Heart Failure

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HEART FAILURE
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Definition of Heart Failure

• Heart failure is a pathophysiological state of
  heart in which, the heart cannot pump enough
  blood to meet the needs required by the
  metabolizing tissue, or to do so only from an
  elevated filling pressure.
• Classification

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Etiological Causes of Heart Failure

• Myocardial damage myocardial ischemia,
  inflammation etc.
• Increased cardiac load
• Increased preload congenital heart diseases with
  left to right shunt.
• Increased afterload hypertension, stenosis of
  cardiac valves.
• Disturbance of the diastolic filling
  constrictive pericarditis, hypertrophic
  cardiomyopathy, etc.

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Pathophysiology

• Compensation ? Decompensation
• Adaptive mechanisms
• Frank-Starling mechanism
• Decreased cardiac ejection fraction ? increased
  ventricular end diastolic volume and pressure
  (LVEDP) ? elongation of the myocardial fiber ?
  increased contractility of the myocardium ?
  restoration of the ejection fraction

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Adjustment of neuro-endocrine systems

• Sympathetic activation
• Increased contractility of the myocardium
• Elevation of norepinephrine blood level
• Down regulation of ?1 receptor
• Activation of RAAS
• Others

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  --???????????,ß??????,???????,??????,????,?????---
  ??????,?????
• ?????????

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Clinical Manifestation

• Three aspects
• 1.general manifestation
• 2. manifestation of Left heart failure polypnea
• dyspnea , signs of pulmonary congestion etc.
• 3. manifestation of right heart failure general
  edema, enlargement of liver, distention of
  jugular vein, anorexia due to congestion of
  stomach
• pleural effusion, etc.

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Auxiliary Examination

• 1.Chest radiography large cardiac sihouette,
  pulmonary venous congestion, edema
• 2. Echocardiography cardiomegaly, ventricular
  disfunction, heart function?(EFlt50?FSlt30?STI?IV
  RT ?? E/A lt1) ,ect.
• 3. Electrocardiogram

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Diagnosis of Heart Failure

• Clinical Findings
• 1.HR?
• 2. Dyspnea, R?
• 3. Liver Enlargement
• 4. Cardiac sound?,Cantering rhythm
• 5. Dysphoria
• 6. Oliguresis, Edema

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  ?????????? ?

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Functional Classification of H.F. (By New
York Heart Association)

• Grade
• I No limitation to ordinary activities
• II Slight limitation to ordinary
  activities
• III Marked limitation to ordinary
  activities
• IV Unable to do any activitybed ridden.
• Congestive heart failure denotes cases with
  symptoms
• and signs of passive congestion.

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• ??????????????(NYHA)??????????,?????????????4??
• I??????????????????????,????????????
• II?(????)??????????????????????????????????????,?
  ??????????????????????
• III?(????)????????????????????(???15??),?????????
  ???,??????????
• IV?(????)??????????,?????????,??????????????????

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• ??????????????,???????????????????????????????,??
  4??
• 0????????
• I?(????)????????lt105ml,???gt30??,????,??gt
  150?/?,???2cm?
• II?(????)????????lt90ml,???gt40??,??gt
  60?/?,??????,??gt 160?/?,???23cm,?????
• III?(????)????????lt75ml,???gt40??,??gt
  60?/?,??????,??gt 170?/?,???gt 3cm,?????????????

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?????????
0 1 2
???(ml/?) gt105 75-105 lt75
????(min/?) lt40 gt40 gt40
??(?/min) lt50 50-60 gt60
??(?/min) lt160 160-170 gt170
???? ?? ??? ???
???? ?? ?? ??
??? ? ? ?
????(cm) lt2 2-3 gt3
?0-2????3-6?????7-9????? gt 10??????
15
??Rose???????
????? ????? ????? ?? ?? ??
????? ????? ????? 0 1 2
? ? ?? ?? ?? ?????(???) ?????(???)
? ? ???? ???? ?? ?? ??
? ? ? ? ?? ?? ?? ???? ????
? ? ? ? ? ? ? ? 0-1y lt50 50-60 gt60
? ? ? ? ? ? ? ? 1-6y lt35 35-45 gt45
? ? ? ? ? ? ? ? 7-10y lt25 25-35 gt35
? ? ? ? ? ? ? ? 11-14y lt18 18-28 gt28
? ? ? ? ? ? ? ? 0-1y lt160 160-170 gt170
? ? ? ? ? ? ? ? 1-6y lt105 105-115 gt115
? ? ? ? ? ? ? ? 7-10y lt90 90-100 gt100
? ? ? ? ? ? ? ? 11-14y lt80 80-90 gt90
? ? ? ? ??(??) ??(??) lt2cm 2-3cm gt3cm
?0-2????3-6?????7-9?????10-12??????
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Management of Heart Failure

• Treatment Strategies
• Ameliorate symptoms
• Maintain cardiac functional state
• Reduce mortality rate
• Reduce hospitalization

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Treatment

• 1. The cause must be removed
• 2. General management bed rest,
  mitigate,oxygen inhalation, reduction of salt
  intake
• 3. Drug Treatment

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Drug Treatment

• Positive inotropic agentscardiac glycosides,
  phosphodiesterase inhibitors
• Vasodilators
• Diuretics
• Angiotensin converting enzyme inhibitors (ACEI)
• Beta-blockers

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• ??????????,????,???????????????????
• ?????????????
• ???????????lt2?0.05-0.06mg/kg,gt2?0.03-0.05mg/kg,?
  ??????1/5????????lt2?0.03-0.04mg/kg,gt2?0.02-0.03mg
  /kg?
• ???????,?????1/2?2/3?

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• ????
• ??(???)????????????,??????1/2?,???2?(1/4?1/4),
  q4h-q6h?q8h?
• ???????????????,???????1/5?,?2??????????????,
  ????12?????????

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• ???????????????????????????
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• ???????????????????
• ??????????????????????????

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Diuretics

• Relieve the congestion status by elimination of
  sodium and water.
• Indicated in pulmonary congestion with dyspnea
  and rales and generalized edema ,ascites
• Agents used
• Thiazideschlorothiazide , chlothalidone
• Loop diureticsfurosimide, bumetanide, ethacrynic
  acid
• Potassium-sparing diureticsspirolectone,
  triamterene, amiloride
• Side effects hypokalemia, hyperglycemia

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ACE-Inhibitors

• Rationales of the ACEI treatment for heart
  failure
• Decreases peripheral circulatory resistance
• Decreases the blood volume
• Decreases the sympathetic activity
• Inhibition of the remodeling process

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ACE-Inhibitors

• Short-term effects
• Symptomatic improvement approximately 2/3 of
  cases with severe heart failure show diurea,
  improvement in dyspnea and less edema.
• Hemodynamic improvement
• increased cardiac output by 25-30
• reduction of PCWP by 20
• decreased peripheral resistance by 30
• BPdrop 10-15
• Heart rateslightly reducsed
• N.B. 1st dose hypotension, transient elevation of
  BUN and creatinin

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ACEI treatment of H.F.

• Long-term effects Reduction of mortality and
  preservation
• of cardiac function.
• SAVE study
• Cases post acute myocardial infarction with
  EFlt40
• Captopril Control P
• Case No. 1115 1116
• Mortality rate
• (42months) RR 21 0.014
• Development
• Of severe H.F. RR 37 lt0.001

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SOLVE study

• 1) Cases of H.F.with symptoms, EFlt35
• Enalapril Control
• Case No. 1285 1284
• Follow up for 41.4 months
• Reduction of mortality rate by 16 (P0.0036)
• 2) Cases of H.F. without symptom, EFgt35
• Enalapril Control
• Case No. 2111 2117
• Follow up for 37.4 months
• Reduction of the death or development of H.F.
• by 37 (Plt0.001)

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Conclusion of ACEI treatment of heart failure

1. ACEI should be used in patients with heart
   failure irrespective to their underlying causes,
   if not contra-indicated.
2. Early application of ACEI can postpone the
   development of congestive heart failure
3. Attention should be paid to hypotension,
   increased blood Cr content and the side effect of
   cough.
4. Agent used Captopril, Enalapril, Perindopril,
   Lisinopril etc.

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Beta-blocker in treatment of H.F.

• Adverse effects induced by prolonged excessive
• sympathetic activity
• Increases peripheral resistance-after-load
• Increases heart rate
• Increases excitability-arrhythmias
• Elevation of NE? cAMP? ? intracellular Ca
  overload ? precipitation of apoptosis and cell
  death
• Beta-blockers can induce negative inotropic
  response

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Clinical Trial US Carvedilol Heart Hailure Study

• Carvedilol Placebo RR P
• No.of cases 696 398
• Mortality rate () 3.2 7.8
  65 lt0.001
• Hospitalization () 14.1 19.6
  27 0.036
•  
•  
• Agents proved to be effective in major clinical
  trails
• Carvedilol, Metaprolol, Bisoprolol

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Indications of Beta-blockers in CHF

1. Beta-blocker is indicated in CHF grade II,III and
   IV irrespective to its cause if not
   contraindicated
2. Used on top of ACEI and diuretics
3. Preferably initiate the treatment in hospital
   especially for severe cases
4. Start with a very small dose (usually 1/8 of the
   target dose), and increase gradually in 1-2 week
   interval.
5. Watch carefully, adjust the dosage of ACEI or
   diuretics if necessary

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Summary of management of H. F.

• Treating the underlying cause and associated
  diseases
• General care daily life adjustments
• Drug therapy
• ACEI
• Diuretics in case presence of congestion
• Beta-blockers
• Digoxin if necessary

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Acute Left Heart FailurePulmonary edema

• Etiological causes Acute myocardial infarction,
  Hypertension, Mitral stenosis, etc.
• Pathophysiology marked increase of the
  pulmonary blood volume and capillary pressure
  resulting exudation in alveoli.
• Clinical features
• Severe dyspnea
• Cough with frothy sputum,blood tinged
• Full of lung rales
• Restlessness to mental retardation

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Management of Acute Left Heart Failure

• Oxygen therapy. Positive pressure oxygenation if
  necessary
• Vasodilator therapy Nitroglycerin,nitropruside
  I.V.
• Diuretics Furosemide I.V.
• Positive inotropic therapy Dobutamine, milrinone
  (N.B. cardiac glycoside is contraindicated in the
  first 24 hr. of AMI)
• Sedatives Morphine in small dosage may help the
  restlessness state

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  ß????????????? ACEI ????????
• ?????????

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