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    Congestive Heart Failure: Roy V, Jutzy, MD

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    Irakiza jean jacques
    This document discusses congestive heart failure, including its definition, types, diagnosis, assessment, treatment strategies, and manifestations. It defines CHF as the heart being incapable of maintaining an adequate cardiac output to meet metabolic demands. Treatment focuses on controlling risk factors, medications like diuretics, ACE inhibitors, beta blockers, and vasodilators, and symptom relief.

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    Congestive Heart Failure: Roy V, Jutzy, MD

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    Irakiza jean jacques
    20 views46 pages
    This document discusses congestive heart failure, including its definition, types, diagnosis, assessment, treatment strategies, and manifestations. It defines CHF as the heart being incapable of maintaining an adequate cardiac output to meet metabolic demands. Treatment focuses on controlling risk factors, medications like diuretics, ACE inhibitors, beta blockers, and vasodilators, and symptom relief.

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    HEART FAILURE .

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    This document discusses congestive heart failure, including its definition, types, diagnosis, assessment, treatment strategies, and manifestations. It defines CHF as the heart being incapable of maintaining an adequate cardiac output to meet metabolic demands. Treatment focuses on controlling risk factors, medications like diuretics, ACE inhibitors, beta blockers, and vasodilators, and symptom relief.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    Download as ppt, pdf, or txt
    20 views46 pages

    Congestive Heart Failure: Roy V, Jutzy, MD

    Uploaded by

    Irakiza jean jacques
    This document discusses congestive heart failure, including its definition, types, diagnosis, assessment, treatment strategies, and manifestations. It defines CHF as the heart being incapable of maintaining an adequate cardiac output to meet metabolic demands. Treatment focuses on controlling risk factors, medications like diuretics, ACE inhibitors, beta blockers, and vasodilators, and symptom relief.

    Copyright:

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    of 46

    CONGESTIVE HEART FAILURE

    Roy V, Jutzy, MD

    LOMA LINDA UNIVESITY


    TREATMENT STRATEGIES
    Diuretics Vasodilators Symptom
    Inotropics relief

    Neurohumoral activation
    ACE-is, -blockers Prevention
    Spironolatone of disease
    progression
    ARBs?, ANP?
    ET-1?
    Gene Anti-remodeling Reversal
    therapy? strategies of HF
    Mann. Circulation 1999; 100: 999-1008
    DEFINITION
    “The situation when the heart is
    incapable of maintaining a cardiac
    output adequate to accommodate
    metabolic requirements and the
    venous return."
    E. Braunwald
    Cardiac Output
    • CO = HR X SV
    • HR
    Activity
    Body temperature
    Drugs
    • Stroke volume
    Contractility
    Preload
    DETERMINANTS OF
    VENTRICULAR FUNCTION
    CONTRACTILITY

    PRELOAD AFTERLOAD

    STROKE
    VOLUME

    - Synergistic LV contraction HEART


    - LV wall integrity RATE
    - Valvular competence

    CARDIAC OUTPUT
    TYPES of CHF
    • LEFT
    • RIGHT

    •SYSTOLIC
    •DIASTOLIC
    DIAGNOSIS
    CLINICAL
    LEFT
    RIGHT
    ECG
    CHEST XRAY
    CARDIAC ECHO
    NUCLEAR IMAGING
    CARDIO-PULMONARY EXERCISE TEST
    CPX TREADMILL
    DIAGNOSIS
    CLINICAL
    LEFT
    RIGHT
    ECG
    CHEST XRAY
    CARDIAC ECHO
    NUCLEAR IMAGING
    CARDIO-PULMONARY EXERCISE TEST
    CPX TREADMILL
    Assessment of CHF
    FLUID STATUS
    CVP - JVP - HJR(AJR) - Edema - Liver size
    Pulmonary crackles - CXR

    LV FUNCTION
    EF-Echo, Nuclear scan
    Exercise tolerance

    LABORATORY
    NYAH Functional class
    CARDIAC PATIENTS
    CLASS I
    No limitation of physical activity
    CLASS II
    Slight limitation of physical activity
    CLASS III
    marked limitation of physical activity
    CLASS IV
    no physical activity without discomfort
    TREATMENT OBJECTIVES

    Survival
    Morbidity
    Exercise capacity
    Quality of life
    Neurohormonal changes
    Progression of CHF
    Symptoms
    Treatment - General

    • Control Risk Factors


    • Restrict Salt < 3. Gm / day
    • Exercise as tolerated
    • Avoid Cardiac depressant drugs such
    as antiarrhythmia, nsaids
    • Vaccinations - Influenza, Pneumonia
    TREATMENT
    Correction of aggravating factors
    Pregnancy Endocarditis
    Arrhythmias (AF) Obesity
    Infections Hypertension
    Hyperthyroidism Physical activity
    Thromboembolism Dietary excess
    MEDICATIONS
    TREATMENT - Drugs
    •ANGIOTENSIN ENZYME INHIBITORS
    (ACEI)
    •DIURETICS

    •BETA BLOCKERS

    •VASODILATORS

    •DIGITALIS & OTHER IONOTROPES

    •OTHERS Antiarrythmia, Antialdosterone,


    Anticoagulants
    ACEI
    MECHANISM OF ACTION
    VASOCONSTRICTION VASODILATATION
    ALDOSTERONE PROSTAGLANDINS
    VASOPRESSIN Kininogen tPA
    SYMPATHETIC Kallikrein
    Angiotensinogen
    RENIN
    Angiotensin I
    BRADYKININ

    A.C.E. Inhibitor Kininase II

    ANGIOTENSIN II Inactive Fragments


    ACEI
    INDICATIONS

    Clinical cardiac insufficiency


    - All patients

    Asymptomatic ventricular
    dysfunction
    - LVEF < 35 %
    ACEI
    CONTRAINDICATIONS

    Renal artery stenosis


    Renal insufficiency
    Hyperkalemia
    Arterial hypotension
    Intolerance (due to side effects)
    DIURETIC EFFECTS
    Volume and preload
    Improve symptoms of congestion
    No direct effect on CO, but
    excessive preload reduction may
    Improves arterial distensibility
    Neurohormonal activation
    Levels of NA, Ang II and ARP
    Exception: with spironolactone
    Beta Blockers - Clinical Effects

    • Slow sinus rate


    • Prolong PR interval
    • No change in QRS or QT interval
    Beta Blockers - Clinical Uses

    • Post MI -  sudden death


    • Hyperdynamic states -
    Hyperthyroidism Pheochromocytoma
    Exercise Stress - emotional,
    anesthesia
    • Slowing ventricular rate in atrial
    fibrillation or flutter
    VASODILATORS
    CLASSIFICATION
    VENOUS Venous
    Nitrates Vasodilatation
    Molsidomine
    MIXED
    Calcium antagonists
    -adrenergic Blockers
    ACEI
    Angiotensin II inhibitors
    K+ channel activators
    Nitroprusside
    Arterial ARTERIAL
    Vasodilatation Minoxidil
    Hydralazine
    NITRATES
    HEMODYNAMIC EFFECTS
    1- VENOUS VASODILATATION
    Pulmonary congestion
    Ventricular size
    Preload Vent. Wall stress
    MVO2

    2- Coronary vasodilatation
    Myocardial perfusion
    3- Arterial vasodilatation • Cardiac output
    Afterload • Blood pressure

    4- Others
    NITRATES
    CLINICAL USES
    Pulmonary congestion
    Orthopnea and paroxysmal nocturnal
    dyspnea
    CHF with myocardial ischemia
    In acute CHF and pulmonary edema:
    NTG s.l. or i.v.
    DIGOXIN
    CLINICAL USES
    AF with rapid ventricular response
    CHF refractory to other drugs
    Other indications?
    Can be combined with other drugs
    Digitalis - Side effects
    • Cardiac
    • GI - Anorexia Nausea Vomiting
    • CNS - Fatigue, malaise Confusion,
    deliriujm, seizures Visual changes
    CHF - Other Agents
    • Diuretics
    • Vasodilators
    Nitrates
    Hydralazine
    ACE inhibitors
    • Beta blockers
    • Calcium channel blockers
    Digitalis - Clinical Uses
    • CHF -
    Improves symptoms
    No effect on survival
    • Atrial fibrillation, flutter -
    Slows ventricular response
    rate
    ANTIARRHYTHMICS
    Sustained VT, with/without symptoms
    - ß Blockers
    - Amiodarone
    Sudden death from VF
    - Consider
    implantable
    defibrillator
    Beta Blockers - Clinical Uses
    • Post MI -  sudden death
    • Hyperdynamic states -
    Hyperthyroidism Pheochromocytoma
    Exercise Stress - emotional,
    anesthesia
    • Slowing ventricular rate in atrial
    fibrillation or flutter
    New Beta Blockers
    • Carvedilol
    • labetalol
    • Bucindolol

    Slow heart rate Antioxident properties


    reduce arrhythmias
    vasodilation
    protect myocardiial cells from catacholamines
    Digitalis - Cardiac Toxicity
    • Dysrhythmias -
    Atrial tachycardia with block
    Accelerated junctional
    tachycardia PVC’s
    • Conduction abnormalities -
    Sinus bradycardia, arrest, or exit
    block AV node -
    2nd or 3rd degree
    Digitalis - Cardiac Toxicity
    • Dysrhythmias - Atrial tachycardia with
    block Accelerated junctional
    tachycardia PVC’s
    • Conduction abnormalities - Sinus
    bradycardia, arrest, or exit block
    AV node - 2nd or 3rd degree
    ALDOSTERONE INHIBITORS
    INDICATIONS
    FOR DIURETIC EFFECT
    • Pulmonary congestion (dyspnea)
    • Systemic congestion (edema)
    FOR ELECTROLYTE EFFECTS
    • Hypo K+, Hypo Mg+
    • Arrhythmias
    • Better than K+ supplements
    FOR NEUROHORMONAL EFFECTS
    • ? Pending the RALES results
    Beta Agonist Drugs
    • Activate ß1 receptors,  cAMP
    • Potent effects on contractility
      myocardial oxygen demand,
    arrhythmias, vasoconstriction
    • Probable deleterious effect on survival

    Prazosin (minipress) Doxazosin (cardura)


    Beta Blockers - Side Effects
    • CV - bradycardia, hypotension, peripheral
    vasospasm, claudication
    • Respiratory - bronchspasm
    • Potentiationof allergic reactions
    • Metabolic -  response to hypo-glycemia,  HDL,
     TG
    • CNS - fatigue, lethargy, depression, memory,
    hallucinations,  sleep
    • Sexual dysfunction
    CHF - Manifestations
    • Increased venous congestion
    • Decreased cardiac output
    Frank-Starling Curve

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