominant Features Ventricular dilation Impaired systolic function Atrial enlargement Stasis of blood in the left ventricle Clinical Presentation Asymptomatic Fatigue, weakness, dyspnea DOE, orthopnea, PND, chest pain S3, S4 Dilated Cardiomyopathy Physical Findings Narrow pulse pressure (difference between systolic and diastolic pressures) Dilated Cardiomyopathy Tests CXR ECG Echo Cardiac cath?? Holter monitor Goals Reduce workload of heart Decrease symptoms of heart failure Pharmacological treatments Digoxin Diuretics Nitrates ACE Inhibitors Beta Blockers Anticoagulants 11

12 If all else fails.. Possible candidate for transplant Hypertrophic Cardiomyopathy 4 Dominant features Ventricular hypertrophy Rapid contraction of left ventricle Impaired relaxation Intracavity systolic pressure gradient Dilated vs. Hypertrophy Dilated cardiomyopathy Problem with contraction Hypertrophic cardiomyopathy Problem with relaxation Hypertrophic Cardiomyopathy Clinical presentation Dyspnea, fatigue, angina, syncope Some people are asymptomatic Sudden death teens and young adults Hypertrophic Cardiomyopathy Physical Findings Systolic murmur Abrupt arterial pulses Split S2 S3, S4 CXR, usually normal ECG Echo Thallium Scan Cardiac Cath Diagnostic Tests 12

13 Goals Decrease force of contraction Decrease outflow obstruction Pharmacological treatments Beta Blockers Calcium antagonists Amiodarone Septal Myotomy Surgical Treatments Restrictive Cardiomyopathy Least common type Abnormality of relaxation Clinical Presentation Dyspnea, fatigue, angina, syncope Exercise intolerance Peripheral Edema Elevated CVP Ascites S3, S4 Physical Findings 13

14 Diagnostic Tests Goals CXR ECG Echo CT Scan Treatment is palliative Pharmacological treatments Diuretics Anticoagulants if in a fib Anti dysrhythmic medications Medical Treatment Sodium and water restrictions Pacemaker Surgical Treatments Excision of Endocardium Mitral or tricuspid valve replacement Cardiac Transplantation Candidacy requirements Medical conditions Age Pre existing conditions Contraindications Infection Malignancy 14