Congestive Heart Failure

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Congestive Heart Failure

• Dr Ian Coombes
• Adopted from Duncan McRobbie
• Principal Clinical Pharmacist (with permission)

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Signs and Symptoms
NYHA Classification

• fatigue
• exertional dyspnoea
• orthopnoea
• PND
• cardiomegaly
• pitting oedema
• crackles
• raised JVP

• NYHA I - no limitation of physical activity
• NYHA II- slight limitation
• NYHA III - marked limitation
• NYHA IV - inability to carry out physical
  activity

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Causes

• acute MI
• hypertension
• toxins (alcohol, cytotoxics)
• viruses/bacteria
• valve disease
• cardiomyopathies

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Prevalence

• 1-2 population
• 3-5 of those gt65 years of age
• 10 of those gt80 years
• 50 patients die within 2 years of diagnosis
• 65 of patients with severe CHF die within 1 yr

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Survival After Initial Diagnosis of HF
100
50
0
3 months
18 months
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Hospitalisations

• 74,500 hospital admissions in 2000/2001
• Length of stay gt 13 days (3x average LOS)
• 1,000,000 in-patient days
• Admission rates projected to increase by gt50
  over the next 25 years
• Readmission rates as high as 50 over 3 months

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Readmission - causes
Over 50 preventable
Erhardt and Cline 1998 (Lancet)
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Signs and Symptoms
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Classifying Heart Failure the New York Heart
Association method

• NYHA I
• No symptoms with ordinary physical activity
  (walking and climbing
• stairs)
• NYHA II (mild)
• Slight limitation of activity with dyspnoea on
  moderate to severe activity (climbing
• stairs or walking uphill)
• NYHA III (moderate)
• Marked limitation of activity. Less than ordinary
  activity causes dyspnoea
• (restricting walking distance and limiting
  climbing to one flight of stairs)
• NYHA IV (severe)
• Severe disability, dyspnoea at rest (unable to
  carry out physical activity without
• discomfort)

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Rules of HF
Remember
symptoms haemodynamics symptoms
survival
Remember COSVxHR BPTPRxCO
Remember Starlings Law preload force of
contraction Lapaces Law large heart
inefficient
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Neurohormonal model of Heart Failure
Sympathetic Response
afterload
cardiac workload
arterio- constriction
nor- epinephrine
cardiac output
aortic blood flow
SNS
Remember CO SV x HR
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Neurohormonal model of Heart Failure
renin-angiotensin-aldosterone
preload
afterload
cardiac workload
Na and H2O retention
arterio- constriction
Remember Starlings Law
aldosterone
cardiac output
remodelling
Renal blood flow
veno- constriction
RAS
angiotensin
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Treatment of Heart Failure
Remember Survival drug treatment
preload
afterload
hydralazine
cardiac workload
diuretics
Na and H2O retention
arterio- constriction
digoxin
spironolactone
aldosterone
nor- epinephrine
cardiac output
nitrates
aortic blood flow
Renal blood flow
veno- constriction
RAS
B-blockers
SNS
ACE-I
angiotensin
naturetic peptides
NEP-I
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Role of Diuretics

• Side effects
• dehydration
• hypotension
• hypokalaemia
• hypomagnesaemia
• hypouricaemia and gout
• non-compliance issues

• loops most effective
• symptomatic relief
• Na retention
• H2O loss
• preload ( ventricle filling pressure)
• afterload (arterial dilatation)

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Role of ACE-inhibitors

• improves mortality (CONSENSUS)
• better than vasodilator therapy (VeHFT I and II)
• large well conducted trials
• preload (inhibits effect)
• afterload (inhibits vasoconstriction)

• Side effects
• hypotension (6)
• hyperkalaemia (6)
• cough (40)
• dizziness (50)
• raised serum creatinine (0.2)

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Circulating Renin-Angiotensin System
angiotensinogen
renin
A C E
Ang II
Ang I
AT1/AT2 receptors
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Potential Role of Angiotensin (1-7)
angiotensinogen
renin
N E P
Ang (1-7)
Ang I
ACE
Ang II
AT1
AT2
ATx
pressor trophic antinatriuretic
depressor antitrophic natriuretic
depressor antitrophic natriuretic
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Potential Role of Angiotensin (1-7)
angiotensinogen
ACE inhibitor
renin
N E P
A C E
Ang (1-7)
Ang (1-5)
Ang I
ACE inhibitor
ACE
Ang II
AT1
AT2
ATx
pressor trophic antinatriuretic
depressor antitrophic natriuretic
depressor antitrophic natriuretic
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Landmark trials with ACE inhibitors in HF
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Role of ARBs

• improves mortality (ELITE I and II / CHARM)
• added into conventional therapy (ValHeft / CHARM)
• Less s/es

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Role of Beta blockers

• improves mortality (CIBIS 2)
• added into conventional therapy
• attenuates sympathetic drive (outweighs -ve
  ionotropic effect)
• not all beta-blockers are equivalent (bisoprolol
  and carvedilol best supported by evidence)

• Side effects
• hypotension
• bradycardia
• peripheral vasoconstriction
• impotence
• bronchospasm

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Role of vasodilator therapy

• preload
• (venodilators - nitrates)
• afterload
• (arterial dilators - prazosin)
• large trials show good benefit but lots of side
  effects

• Side effects
• hypotension
• headache
• tachycardia
• SLE (hydralazine)

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Role of Digoxin

• used in initial trials
• myocardial contractility
• lost favour because of toxicity
• renally cleared - dependent on age, weight RF

• Side effects
• anorexia
• N,V,D
• abdominal pain
• visual disturbances
• drowsiness
• arrythmias
• heart block

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Role of spironolactone

• improves mortality (RALES)
• added into conventional therapy
• attenuates aldosterone effect
• only small doses required

• Side effects
• hyperkalaemia
• gi disturbances
• impotence
• gynocomastia
• rash

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Adjunct Therapy

• Digoxin in SR
• DIG trial no mortality benefit but reduction in
  hospitalisations and improved symptoms
• useful in symptomatic patients where other drug
  therapy is optimised
• should not be withdrawn from pts with HF
• Anticoagulation
• if prolonged bed rest prophylactic heparin
• if LV dilatation / thrombus chronic warfarin
  therapy

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Mortality remains high

• ACEi Risk reduction 35 (mortality and
  hospitalizations)
• ? Blockers Risk reduction 38 (mortality and
  hospitalizations)
• Oral nitrates and hydralazineBenefit vs.
  placebo inferior to enalapril (mortality)

However 4-year mortality remains 40
Davies et al. BMJ 2000320428-431 Gibbs et
al. BMJ 2000320495-498
Davies et al. BMJ 2000320428-431 Gibbs et
al. BMJ 2000320495-498
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Role of other treatments

• ?? Ca channel antagonists - -ve ionotropic,
  amlodipine appears safe
• ?? other antiarrythmics -
• dobutamine - increases CO, but palliative
• Levosimendan- severe CHF
• naturetic peptide inhibitors / recombinant
  naturetic peptides- omapatrilat / neseritide
• Biventricular pacing - severe CHF high cost
• transplantation - 85 survival _at_ 5yrs

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Congestive cardiac failurePharmaceutical Care
Plan
Need for Drug Diagnosis of CHF Selection of
Specific Drug Symptom control - diuretics
Decrease mortality ACE,
B-blockers Co-modibdity anticoagulation
Patient factors Selection of Regimen Loading
doses, maintenance dose Drug
factors Provision of Drug Timely,
accurate Administration of Drug Timing,
food Monitor Effectiveness Symptoms,
pulse,cholesterol, side effects Counsel /
Educate Expected effects, side
effects Risks vs benefits Evaluate
Effectiveness Beneficial effects gt detrimental
effects??