CONGESTIVE HEART FAILURE

1
CONGESTIVE HEART FAILURE

• Five millions Americans have CHF
• 550,000 New cases every year
• 800,000 Patients with CHF hospitalized every year
• 250,000 die every year
• 50 Patients die with in five years
• 150 increase in the last 20 year
• 2.6 total population has this disease
• Incidence and associated morbidity and mortality
  is
• expected to increase in future

2

• Congestive Heart Failure
• Two types
• 1. High output failure
• -Increased
  demand
• 2. Low output failure
• - Systolic
  dysfunction
• - Diastolic
  dysfunction
• - Mixed

3

• Congestive Heart Failure
• Definition
• Systolic HF
• Ventricles are unable to deliver
  adequate quantity of blood to tissue at rest or
  during normal activity because of anatomical or
  functional abnormalities and/or increased demand
  on heart
• Diastolic HF
• It is pulmonary venous congestion and
  resultant symptoms in the presence of normal or
  near normal EF gt 40 LV systolic function

4

• Congestive Heart Failure
• Two theories about Systolic Dysfunction
• 1. Old theory -- Pump failure
• - Improve hemodynamics
• 2 New theory--- Neuro Hormonal theory
• There is correlation
  between prognosis of
  
  
  CHF and level of
• -Endothilin
• 
  -Norepinephrine
• -Renin

5

• Congestive Heart Failure
• Factors influencing prevalence and outcome
• Age
• Race
• Gender
• Age
• 1or less in 50 year or younger
• 5 in 50 - 70 years
• 10 in over 70 years
• 15 in over 80 years
• There will be doubling of patients over 65 years
  by 2030

6

• Congestive Heart Failure
• 2. Race
• Higher incidence in blacks
• 3.5 in black men
• 3.1 in black woman
• 2.3 in white man
• 1.5 in white woman
• HF in black men poor prognosis
• 3. Gender
• Higher prevalence in men 70 years and younger
• Higher prevalence in women 70 years and older
• This may be due to increase in average life
  expectancy in women

7

• Congestive Heart Failure
• Cost
• 21- 50 billions/ year
• 1/3 cost on outpatient care
• 2/3 cost on hospital care
• Care of CHF - 3 times for cancer
• - 2 times for MI
• Average cost of CHF / admission 8000

8

• Heart Failure Congestive
• Mortality
• One year mortality 17
  
• Two year mortality 30
  
• Three year mortality 56
• Treatment is very inadequate
• Data for benefits of ACE inhibitors is very
  compelling and is there for a decade
• ACE inhibitors prescribed for eligible CHF
  Patients
• Cardiologists 80
• Internists 71
  
• FP
  60

9

• Congestive Heart Failure
• Etiology of Systolic HF
• CAD is most common
• -Produces Ischemic cardiomyopathy
• Hypertension 2nd common
• Non ischemic Cardiomyopathy
• -Commonest is idiopathic dilated
• Other Causes
• Cardiac
• Valvular HD
• Myocarditis
• Pericardial disease
• Arrhythmias

10

• Etiology cont.
• Noncardiac
• Alcohol/Thiamine Deficiency
• Diabetes mellitus
• Infection
• Shock
• Pregnancy
• Pulmonary Embolism
• Anemia
• Drugs
• Hyper or hypothyroidism
• Pulmonary hypertension
• Infilterative diseases like-
• - Sarcoidosis
• - Hemochromatosis
• - Amyloidosis
• - TB
• - Tumors

11

• Congestive Heart Failure
• Etiology cont.
• Diastolic HF
• Most common
• - CAD
• - Hypertension
• Others
• - Diabetes mellitus
• - Aortic stenosis
• - Hypertrophic cardiomyopathy
• - Infiltrative cardiomyopathy

12

• Congestive Heart Failure
• Pathophysiology
• Conceptual basis of progress of LV dysfunction
  has now turned to
• - Norepinephrine
• - Angiotensin
• - Aldosterone
• Elevated levels of these hormones has been
  correlated to poor prognosis
• Interventions targeted at to decrease impact of
  these hormones- improve mortality
• This has been shown in several large mortality
  trials

13

• Congestive Heart Failure
• Work up
• History and physical exam
• CAD risk factor evaluation
• Previous studies
• Determination of co-morbid conditions
• Laboratory studies
• Further work up

14

• Congestive Heart Failure
• History
• Careful history is very important
• Ask for if they have or have had any conditions
  like CAD, HTN, Thyroid disease, DM, MI
• FACES Mnemonic for HF
• Are you easily Fatigued by your usual activity?
• Have you experienced an altered Activity or
  exercise pattern?
• Are you Comfortable walking up one flight of
  stairs?
• Do you have Edema swelling?
• Are you Short of breath?

15

• Congestive Heart Failure
• Functional status
• Should be recorded in NYHA scale
• Should be assessed yearly
• Class1 No limitation of physical activity.
  Ordinary activity does not cause undue
  fatigue, dyspnea, or anginal pain
• Class2 Slight limitation of physical activity.
  Ordinary physical activity results in symptoms
• Class3 Marked limitation of physical activity.
• Comfortable at rest, but less than ordinary
  activity
• causes symptoms
• Class4 Symptoms present even at rest.

16
Symptoms

• Two major classes of symptoms
• Due to excess fluid accumulation
• - Dyspnea
• - Edema
• - Hepatic congestion
• - Ascities
• Due to decreased CO
• - Fatigue
• - weakness

17
Physical finding

• S3
• associated with atrial pressure gt20 mm and
  increased
• ventricular end diastolic pressure gt15 mm
  and increased BNP
• Decreased cardiac output
• Sinus tachycardia
• diaphoresis
• Peripheral vasoconstriction
• Decreased CO is suspected when pulse
  pressure is lt25 mm
• Pulsus paradoxus a sign of severe LV
  dysfunction
• Volume overload
• - pulmonary congestion, JVD
  and edema

18
Physical finding

• Ventricular Enlargement
• Pulmonary HTN

19

• Congestive Heart Failure
• Lab studies
• CBC
• Chemistry profile
• Fasting lipid profile
• Urinalysis
• EKG
• Chest X-Ray
• Consider in unexplained HF
• Magnesium, Calcium, Phosphorus Selinium, Thiamine
• TSH
• Urine drug screen
• Ferritin
• Albumin

20

• Congestive Heart Failure
• Diagnostic Evaluation needed for
• Determine the type of cardiac dysfunction
• Find correctable causes of HF
• Determine prognosis
• Guide treatment
• Further work up needed in
• All patients with suspicion or Diagnosis of CHF
  should have ECHO done
• If ECHO results are inconclusive, order MUGA scan
• For patience with the risk factors but no angina
• -Non invasive testing like treadmill
  test, stress ECHO or Stress
  Cardiolite

21

• Congestive Heart Failure
• Cardiac cath. for patients with
• Angina
• Known large area of ischemia
• Hibernating myocardium
• Unexplained HF
• CABG in multivessel disease with
• decreased systolic function leads to
• decreased mortality and significantly
• improves symptoms of angina and HF

22

• Congestive Heart Failure
• Ambulatory rhythm monitoring
• When rhythm disturbance suspected in HF
• Sudden death due to arrhythmias is major cause of
  mortality in HF
• Many studies have shown that ICD provides a major
  survival advantage in symptomatic or inducible
  ventricular arrhythmias with or without HF

23

• Congestive Heart Failure
• Other Studies
• Serum level of Atrial natriuretic peptide ANP,
  Brain natriuretic peptide BNP, norepinephrine
  and other neuroharmones are elevated in HF
• ANP and BNP may predict prognosis and used in
  many centers to monitor patients with HF

24

• Heart Disease
• 
  
• 
  Myocardial depression
• Increased Myocardial
  Atrial
  underfilling
• work load
  
• 
  Decreased SV
• Increased After load
• 
  Activates
  Baroreceptors in
• 
  LV,Aortic
  arch,Carotid sinus
  
• 
  Sympathetic NS
• 
  activation
• 
  1.
  Decreased organ perfusion
• Vasoconstriction
  
• 
  2. Stimulates vasomotor
• 
  regulatory
  center

25

• Congestive Heart Failure
• Treatment
• ACEI/ARB
• BETA BLOCKERS
• DIURETICS
• ALDACTONE
• DIGOXIN
• New hormonal inhibitors
• Antiplatelets
• Anticoagulants
• Non pharmacological treatment

26

• Congestive Heart Failure
• ACE inhibitors
• ACE inhibitors modify neurohormonal activity in
  HF by inhibiting
• Angiotensin 1
  Angiotensin 2
• This leads to
• -Peripheral vasodilation
• -Decreased afterload
• -Decreased BP
• This leads to down regulation of sympathetic NS
  -- improves baro receptor function
• Patients who received most benefit had greatest
  neurohormonal activation

27

• Congestive Heart Failure
  ACEI/ARBS
• Mortality benefits of ACE inhibitors in major
  trials
• Trial Name Study Group Drug studied All
  cause mortality
• 
  reduction
  
  
• CONSESUS 253 Pts., Enalapril
  Vs placebo 27
• NYHA 23
• SOLVD 2,569 Pts.
• NYHA 2,34
  Enalapril Vs placebo 16
• V-HeFT 2 804 Pts.
  Enalapril Vs hydralazine 28
  NYHA 2,34
  plus ISDN
• SAVE 2,231 post-MI pts.
• with EF 40
  
  Captopril Vs placebo 19
  

28

• Congestive Heart Failure
• In pooled studies of HF, overall reduction in all
  cause mortality 23
• This benefit extends to
• Ischemic and non ischemic cardiomyopathy
• Symptomatic and non symptomatic LV dysfunction
• Addition to survival benefits ACEI
• Improve symptoms
• Increase exercise capacity
• Decrease No. of hospitalization
• Increase EF
• Decrease recurrent MI

29

• Congestive Heart Failure
• Doses
• Despite proven survival, many eligible patients
• - Either dont receive ACEI
• - Or receive low doses
• ATLAS study was conducted for optimal dose of
• ACEI
• Lisinopril --- Two groups
• Low dose 2.5---5mg/day
• High dose 32.5--35 mg/day

30

• Congestive Heart Failure
• Both groups achieved similar improvement of
• Symptoms
• Functional class
• But group with high dose has
• 12 lowers relative risk of death or
  hospitalization
• 24 fewer hospitalizations with HF
• Results of ATLAS study suggest
• 1. High dose of ACEI independent of symptomatic
  relief or hemodynamic effects as long as
  tolerated
• 2. Low dose if hypotension, renal insufficiency
  or hyperkalemia

31

• Congestive Heart Failure
• Angiotesin receptor blockers
• ACEI
• Block A2 production through ACE pathway
• Inhibit breakdown of vasodilator Bradykinin which
  ARBS don't
• ARBS block A2 production from all pathways, so
  theoretically have advantage
• Elite1 and Elite2 studies done to compare ACE and
  ARBS
• Elite1-- Showed advantage of ARBS
• Hospitalization Decreased by 30
• Elite2--- showed no difference

32

• Congestive Heart Failure
• Combination of ACEIARBS
• Blocks A2 production from all pathways
• Inhibit breakout of bradykinin
• But disturbing trend
• Increased mortality and morbidity in patients
• receiving combination of Valsartan and
• Beta blockers

33

• Congestive Heart Failure
• Most expert agree that
• ACEI should be first line therapy
• ARBS if ACEI not tolerated
• Combination in patients not fit for Beta-blockers

34

• Congestive Heart Failure
• Beta blockers
• We know that increased Sympathetic activity
• in HF --- Increase in circulating
• norepinephrine ---- stimulation of alpha and
• beta-receptors. This chronic elevation
• causes-
• Myocyte necrosis
• Progressive LV dysfunction

35

• Congestive Heart Failure
• Increased CNS sympathetic flow
• Increased Cardiac sympathetic activity
  Increased sympathetic
• 
  activity to kidney
• 
  
• Beta1 receptor Beta2 receptos Alpha1
  receptors
• 
  
• 
  Na retention
• 
  
  
  Vasoconstriction
• Myocyte hypertrophyDeath,
• Dilatation, Ischemia, Arrhythmia
• Effect of Sympathetic activity in Chronic HF

36

• Congestive Heart Failure
• 15 trials have shown that beta-blockers
• Reduce all cause mortality by 32
• Reduce combined risk of death due to CHF by 37
• Reduce hospitalization by 37
• Increase ejection fraction by 29
• Improve symptomatic and functional class
• Well tolerated in all studies
• Discontinuation rate 9 to 15
• As with ACEI, reduction of mortality
• appears to be dose related

37

• Congestive Heart Failure
• Mortality benefits of beta blockers in major
  trials
• Trial name Study group Drugs
  studied All cause mortality reduction
• 
  
• US Carvedilol 1,094 Pts.NHYA Carvedilol vs
  placebo 65
• HF Study 2,3, or 4 CHF
• CIBIS-2 2,647 Pts.NYHA Bisoprolol
  vs placebo 34
  3 or 4 CHF
• MERIT-HF 3,991 Pts. NYHA Metoprolol XL
  34
  3 or 4 CHF Vs placebo

38

• Congestive Heart Failure
• Beta blockers
• Should be considered disease modifying rather
  than rescue agents
• Are effective irrespective of Etiology of CHF and
  age of pt.
• Utility lies in blocking neurohormonal Cascade
• Indicated in all chronic symptomatic HF pts.
• BEST study reports some racial differences but
  conclusions are awaited
• All trials compare beta-blocker with placebo
• Another trial which compares Coreg with
  Metoprolol shows Coreg
• as better than Metoprolol.

39

• Congestive Heart Failure
• Criteria for Beta Blockers
• LV systolic dysfunction
• Ejection Fraction lt 40
• Mild to moderate impairment in functional
  capacity
• NYHA class 2 and 3, even 4
• Optimal and stable circulation
• No C/I to beta blockers

40

• Congestive Heart Failure
• Patients not fit for Beta-Blockers
• HF without LV systolic dysfunction
• Hemodynamically unstable
• Circulation requiring i.v. ionotropic support
• NYHA class 4 -- not anymore
• COPERNICUS trial evaluated use of Coreg in pts.
  NYHA class 4, was terminated early because of
  benefits

41

• Congestive Heart Failure
• Doses of Beta blockers
• Drug Starting dose Target dose
  Cost
• Coreg 3.125 mg/day 25 to 50 mg twice
  93
• Lopressor 12.5 mg/day 50 to 100 mg b.i.d.
  42
• Toprol XL 12.5 mg/day 200 mg/day
  52
• Bisoprolol 1.25 mg/day 10 mg/day
  35
• Beta-blockers should be adjusted to maximum
  tolerated doses

42

• Congestive Heart Failure
• Comparison Beta blockers used in mortality trials
• Beta blocker Receptors
  Vasodilating propertie
• Bisoprolol Beta1- selective
  no
• Lopressor Beta1- selective
  no
• Toprol XL
• Coreg Alpha1,beta12
  yes
• Bisoprolol Beta12
  yes mild
• Coreg has advantage of Alpha and beta-receptor
  blockage
• COMET study compared Metoprolol and Coreg .

43

• Congestive Heart Failure
• Steps in management of side effects
• Problem step1 step2
  step3
• Symptoms of Decrease Decrease
  Decrease
• vasodilation Diuretic vasodilator
  Beta-blocker
  
  
  
  
  dose dose
  dose
• Symptoms of Increase Decrease
• fluid retention diuretic
  beta-blocker
• dose
  dose
• Symptomatic Check dig. level Decrease
• bradycardia and adjust
  beta-blocker
• dose
  dose

44

• Congestive Heart Failure
• Aldosterone Antagonists
• In HF
• Increased activity of RAS system leads to
• Decreased renal perfusion
• Decreased hepatic clearance
• As result of above in pts. of HF
• Plasma level of Aldosterone is 20
  times
• Aldosterone has multiple effects that promote HF
• NA retention
• Sympathetic activation
• Parasympathetic inhibition
• Baroreceptors dysfunction
• Myocardial vascular fibrosis

45

• Congestive Heart Failure
• Until recently Aldosterone antagonists were not
  used because
• Concerns of hyperkalemia
• Weak diuretic activity
• Assumption that ACEI inhibit aldosterone
• Recent studies have shown that ACEI only
• transiently inhibit aldosterone

46

• Congestive Heart Failure
• RALES study has shown significant survival
• benefits in patients with NYHA 34 who are
• pretreated with ACEI
• 1663 Patients either received aldactone 25-50
• mg or placebo stopped early because
• Significant reduction in the risk of death
• Slow progression of HF
• Significant reduction in the risk of death
• Improved functional class
• Study excluded patients with creatinine levels
  2.5
• or more and K level gt 5 mEq

47

• Congestive Heart Failure
• Currently Aldactone therapy should be considered
  in all patients with severe symptomatic HF in
  absence of significant renal impairment and
  hyperkalemia
• Role of aldosterone antagonists in patients with
  mild HF or those being treated with beta blockers
  is currently unknown

48

• Congestive Heart Failure
• Hydralazine and Isosorbide dinitrate
• Combination decreased mortality in HF
• Decreased mortality by 25 in one study
• Patient who cannot tolerate beta-blockers should
  be given this combination
• Used individually don't decrease mortality
• Tolerance is an issue
• Doses
• Isosorbide dinitrate Isordil --- 20-80 mg tid
  or qid
• Hydralazine Apresoline
• -10 mg tid Initially
  -Increase to 25-100 mg tid

49

• Congestive Heart Failure
• Digoxin
• 6800 Patients studied ---Digoxin Vs Placebo
• Digoxin
• Did not reduce overall mortality
• Decreased rate of hospitalization, both overall
  and CHF
• Effective for treating symptoms of CHF in absence
  of dysarrhythmia
• Increased functional capacity in NYHA 23
• Symptoms of HF worsened if digoxin withdrawn
• Dose 0.125-0.25 mg

50

• Congestive Heart Failure
• Diuretics
• Mainstay of symptomatic treatment of CHF
• Short-term studies have shown that diuretics
• Improve symptoms of sodium and water retention
• Increase exercise tolerance
• Increase cardiac function regardless NYHA class
• No data available to support decrease in
  mortality or morbidity
• Tolerance could be problem, try to change
  diuretic every year
• Renal insufficiency--use loop diuretics
• Lasix 20--320 mg qd -qid
• Bumex 1-8 mg qd or divided doses
• Aldactone synergistic with loop diuretics
• Note HCTZ is not effective in severe HF

51

• Patient with chronic heart failure
• Assessment of left
  ventricular function
• Left ventricular ejection
  fraction lt 40
• Assessment of fluid and
  volume status
• Signs/ symptoms Diuretics No
  signs/ symptoms
• of fluid retention
  
• 
  - Digoxin
  
  
• 
  Aldactone
• 
  
• 
  ACE inhibitors
• 
  Beta blockers

52

• Congestive Heart Failure
• Antiplatelets and anticoagulants
• Risk of thromboembolism in HF 1.6 to 3.2 /
  year
• But routine anticoagulation is not recommended
  yet
• Helpful in HF and
• Atrial fibrillation
• Mitral regurgitation
• LV thrombus visualized by echo
• Anterior MI
• Severe dilated cardiomyopathy EF lt 20
  
  
• Not helpful in patients with HF and sinus rhythm
• WATCH trial is underway to determine whether
• anticoagulation with warfarin, plavix or aspirin
  will reduce
• mortality and morbidity in chronic HF
• Some concerns regarding aspirin may offset
  benefits of ACEI

53

• Effects of different drugs
• Drug Symptoms Exercise tolerance Survival
  Hospitalization
• Diuretics Improved Improved
  Unknowen Unknown
• ACEI Improved Improved
  Improved Decreased
• BB Improved Equivocal
  Improved Decreased
• Digoxin Improved Improved
  No effect Decreased

54

• Congestive Heart Failure
• Newer neurohormonal inhibitors
• Neurohormonal hypothesis of HF has spawned reason
  for various new potential treatments
• - Endothelial receptor antagonist
• - Vasopeptidase inhibitors
• - Synthetic nartriuretic peptide
• Studies not complete but preliminary data is
  encouraging

55

• Congestive Heart Failure
• Non pharmacological treatment
• Dietary sodium restriction
• No studies to show morbidity and mortality effect
• Minimizes doses of HF drugs
• Restrict sodium to 4 mg / day
• Exercise training
• Moderate exercise training
• Improves quality of life
• Decrease mortality in stable chronic HF
• Recent studies have shown
• Moderate exercise on stationery bike for 2-3
  hrs./week
• Decreases mortality
• Decrease hospital admissions by 4-14 months

56

• Congestive Heart Failure
• Treatments that has no benefits or are harmful
• 1 Calcium channel blockers
• No trials available for CCB that they
• - Lower mortality or hospitalization
• - Improve quality of life
• Older short acting CCB can worsen HF
• Second-generation CCB like Norvasc may be
  exception
• 2 Periodic dobutamine infusion
• Dose 5-8 mcg/kg/m over 1-2 days every 3-4 months
• Not contraindicated as symptoms may improve
• Mortality is increased

57

• Congestive Heart Failure
• 3 Milrinone
• PROMISE study showed that MILRONE 40 mg/
• increases mortality by 35 in NYHA 34
• 4 Antiarrhythmic agents
• Antiarrhythmic agents used to treat asymptomatic
  arrhythmias not recommended, may be harmful
• 70 patients with HF can have asymptomatic
  episodes of non-sustained VT for lt 30 seconds

58

• Congestive Heart Failure
• Diastolic HF
• Goal of therapy is to slow the rate to allow time
  for ventricular filling
• Take off digixin and ACEI
• Beta blockers
• Inderal 60-80 mg tid or qid
• Lopressor 50-100 mg bid
• Timolol 10 mg bid
• Atenolol 50 mg bid or 100 mg qd
• Calcium Channel blockers
• Cardizem - Initially 60 mg tid
• - Go to 360 mg qd
• Verapamil - 60 mg tid initially
• - Increase to 480
  mg in 3 divided doses

59

• Congestive Heart Failure
• Follow up
• Contact frequency
• Q 3-6 months if stable on medicationsgt one year
• Increase frequency as needed if change in
  symptoms or medication
• Every visit
• Interval history
• Symptoms like PND, DOE, Orthopnea, edema
• Wt.
• Blood pressure/Pulse
• Medication review
• -Including OTC and herbal
• -Instructions to Avoid NSAIDS
• -New prescription from other physicians
• Tobacco use
• HYHA class

60

• Congestive Heart Failure
• Follow upcont.
• Yearly
• Flu vaccine
• Pneumovax once, repeat if indicated
• CHF Teaching
• Chemistry profile- yearly/3 months as indicated
• As needed
• Dig. level
• Lipid profile
• INR if on Coumadin
• ECHO
• Stress Test
• Consultation

61

• Congestive Heart Failure
• Education and Counseling
• Patients and their families/caregivers should
• be counseled regarding -
• Nature of heart failure
• Medication
• Dietary restrictions
• Symptoms of heart failure
• What to do if symptoms occur or worsen?
• Prognosis
• Emotional issues
• Encourage to complete advance directives

62
Factors contributing in worseniing of CHF

• Cardiovascular factors
• - Ischemia or infarction
• - Uncontrolled HTN
• - Valvular HD
• - A. fib
• - Tachycardia
• - PE
• Pt. Related factors
• - Noncompliance
• - Alcohol
• - Drugs
• - Dietary issues

• Systemic factors
• - Meds
• - Infecions
• - Anemia
• - Uncontrolled DM
• - Thyroid dysfunction
• - Electrolyte imbalance
• - Pregnancy