DR. Med. Dr.

Tike Hari Pratikto, SpJP, FIHA,FICA

DEFINITION
The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. (E. Braunwald) The inability of the heart to pump blood forward at a sufficient rate to meet the metabolic demands of the body (forward failure), or the ability to do so only if the cardiac filling pressure are abnormally high (backward failure), or both. (Pathophysiology of Heart Disease 4 th ed, Liily, Leonard S)

DEFINITION
Heart Failure is a clinical syndrome in which patients have the following features :

Symptoms typical of HF (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling

And

Signs typical of HF
(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly)
And

Objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart soud, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration)

Symptoms

ACC/AHA A New Approach To The Classification of HF

At Risk For Heart Failure
Stage A At high risk of HF but without structural heart disease or symptoms of HF Stage B structural heart disease but without signs/symptoms of HF

Heart Failure
Stage C Structural heart disease with prior or current symptoms of HF Stage D Refractory HF requiring specialized interventions

e.g. patient with -Hypertension -Atherosclerosis disease -Diabetes -Obesity -Metabolic syndr -Using cardiotoxin -with Familial history
Structural heart disease

e.g. patient with -Previous MI -LV remodeling: including LVH, low EF -Asymptomatic valvular disease

e.g. patient with -Known structural heart disease -Shortness of breath and fatigue, reduced exercise tolerance

Development of HF symptoms

Refractory symptoms of HF at rest

e.g. patient with -Who have marked symptoms at rest despite maximal medical therapy (recurrently hospitalized /cannot be safely discharged from hospital without specialized intervention

2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

Determinant of ventricular function

CONTRACTILITY PRELOAD STROKE VOLUME
- Synergistic LV contraction - LV wall integrity - Valvular competence

AFTERLOAD

HEART RATE CARDIAC OUTPUT

TREATMENT
The goal of treatment : relieve symptoms and signs prevent hospital admission improve survival Treatment strategy for the use of drugs in patients with HR-REF Three neurohumoral antagonist ACE inhibitor (or Angiotensin Receptor Blocker (ARB)) Beta-blocker MRA (Mineralocorticoid Receptor Blocker) The aforementioned drugs commonly used in conjunction with a diuretic given to relieve the symptoms and signs of congestion

Evaluation of acutely decompensated chronic HF

THANK YOU

Diagnosis of heart failure

The diagnosis of HF-REF requires three conditions to be satisfied : The diagnosis of HF-PEF requires for conditions to be satisfied :

Symptoms typical of HF

Symptoms typical of HF

Signs typical of HF

Signs typical of HF

Reduced LVEF

Normal or only mildly reduced LVEF and LV not dilated Relevant structural heart disease (LV hypertrophy/LA enlargement) and/or diastolic dysfunctions

Diuretics
Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion

Initiation of diuretic therapy Check renal function and serum electrolytes

Most patients are prescribed loop diuretics rather than thiazides due to higher efficiency of induced diuresis and natriuresis
Self-adjustment of diuretic dose based on daily weight-measurements and other clinical signs of fluid retention should be encouraged in HF outpatient care. Patient education is required

ACE inhibitors
Patients who should get ACEI LVEF 40%, irrespective of symptoms

Initiation of an ACEI : Check renal function and serum electrolytes Consider dose up-titration after 2-4 weeks Do not increase dose if worsening renal function or hyperkalaemia It is common to up-titrate slowly but more rapid titration is possible in closely monitored patients

ACE Inhibitors (Dosage)

Starting dose (mg) ACE Inhibitors Captopril Enalapril Lisinopril Ramipril Trandolapril 6.25 mg t.i.d 2.5 b.i.d 2.5- 5 o.d 2.5 o.d 0.5 o.d 50 t.i.d 10-20 b.i.d 20-35 o.d 5 o.d 4 o.d Target dose (mg)

ACE Inhibitors (Potential adverse effect)

Worsening renal function Cr up to 50% from baseline / < 265 mmol/L (~3 mg/dL) acceptable Cr 265 mmol/L (~3.0 mg/dL) - 310 mmol/L (~3.5 mg/dL) halve dose of ACEI and monitor blood chemistry closely Cr > 310 mmol/L (~3.5 mg/dL) stop ACEI immediately and monitor blood chemistry closely Hyperkalemia K > 5.5 mmol/L halve dose of ACEI and monitor blood chemistry closely K > 6.0 mmol/L stop ACEI immediately and monitor blood chemistry closely Symptomatic hypotension

Reduce the dose of diuretics and other hypotensive agents (except ARB/ b-blocker / dosterone antagonist)
Cough troublesome cough switch to an ARB

ARBs
Patients who should get an ARB LVEF 40% and either As an alternative in patients with mild to severe symptoms (NYHA fc II-IV) who are intolerant of an ACEI Or in patients with persistent symptoms (NYHA fc IV) despite treatment with an ACEI and beta blocker

Initiation of an ARB Check renal function and serum electrolytes

Consider dose up-titration after 2-4 weeks

Do not increase dose if worsening renal function or hyperkalaemia It is common to up-titrate slowly but more rapid titration is possible in closely monitored patients

ARBs (dosage)
Starting dose (mg) Target dose (mg)

ARB
Candesartan 4 or 8 mg o.d 32 o.d

Valsartan
Losartan

40 b.i.d
50 o.d

160 b.i.d
150 o.d

Beta-blockers
Patients who should get a beta-blocker LVEF 40%

Mild to severe symptoms (NYHA fc II-IV)

Optimal dose level of an ACEI or/and ARB Patients should be clinically stable (e.g. no recent change in dose of diuretic)

Initiation of a beta-blocker Beta-blocker may be initiated prior to hospital discharge in recently decompensated patients with caution

Visits every 2-4 weeks to up-titrate the dose of beta-blocker (slower dose uptitration may be needed in some patients). Do not increase dose if signs of worsening HF, symptomatic hypotension (e.g. dizziness) or excessive bradycardia (pulse rate <50/minute) at each visit

Beta-blockers (dosage)
Starting dose (mg) Target dose (mg)

Beta blockers Bisoprolol

Carvedilol Metoprolol (CR/XL) Nebivolol

1.25 mg o.d
3.125 b.i.d 12.5/25 o.d 1.25 o.d

10 o.d
25-50 b.i.d 200 o.d 1o.d

Mineralocorticoid receptor antagonist (MRA)

Patients who should get an MRA LVEF 35% Moderate to severe symptoms (NYHA fc II-IV) Optimal dose of beta-blocker and an ACEI or an ARB (but not an ACEI and an ARB)

Initiation of spironolactone (eplerenone) Check renal function and serum electrolytes Consider up-titration after 4-8 weeks. Do not increase dose if worsening renal function or hyperkalaemia

Diuretics and MRAs (dosage)

MRA (potential adverse effects)

Potential adverse effect Hyperkalemia K > 5.5 halve dose K > 6.0 stop Worsening renal function Cr > 220 umol/L (~2.5 mg/dl) halve dose Cr > 310 umol (~3.5 mg/dl) stop

Breast tenderness and/ enlargement Switch from spironolactone to eplerenone

Ivabradine
Ivabradine is a drug that inhibits the I f channel in the sinus node. Its only known pharmacological effect is to slow heart rate in patients in sinus rhythm (it does not slow the ventricular rate in AF)

Patients who should get an Ivabradine

Mild to severe symptoms (NYHA fc II-IV) Sinus rhythm with a rate 70 bpm LVEF 35%

Digoxin
In patients in sinus rhythm with symptomatic HF and LVEF 40%, this treatment improve patient well -being and reduce hospital admission for worsening HF Patients in AF with ventricular rate at rest >80, and at exercise >110-120 beat/minute should get digoxin

In patients with sinus rhythm and left ventricular systolic dysfunction (LVEF 40%) receiving optimal doses of diuretic, ACEI or/and ARB, beta-blocker and aldosterone antagonist if indicated, who are symptomatic, digoxin may be considered )

Hydralazine and ISDN

Patients who should get H-ISDN An alternative to an ACEI/ARB where both of the latter are not tolerated As add-on, therapy to an ACEI if ARB or aldosterone antagonist is not tolerated or if significant symptoms persist despite therapy with an ACEI, ARB, beta-blocker, and aldosterone antagonist Initiation of H-ISDN Consider dose up-titration after 2-4 weeks. Do not increase dose with symptomatic hypotension

Arrhythmia, bradycardia, and atrioventricular block in patients with heart failure with reduced EF and heart failure with preserved EF
Atrial Fibrillation
The most common arrhythmia in HF
increases the risk of thrombo-embolic complications (particularly stroke) and may lead to worsening of symptoms The following issues need to be considered in patients with HF and AF, especially a first episode of AF or paroxysmal AF: Identification of correctable causes (e.g. hyperthyroidism, electrolyte disorders, uncontrolled hypertension, mitral valve disease). Identification of potential precipitating factors (e.g. recent surgery, chest infection or exacerbation of chronic pulmonary disease/asthma, acute myocardial ischaemia, alcohol binge) as this may determine whether a rhythm-control strategy is preferred to a rate-control strategy. Assessment for thromboembolism prophylaxis.

Atrial Fibrillation
Thrombo-embolism prophylaxis

Ventricular arrhythmia in HF

Importance and management of other co-morbidity in HF-REF and HF-PEF

Angina

Chronic obstructive pulmonary disease and Asthma may cause diagnostic difficulties, especially in HF-PEF

Beta-blockers are contraindicated in asthma but not in COPD selective beta-1 adrenoceptor antagonist (i.e. bisoprolol, metoprolol succinate, or nebivolol) Preferred
Oral corticosteroids cause sodium and water retention worsening of HF

Diabetes Melitus
Associated with poorer functional status and worse prognosis

Prevented by treatment with ARBs and possibly ACE inhibitors.

Beta-blockers are NOT contraindicated in diabetes and are as effective in improving outcome in diabetic patients as in nondiabetic individuals

Thiazolidinediones (glitazones) sodium and water retention and increased risk of worsening HF and hospitalization
Metformin is NOT recommended in patients with severe RENAL or HEPATIC IMPAIRMENT

HYPERTENSION

Acute Heart Failure

Defined as the rapid onset of, or change in, symptoms and signs of HF. It may occur with or without previous cardiac disease.

ESC guidelines for the Diagnosis & Treatment of Acute and Chronic Heart Failure 2012

Epidemiology
In Europe, Scottish data, in a hospital registry survey 4,7% of hospitalizations in women, and 5,1% in men were do to HF The crude incidence of HF of all grades of severity varies from 2,3 to 3,7 per 1000 per annum

CHD is the aetiology of AHF in 60-70% of patient, particularly in the elderly peoples, while in young subjects, frequently cause by DCM, arrhythmia, congenital or valvular heart disease, or myocarditis

Precipitants and causes

Clinical classification
Worsening or decompensated chronic HF
There is usually a history of progressive worsening of known chronic HF on treatment and evidence of systemic and pulmonary congestion

Pulmonary oedema
Present with severe respiratory distress, tachypnoea and orthopnoea with rales over on lung fields. Artery O2 saturation is usually <90%

Hypertensive HF
Signs and symptoms of HF accompanied by high blood pressure and usually relatively preserved left ventricular systolic function

Cardiogenic shock
Defined as evidence of tissue hypoperfusion induced by HF after adequate correction of preload and major arrhythmia

Isolated right HF
Characterized by a low output syndrome in the absence of pulmonary congestion

ACS and HF
Clinically depicted symptoms and laboratory evidence of an ACS.

Treatment of acute heart failure

Oxygen Given to treat hypoxemia (SpO2 <90%). And should not be used routinely in non-hypoxemic patients causes vasoconstriction & reduced cardiac output Diuretics

 Vasodilators

 Positive Inotropes or vasopressors or both

Goals of treatment in acute heart failure

Immediate (ED/ICU/ICCU) Treat symptoms Restore oxygenation Improve haemodynamics and organ perfusion Limit cardiac and renal damage Prevent thrombo-embolism Minimize ICU length of stay

EPIDEMIOLOGY
Most of the knowledge about the epidemiology, risk factors,prognosis, treatment, and prevention of HF is based on North American and European studies
Europe The prevalence of symptomatic HF range from 2-3% Prevalence in 70- to 80-year-old people is between 10 and 20%. 15 million HF pts in 900 million total population Overall 50% of patients are dead at 4 years. Forty per cent of patients admitted to hospital with HF are dead or readmitted within 1 year
(ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure ,2008)

USA Nearly 5 million HF pts. 500,000 pts are HF for the 1st time each year. Last 10 years number of hospitalizations has increased. Nearly 300,000 patients die of HF each year.

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Terminology related to the time-course of heart failure

A patient who/whose Never exhibited the typical signs or symptoms of HF asymptomatic LV systolic dysfunction Have had HF chronic HF Chronic stable HF conditions deteriorates decompensated Chronic stable HF resolves from acute condition compensated HFs condition presents acutely New (de novo) HF

Suspected Heart Failure

Acute onset

Non-acute onset

ECG Chest x-ray Echocardiography BNP/NT-pro BNP

ECG Possibly Chest x-ray

BNP/NT-pro BNP

Echocardiography

ECG normal and NT-proBNP <300 pg/mL or BNP <100 pg/mL

ECG abnormal or NT-proBNP 300 pg/mL or BNP 100 pg/mL

ECG abnormal or NT-proBNP 125 pg/mL or BNP 35 pg/mL

ECG normal and NT-proBNP <125 pg/mL or BNP <35 pg/mL

Heart failure unlikely

Echocardiography
If heart failure confirmed, determine aetiology and start appropiate treatment

Heart failure unlikely

Starting dose (mg) MRA Eplerenone Spironolactone 25 mg o.d 25 o.d

Target dose (mg) 50 o.d 25-50 o.d