Conges've

Heart Failure
 Conges've Heart Failure
•  Heart failure is the progressive inability of the
heart to supply adequate blood flow to vital
organs
•  Heart Failure = ↓Cardiac Output (CO)
↓CO = ↓Blood volume = ↓Heart Pumping
•  It is classically accompanied by significant fluid
reten'on
•  It is a leading cause of mortality and morbidity
 Causes of CHF

Coronary artery spasm

CAD

atherosclerosis
Platelet aggregation
thrombosis

Coronary artery stenosis

w/ subsequent MI
What are the causes of HF prevalence?
MYOCARDIAL INFARCTION
1. Myocardial Damage (Heart ANack) / ISCHEMIA
2. HTN
3. cardiomyopathy
4. valvular heart disease
5. congenital heart disease
6. behavioral
7. Pulmonary disease SMOKING…

8. aging
9. anemia
10. Diabetes
 Clinical Features of CHF

•  Reduced force of cardiac contrac'on

•  Reduced cardiac output
•  Reduced 'ssue perfusion
•  Increased peripheral vascular resistance
•  Edema
Physiology of the Heart
How the heart normally functions
Pathophysiology of CHF
What happens to the heart when you have CHF?
 Diagnos'c Tools
•  Chest X ray à Check heart size
•  Ejec'on Frac'on (EF) à check the amt of
blood leaving the heart
•  Blood test à check for MI
•  Blood Pressure
•  ECG à Check for arrhythmia, MI
•  Exercise Stress Test
•  Echocardiogram/CAT Scan à to measure EF
NORMAL CHEST X-RAY CHEST X-RAY W/ CHF
 EJECTION FRACTION

The ejecXon fracXon (EF) refers to the amount, or percentage, of blood that is pumped
(or ejected) out of the ventricles with each contracXon.

A LOW EF is an early indicaXon of Heart Failure

An EF between 40% to 55% indicates damage (i.e. heart a\ack) but does
not necessarily mean the paXent has HF.
 HF based on EF
•  Preserved ejec'on frac'on (HFpEF) – also
referred to as diastolic heart failure. The heart
muscle contracts normally but the ventricles do
not relax as they should during ventricular filling
(Heart muscles may be thickened or sXff).
•  Reduced ejec'on frac'on (HFrEF) – also referred
to as systolic heart failure. The heart muscle
does not contract effecXvely and less oxygen-rich
blood is pumped out to the body.
 2 factors involved in HF
NEUROHORMONAL 1.  ↓ Cardiac Output
COMPENSATORY 2.  Compensatory Mech.
MECHANISM
 Symptoms Associated with CHF: severity
depends on the degree of CHF

•  ACUTE CHF •  CHRONIC CHF

–  Tachycardia –  Various arrhythmias
–  Shortness of breath –  Hypertension
–  Edema (pulmonary/ –  Cardiomegaly
peripheral) –  Edema (pulmonary/
–  Decreased exercise peripheral)
tolerance
Symptoms Associated with CHF: severity
depends on the degree of CHF
 Classes of CHF
•  Class I: Symptoms with more than ordinary
ac'vity
•  Class II: Symptoms with ordinary ac'vity
•  Class III: Symptoms with minimal acXvity
–  Class IIIa: No Dyspnea at rest
–  Class IIIb: Recent Dyspnea at rest
•  Class IV: Symptoms at rest
 Treatment for CHF
Medications used for the management of CHF
 When “BAAD” is Good…

Beta-Blocker ACE inhibitors/ARB

Metoprolol ER = 200 mg Lisinopril = 20-40 mg
Bisoprolol = 10 mg Losartan = 100 mg
Carvedilol = 50 mg

Aldosterone Diure'c & Digoxin

antagonist Furosemide = 20 mg
Digoxin = 0.125 mg
Spirinolactone = 25 mg
Eplerenone = 50 mg

 Drugs for CHF
•  Vasodilators
•  ACE Inhibitors / Angiotensin Receptor
Blockers
Provides the cornerstone for
•  DiureXcs HF therapy

•  Beta blockers
•  Digoxin
•  Other Cardiac Inotropes – Dobutamine,
Milrinone
 Drugs used in various Stages of CHF
•  MILD CHF •  SEVERE CHF
–  DiureXcs (if with edema) –  Digoxin
–  Beta blockers (stable HF) –  DiureXcs
–  ACE inhibitors –  ACE inhibitors
–  Nitrovasodilators (esp. –  Nitrovasodilators
for African American)
•  MODERATE CHF
–  Digoxin
–  ACE inhibitors
–  CombinaXon DiureXcs
 Beta Blockers
•  Acts primarily by inhibiXng the sympatheXc
nervous system
•  Increases beta receptor sensiXvity (up
regulaXon)
•  Provide cardioprotecXon (prevents
cardiomyopathy)
•  ↓Oxygen demand
 Reminders…
•  Start at low dose and monitor for bradycardia
•  Carvedilol and Metoprolol are the most
commonly used for CHF amongst beta
blockers
PRECAUTIONS CONTRAINDICATIONS

•  Bradycardia •  ReacXve Airway disease

•  Decompensated HF •  Severe Peripheral Arterial
Disease (PAD)
•  First Degree AV Block
 ACE Inhibitors
•  First agent to show improved survival and
cardiac funcXon.
•  Delays or reverse cardiac remodeling.
•  Reduce vasoconstricXon

PRECAUTIONS CONTRAINDICATIONS

•  K+ > 5 mEq/L •  Bilateral renal artery

•  GFR < 30 mL/min stenosis
•  Nuisance cough •  Angioedema
•  Pregnancy (fetal toxicity)
•  Unstable hypotension
•  Severe AorXc Stenosis
Angiotensin Receptor Blockers (ARB)
•  AlternaXve to ACE inhibitors (because of
nuisance cough)
•  Improve survival, but not as good as ACEi in
pts with post-MI, LV systolic dysfuncXon & HF.
PRECAUTIONS CONTRAINDICATIONS

•  K+ > 5 mEq/L •  Bilateral renal artery

•  GFR < 30 mL/min stenosis
•  Pregnancy (fetal toxicity)
•  Unstable hypotension

 Aldosterone Antagonist
Spironolactone : Aldosterone antagonist
•  Improved survival when added to beta
blockers+ACEi for paXents with systolic HF
PRECAUTIONS CONTRAINDICATIONS

•  K+ > 5 mEq/L •  Painful gynecomasXa

•  GFR < 30 mL/min (alternaXve = eplerenone)
•  Use of salt subsXtutes (KCl
instead of NaCl)

 Diure'cs
•  Manage hypervolemia
•  Improve symptoms related to edema
•  Furosemide is the most commonly used loop
diureXcs (Ethacrynate Na= 100% oral bioavailable)

PRECAUTIONS CONTRAINDICATIONS

•  K+ < 4 mEq/L (combine with •  HypersensiXvity

K sparing diureXcs) •  Anuria
•  Hypotension / hypovolemia

 Hydralazine & Nitrates
•  Improved survival –
especially to African
Americans
•  Useful alternaXve to
ACEi or ARBs in pts at
risk of Acute Renal PRECAUTIONS CONTRAINDICATIONS

Failure (ARF). •  Hypotension •  HypersensiXvity

•  Reflex tachycardia •  DissecXng aorXc
aneurysm
 Digoxin
•  InhibiXon of Na/K ATPase pump increase
intracellular sodium concentraXon –
eventually increase cytosolic calcium
•  Digoxin is used as a first-line drug in paXents
with congesXve heart failure who are in atrial
fibrilla'on
Digoxin
 Digoxin
Adverse effects / Precau'ons :
•  AV block and bradycardia
•  Amiodarone and verapamil can increase the
plasma concentraXon of digoxin by inhibiXng
its excreXon
 Digoxin
Digoxin toxicity treatment:
•  Toxicity can be treated with higher than
normal doses of potassium
•  Digoxin anXbody (digibind) is used specifically
to treat life-threatening digoxin overdose
 Cardiac Inotropes
•  Phosphodiesterase III Inhibitors PosiXve
inotropic and vasodilator – Milrinone
(Primacor)
•  Dobutamine is a beta-1 agonist which
increase contracXlity and cardiac output
 Milrinone

↑Ca in muscles
(heart)

↑Heart Contrac'on
Pharmacologic Recommenda'ons
DRUG CLASS RECOMMENDATIONS
ACE Inhibitors •  All paXents with CHF
ARBs •  All paXents with HF intolerant to ACEi
•  AlternaXve to ACEi
Beta Blockers •  All paXents with Stable HF
Hydralazine & •  African American pts with HF
Nitrates •  For pts with renal disease
Digoxin •  May be beneficial in pts with HF

Yancy CW, et.al. Circula1on 2013:128;e240-e327

 Guideline Recommenda'on
•  Aldosterone antagonist are recommended for
paXents with:
–  NYHA class II to IV HF
–  LVEF of 35% or less
–  PaXents who had MI and has LVEF of 40% or less
–  HF with DM, unless contraindicated
–  Watch out for risks of Hyperkalemia (esp. for people with
renal failure)
Yancy CW, et.al. Circula1on 2013:128;e240-e327
 Guideline Recommenda'on
•  PaXents with HF admi\ed with significant fluid
overload should be promptly treated with IV loop
diure'cs.
•  Sta'ns are not beneficial as adjuncXve therapy when
prescribed solely for the diagnosis of HF in the
absence of other indicaXons.
•  An'coagula'on is not recommended in paXents
with chronic systolic HF without atrial fibrillaXon or
cardioembolic source.
Yancy CW, et.al. Circula1on 2013:128;e240-e327