Congestive Heart Failure The Road to Recovery Philip D Houck M.D.

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Determinants of Myocardial Performance

• Afterload - The resistance to flow. The size of
  the arterioles.
• Which patient has the highest afterload? (A)
  120/80
• (B) 220/80

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Determinants of Myocardial Performance

• Which patient has the highest afterload?
  (A) 120/80
• (B) 220/80
• (A) - EF 15 Pulmonary Edema cool skin
• (B) - 15 y/o 18 min. of Bruce ETT

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Determinants of Myocardial Performance

• Which patient has the highest afterload? (A)
  120/80
• (A) - EF 15 Pulmonary Edema cool skin cardiac
  out put is 3 l/min

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Determinants of Myocardial Performance

• Afterload SVR (Mean BP - CVP) 80/CO
• (A) - EF 15 Pulmonary Edema cool skin SVR
  (93.3-10)80/3 2222
• (B) - 15 y/o 18 min. of Bruce ETT
• SVR (126.6-5)80/20 486

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Determinants of Myocardial Performance

• Afterload SVR (Mean BP - CVP) 80/CO
• or
• Cardiac output Mean BP80/SVR
• Cardiac output in patients even with low blood
  pressure can be increased by lowering SVR
• Do not be afraid of gradually increasing ACEI
• Cardiac output should be high
• More medication is therefore good

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Determinants of Myocardial Performance

• Afterload - The resistance to flow
• How do we decrease Afterload?

Vasodilators Nitroprusside, Natrecor
ACEI / ARB
Hydralazine/Nitrates Mechanical Balloon Pump
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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium

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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium
• How is contractility increased?
• The only oral agent - Digoxin
• IV - Beta Agonist - Epinephrine Dopamine
  Levophed Dobtuamine Isuprel
• - Phosphodiesterase Inhibitors -
  Amrinone Milrinone
• Viagra

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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill

Pericardium
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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill

LVH, infiltrative excess calcium
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Diastolic Heart Failure
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15
5
vol1
vol2
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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill.
• How can we improve Compliance?
• Natrecor
• Spironolactone
• Ranolazine

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Physical Exam

• Preload JVD (R), S3 and/or rales (L)
• Afterload Carotid pulse (L), systolic pulmonary
  artery tap (R)
• Contractility PMI (L)
• Compliance S4 (R)
• These simple physical findings should completely
  describe the hearts performance
• and determines the medications that help

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Equation of Life

• CO X Hgb O2 consumption / AV O2 difference
• Cardiac output X Hemoglobin
• The lower the blood count the higher the cardiac
  output
• You can compensate for lower cardiac output by
  having a higher blood counts
• Anemia (low blood count) is associated with CHF

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Physical Examfor the equation of LIFE
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How do CHF Patients suffer as they die?

• Wide range of symptoms, which were frequently
  distressing and often lasted greater than 6
  months
• Pain was most common in 50
• Dyspnea was second most common
• Low mood, anxiety
• urinary incontinence

Living and dying with heart failure the role of
palliative care Gibbs, McCoy,Gibbs,Rogers,
Addington-Hall Heart 200288(supplII)ii36-ii39
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How do your CHF Patients die?

• Ventricular tachycardia/fibrillation
• Pulseless electrical activity after a
  defibrillator shock
• Pump failure low output
• Sepsis from GI track due to bowel ischemia
• Congestion and respiratory failure
• Infection from skin breakdown
• Liver or kidney failure
• Inadequate reserve to meet extra demand

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CHF patients can choose their mode of death

• 28 of deaths can be avoided by defibrillator
  therapy
• The mode of death changes to PEA, low out put,
  congestion or organ failure, failure to meet
  increase demands
• Defibrillators are not for everyone

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Strongest indicators of in-hospital death
Risk factor BUN (mg/dL) Systolic BP (mm Hg) Creatinine (mg/dL)
Predictive level gt43 lt115 gt2.75
Fonarow GC et al. JAMA 2005 293572-580.
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Heart Failure in Women Overview

• Affects older women disproportionately
• Risk factors include hypertension, diabetes,
  obesity
• More likely to have heart failure with preserved
  systolic function
• Better prognosis than in men
• Worrisome evidence of lesser responsiveness to
  ACE inhibitors similar responsiveness to
  b-blockers

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Heart Failure in African Americans Overview

• Affects 3 of the African American population
• Atypical natural history
• Unique epidemiology
• Lower incidence of associated epicardial coronary
  artery disease
• More likely to be associated with a historyof
  hypertension
• Worrisome prognosis
• Higher rate of hospitalization
• Likely to have similar mortality risk
• Question of altered responses to medical therapy

Yancy CW. J Card Fail. 20006183186.
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Heart Failure in African Americans Etiology

• Unique natural history
• Occurs at an earlier age
• Associated with more advanced left ventricular
  dysfunction at time of diagnosis
• Worse clinical class at time of diagnosis
• Higher incidence of left ventricular hypertrophy,
  especially concentric hypertrophy
• Lack of definitive relationship between
  psychosocial factors and onset of disease

Yancy CW. J Card Fail. 20006183186.
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Etiology of Heart Failure inAfrican Americans
Patients With Coronary Artery Disease-Based HF
80
60
40
Percent
20
0
V-HeFT I
V-HeFT II
SOLVD
US Carv
BEST
MERIT-HF
Patients With Hypertension-Based HF
80
60
Percent
40
20
0
V-HeFT I
V-HeFT II
SOLVD
US Carv
BEST
MERIT-HF
AA
non-AA
The BEST Investigators. N Engl J Med.
200134416591657 Packer M et al. N Engl J Med.
199633413491355 MERIT-HF Study Group. Lancet.
199935320012007 Cohn JN et al. N Engl J Med.
198631415471552Cohn JN et al. N Engl J Med.
1991325303310 The SOLVD Investigators. N Engl
J Med. 1991325293302.
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Pearls
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Pearls

• Dizziness - reduce, D/C diuretics
• Look for exacerbation reasons ( atrial
  arrhythmia, anemia, non-compliance)
• CHF drives salt and fluid cravings - constantly
  remind your patients -daily weight
• avoid NSAIDs (Advil Motrin)
• erythropoiten is very good
• Add Hydralazine/nitrates for failures consider
  ARB addition to ACE

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How do you titrate all the medications?And what
order?
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Pearls
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Patient Flow

• Hand off between hospital and out patient therapy
• Titrate medications with compliance D/C
  Diuretic
• Educate in salt, potassium, fluid balance, and
  weight
• Not getting better Bi V Defibrillator
• equation of life
• Monitor for non compliance social/economic
  issue
• Hydralazine /nitrate or ARB
• Consider Geometric solutions control of ectopy
• Prometheus EECP and stem Cells Co Q 10
• Look for new endocrine failures for hypotension
• Statins Statins Statins
• Back off - Hospice or Transplant

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Patient seems well with persistently elevated BNP
BNP Brain Naturetic Peptide - a Heart Hormone lt
120 heart is happy Can be compensated when
elevated Know your number
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Last Pearl

• Good is Better
• The Enemy of Good is Better
• i.e. -Watermelon Syncope

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Impella LV Assist Device
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External Counterpulsation
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Cardiac Transplantation
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Ventricular assist device
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Stem Cells the Future

• Regenerative Medicine
• Control of Inflammation
• Electrical Remodeling
• The future is now Exercise increases stem cells

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Summary

• Heart failure is expensive and causes suffering
• Heart Failure can improve with good life quality
• Patients need to have good nutrition and avoid
  excess salt, fluids, calories
• Patients need to take medications as prescribed
  and understand their purpose
• Exercise 1 hour per day
• Help your Doctors Nurses Dieticians with your
  complaints and work together for a solution
• If these simple instructions are followed
  expensive operations might be avoided