Heart Failure

Kidney Function Restoration Program

Kidney Damage Holistic Treatment

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Definitions (Brounwald's Heart Disease. 7th ed.. 2004)

• Failure of heart to pump blood forward at sufficient rate to meet metabolic demands of peripheral tissues or ability to do so only at abnormally high cardiac filling pressures

• Low-output (1 cardiac output) vs. high-output (t stroke volume • t cardiac output)

• Left-sided (pulmonary edema) vs. right-sided (T JVP. hepatomegaly, peripheral edema)

• Backward (T filling pressures, congestion) vs. forward (impaired systemic perfusion)

• Systolic (inability to expel sufficient blood) vs. diastolic (failure to relax and fill normally)

Figure 1-3 Approach to Wt-pdcd heart failure

Left-sided Heart Failure h i/o mitrat valve d consider myxoma, pulmonary VOD


High SV







(usually right-sided failure)

¿ Contractility IschemiaMI DCMP

T Afterloaö

AS. HCMP HTN crisis Chronic AIMR Coarctation

High Output AV fistula Pagets Sepsis Beriben Anemia Thyrotoxicosis

I Forward Flow

(usually right-sided failure)

Tamponade Constriction



• Low output: fatigue, weakness, exercise intolerance. A MS. anorexia

• Congestive: left-sided -» dyspnea, orthopnea, paroxysmal nocturnal dyspnea right-sided — peripheral edema. RUQ discomfort

Functional classification (New York Heart Association)

• Class I: symptomatic only with greater than ordinary activity

• Class II: symptomatic with ordinary activity

• Class III: symptomatic with minimal activity

• Class IV: symptomatic at rest

Physical exam (JAMA 2002:287:628)

• Hemodynamic profile

T JVP (80% Of the time JVP 10-PCWP 22.J Hecrt Lunf from 1999:18:1126) <• hepatojugular reflux 1 cm t in JVP for -15 sec with abdominal pressure

73% Se & 87% Sp for RA 8 and 55% Se & 83% Sp for PCWP 15 (AfC 1990.66:1002) Valsalva square wave (1 SBP thru strain) (/ama 1996:275 630)

S3 (in Pts w/ HF — 40% T risk of HF hosp.or pump failure death: nejm 2001:345 574) rales, dullness at base Y pleural effus. (often absent due to lymphatic compensation) • hepatomegaly, ascites and jaundice, peripheral edema Perfusion ("warm" vs. "cold"): narrow pulse pressure (- 25% of SBP). cool & pale extremities. 1 UOP. muscle atrophy

• Other signs: • Cheyne-Stokes respirations, abnormal PMI (diffuse, sustained, or lifting depending on cause of heart failure). S« (diastolic dysfunction), r murmurs (valvular disease, distorted MV annulus. displaced papillary muscles)

Evaluation for the presence of heart failure

• CXR: pulm edema, pleural effusions (usually R > L). • cardiomegaly, Kerley B-lines

• Natriuretic peptides (BNP & NT-proBNP) to exclude HF as cause of dyspnea (see

"Dyspnea"); also to predict risk of rehosp. (Gre 2003:107:1278)

• Evidence of i perfusion to vital organs: 1 BUN, Î Cr. I serum Na. abnormal LFTs

• Echocardiogram: ; EF and t chamber size -» systolic dysfxn hypertrophy, abnormal MV inflow, tissue Doppler abnormalities -* ? diastolic dysfxn valvular abnormalities: pericardial abnormalities

• PA catheterization: î PCWP. i CO and T SVR (low-output failure)

Evaluation of the causes of heart failure

• ECG: evidence for CAD. LVH. LAE. heart block (? infiltrative CMP), low voltages (? DCMP)

• Coronary angiography (or ? CT coronary angiography)

• If no CAD. w/u for nonischemic DCMP. HCMP. or RCMP (see "Cardiomyopathies")

Diet, exercise ACEI

ATII receptor blockers (ARBs)

Hydralazine • nitrates


(data for Carvedilol, metoprolol. bisoprolol) Aldosterone antagonists

Biventricular pacing

Diuretics Digoxin

Anticoagulation Restoration of sinus rhythm

Treatment of Chronic Heart Failure

Na 2g/d, fluid restriction, exercise training in ambulatory Pts 40% i mort-in NYHA IV (CONSENSUS. nejm 1987:316:1429) 16% I morLin NYHA ll/lll (SOLVD-T.N^M 1991:325:293) 20% 1 mort. in asx, post-MI. EF -40% (Save nejm 199*327:669) 20% 1 reMI; 20-30% 1 rehosp for HF (t amt of benefit wI I EF) 30% 1 HF in asx Pts w/ EF 35% (SOLVD-RNQM 1992.327 685) High-dose ACEI ( - 30 mg/d of lisinopril) more efficacious than low-dose (<5 mg/d) (ATLAS.On 1999:1002312) Watch for azotemia, t K (can ameliorate by low-K diet, diuretics, kayexalate). cough, angioedema Consider in Pts with i EF and sx, in addition to ACEI or as alternative if cannot tolerate ACEI (eg, blc cough) Non-inferior to ACEI (VAUANT.n^m 2003:349.1893) Good alternative if ACEI intol (CHARMAhffracwiawt 2003361772) 25% I HF (Vai-HEFT, nejm 2001:345 1667) and 15% 1 mort. when added to ACEI (CHARM-Added. Lancet 2003:362767) Consider if cannot tolerate ACEI/ARB or in blacks wI Gass lll/IV 25% I mort. dw placebo (V-H«FT I, nejm 1986:314:1&47) Inferior to ACEI (V-HcFT II.NQM 1991:325:303) 40% i mort. in blacks on standard Rx (A-HeFT. nejm 2004:351:2049) EF will transiently I, then T. Contraindic in decompensated HF. 35% i mort. & 40% I rehosp. in NYHA ll-IV (/ama 2002:287:883) Carvedilol superior to metoprolol tartrate (COMET. Lancet 2003:3627) Consider if HF severe or post-MI. odeq. renal fxn; watch for T K 30% 1 mort. in NYHA lll/IV & EF 35% (RALES, nejm 1999:341 709) 15% J mort. in HF post-MI. EF 40% <ephesus.n^m 2003:3481309) Consider if rcfroctory HF, EF .35%, and QRS ■ 120 ms. and especially if also evid. of dyssynchrony on echocardiography 36% 1 mortality & improved EF (CARE-hf, nejm 2005:3521539) Consider in I" prevention if I EF or for 2° prevention i mort. in Pts w/ Ml & EF s 30% (MADit ii.ne/m 2002346:877) (but no A mort 6-40 d post-MI; dinamit.nqm 2004:3512481) 23% i mort in all DCMP. EF - 35% (SCD-HoFT. nejm 2005:352225) 1 arrhythmic death in nonisch DCMP (DEFINITE, nejm 2004:350^2151) Loop • thiazides diuretics (sx relief; no mortality benefit) 23% i HF hosp.no A mortality (DJG trul. nejm 1997:336:525) ! t mort in women. ? related to * levels (nejm 2002347.1403) ? optimal dig concentration 0.5-0.8 ng/ml (/ama 2003289:871) Consider if AF, LV thrombus, large akinetic IV segment, EF ■ 30% Catheter ablation of AF 21% T in EF. improvement in sx. exercise capacity. & QoL (nejm 2004:351:2373)

(Ore 2002:105:2099.2223; NEJM 2003:348:2007)

Recommended Therapy by CHF Stage

Stage (Not NYHA Class) Pt Characteristics Therapy


High risk for HF © Structural heart dz Asx

HTN.DM.CAD Cardiotoxin exposure FHx of CMP

Treat HTN. lipids. DM. SVT D/c smoking. EtOH Encourage exercise AC El if HTN. DM. CVD. PAD


© Structural heart dz Asx

Prior Ml. 1 EF. LVH Or Asx valvular dz

All measures for stage A AC El & ßB if MI/CAD or i EF


(+) Structural heart dz © Symptoms of HF (prior or current)

Overt HF

All measures for stage A ACEI. ßB. diuretics. Na restrict Consider aldactone. ICD. BiV Consider nitrate/hydral. digoxin


Refractory HF requiring specialized interventions

Sx despite maximal medical Rx

All measures for stage A-C Mechanical assist devices Transplant. IV inotropes

Précipitants of acute heart failure

• Myocardial ischemia or infarction

Renal failure (acute, progression of CKD. or insufficient dialysis) " preload

• Hypertensive crisis (incl. from RAS), worsening AS » Î L-sided afterload

Dietary indiscretion or medical noncompliance

• Drugs (|JB. CCB. NSAIDs.TZDs) or toxins (EtOH. anthracydines)

• Myocarditis, infective endocarditis, arrhythmias

• COPD or PE t R-sided afterload

• Anemia, systemic infection, thyroid disease

Treatment of acute pulmonary edema (LMNOP)

• Morphine (i sx of dyspnea + venodilator afterload reduction)

• Nitrates (venodilator)

• Oxygen & non-invasive ventilation (i mort.;JAMA 2005:294 3124; tone« 2006:367.1155)

• Position (sit Pt up & have legs dangling over side of bed 1 preload)

Treatment of advanced heart failure (/ama 2002:287628)

• Tailored Rx w/ PA catheter (qv); goals of MAP 60. CI 12. SVR 800. PCWP 18

• IV vasodilators: NTG. nitroprusside (risk of coronary steal in Pts w/ CAD)

nesintide i PCWP & sx {JAMA 2001287:1531). but may Î Cr & mortality (/ama 2005:293:1900)

• Inotropes (properties in addition to î inotropy listed below)

dobutamine: vasodilation at doses p.g/kg/min; mild i PVR; desensitization over time dopamine: splanchnic vasodil. t GFR & natriuresis; vasoconstrict at pig/kg/min milrinone: prominent systemic & pulmonary vasodilation; I dose by 50% in renal failure

• Ultrafiltration: 1 L greater fluid loss at 48 h and 50% i in rehosp. (/acc 2007:49:675)

• Mechanical circulatory support intraaortic balloon pump (IABP): 1 afterload & î coronary perfusion ventricular assist device (LVAD): can use as a bridge to transplantation; as destination therapy (48% l mort, c/w med Rx: REMATCH. NEjM 2001:345:1435). or possibly as platform for recovery (Ntyvi 2006:355:1873); percutaneous VAD under study

• Cardiac transplantation: 15-20% mort, in 1st year, median survival 10 y

Heart failure with preserved EF (Cire 2002:105:1387.1503 & 2003.107:659. ne/m 2004.351 1097)

• 40-60% of Pts w/ HF have normal or only min. impaired systolic fxn (EF -40%) <NEJM

2006:355:251,260). Mortality rates similar to those w/ systolic dysfxn. 30% of population over age 45 wI diastolic dysfxn on echo. 20% mild. - 10% mod/sev. but only 50% of severe and 5% of moderate cases were symptomatic (/ama 2003:289:194)

• Etiologies causes of impaired relaxation: ischemia, LVH. HCMP, aging, hypothyroidism causes of 1 passive stiffness: prior Ml. LVH. RCMP

• Diagnosis: clinical s/s of HF w/ preserved systolic and impaired diastolic fxn:

abnormal MV inflow: E/A reversal and As in E wave deceleration time I myocardial relax.: 1 isovolumic relax, time and i early diastole tissue Dopplcr velocity LV hypertrophy. LA dilatation

• Treatment: diuresis for volume overload. Na/fluid restriction

HR & BP control w/ (3B. CCB.ACEI.ARB (i rehosp.. CHARM.fYeicrved.Looc« 2003:362 777) relief of ischemia, statins

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