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    Chap253-Heart Failure Management

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    Doctor Castle
    1) Heart failure is defined as a clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood, leading to symptoms like dyspnea and fatigue. 2) Management involves treating different types of heart failure like HFpEF, HFrEF, and acute decompensated heart failure. It also involves managing comorbidities and using devices and therapies to improve cardiac function. 3) Drug therapies that block the renin-angiotensin-aldosterone system and beta blockers form the cornerstone of treatment for HFrEF to reduce symptoms, hospitalizations, and mortality. Other therapies aim to further improve cardiac function and reduce sudden cardiac death risk.

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    Chap253-Heart Failure Management

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    Doctor Castle
    31 views42 pages
    1) Heart failure is defined as a clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood, leading to symptoms like dyspnea and fatigue. 2) Management involves treating different types of heart failure like HFpEF, HFrEF, and acute decompensated heart failure. It also involves managing comorbidities and using devices and therapies to improve cardiac function. 3) Drug therapies that block the renin-angiotensin-aldosterone system and beta blockers form the cornerstone of treatment for HFrEF to reduce symptoms, hospitalizations, and mortality. Other therapies aim to further improve cardiac function and reduce sudden cardiac death risk.

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    1) Heart failure is defined as a clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood, leading to symptoms like dyspnea and fatigue. 2) Management involves treating different types of heart failure like HFpEF, HFrEF, and acute decompensated heart failure. It also involves managing comorbidities and using devices and therapies to improve cardiac function. 3) Drug therapies that block the renin-angiotensin-aldosterone system and beta blockers form the cornerstone of treatment for HFrEF to reduce symptoms, hospitalizations, and mortality. Other therapies aim to further improve cardiac function and reduce sudden cardiac death risk.

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    © All Rights Reserved
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    31 views42 pages

    Chap253-Heart Failure Management

    Uploaded by

    Doctor Castle
    1) Heart failure is defined as a clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood, leading to symptoms like dyspnea and fatigue. 2) Management involves treating different types of heart failure like HFpEF, HFrEF, and acute decompensated heart failure. It also involves managing comorbidities and using devices and therapies to improve cardiac function. 3) Drug therapies that block the renin-angiotensin-aldosterone system and beta blockers form the cornerstone of treatment for HFrEF to reduce symptoms, hospitalizations, and mortality. Other therapies aim to further improve cardiac function and reduce sudden cardiac death risk.

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    of 42

    HEART

    FAILURE:
    Management
    BY: PGI Czarine P. Castillon
    What is Heart Failure?
    Defined as a complex clinical syndrome that results from
    structural or functional impairment of ventricular filling
    or ejection of blood, which in turn leads to the cardinal
    clinical symptoms of dyspnea and fatigue and signs of
    HF, namely edema and rales.

    Accdg to American College of Cardiology Foundation (ACCF)/American Heart


    Association (AHA) guidelines
    Management:

    01 HFpEF
    HF with preserved EF
    (40-50%) 02 ADHF
    Acute Decompansated
    Heart Failure

    03 04
    HFrEF Mgt of Selected
    Heart Failure with Co-morbidity
    reduced EF (40%)
    Management:

    Cardiac

    05 Resynchronization
    Therapy 06 SCD Prevention

    07 08
    Surgical Disease Mgt and
    Therapy Supportive Care
    01
    HFpEF
    Therapeutic targets: control of congestion,
    stabilization of heart rate and blood pressure,
    and efforts at improving exercise tolerance.
    02
    ADHF
    A heterogeneous clinical syndrome most often
    resulting in need for hospitalization due to
    confluence of interrelated abnormalities of
    decreased cardiac performance, renal dysfunction,
    and alterations in vascular compliance.
    Parameters assoc with worse outcomes:

    BUN >43 mg/dL SBP <115 mmHg

    S. Creatinine
    Elevated troponin I
    >2.75 mg/dL
    ADHF
    ADHF
    ● It is generally advisable to continue diuresis until euvolemia has been achieved.
    ● CARDIORENAL SYNDROME, an increasing cpx of ADHF, it reflects the interplay
    between abnormalities of heart and kidney function, with deteriorating function of one
    organ while therapy is administered to preserve the other.
    ● ULTRAFILTRATION is an invasive fluid removal technique that may supplement the need
    for diuretic therapy. Study argues against using UF as a primary strategy in patients with
    ADHF who are nonetheless responsive to diuretics.
    ● Inotropic therapy in those with a low-output state augments cardiac output, improves
    perfusion, and relieves congestion acutely.
    ● Studies are in universal agreement that long-term inotropic therapy increases mortality.
    ● Currently indicated as bridge therapy (to either left ventricular assist device support or to
    transplant) or as selectively applied palliation in end-stage heart failure.
    03
    HFrEF
    RAAS blockers and betablockers form the
    cornerstone of pharmacotherapy
    RAAS blockers and beta blockers lead to attenuation of decline
    and improvement in cardiac structure and function with
    consequent reduction in symptoms, improvement in QOL,
    decreased burden of hospitalizations, and a decline in mortality
    from both pump failure and arrhythmic deaths
    Neurohormonal Antagonism
    Neurohormonal Antagonism
    ● Meta-analyses suggest a 23% reduction in mortality and a 35% reduction in the
    combination endpoint of mortality and hospitalizations for heart failure in patients
    treated with ACEIs.
    ● Patients treated with beta blockers provide a further 35% reduction in mortality on
    top of the benefit provided by ACEIs alone.
    ● Optimally titrated doses of both ACEIs and beta blockers should be established in a
    timely manner
    Mineralocorticoid Antagonists

    ● Aldosterone antagonism is associated with a reduction in mortality in all stages of


    symptomatic NYHA class II to IV HFrEF.
    ● Elevated Aldosterone levels promote sodium retention, electrolyte imbalance, and
    endothelial dysfunction and may directly contribute to myocardial fibrosis
    ● Renal function and serum potassium levels must be closely monitored.
    RAAS THERAPY AND NEUROHORMONAL
    “ESCAPE”

    ● Neurohormonal “escape” that circulating levels of angiotensin II return to pretreatment


    levels with long-term ACEI therapy.
    ● ARBs blunt this phenomenon by binding competitively to the AT1 receptor.
    ● Initial clinical strategy:
    A two-drug combination: ACEI and BB
    ACEI and ARB (if beta blocker intolerant)
    ARB and BB (if ACEI intolerant)
    ● In symptomatic patients (NYHA class II–IV), an aldosterone antagonist should be strongly
    considered, but four-drug therapy should be avoided.
    ARTERIOVENOUS VASODILATION

    ● The combination of hydralazine and nitrates has been demonstrated to improve survival
    in HFrEF.
    ● Hydralazine - reduces systemic vascular resistance and induces arterial vasodilatation by
    affecting intracellular calcium kinetics.
    ● Nitrates - transformed in smooth muscle cells into nitric oxide, which stimulates CGMP
    production and consequent arterial-venous vasodilation.
    NOVEL NEUROHORMONAL
    ANTAGONISM

    ● Endothelin antagonist bosentan is associated with worsening heart failure in HFrEF.


    ● Moxonidine worsens outcomes in left heart failure
    ● Omapatrilat hybridizes an ACEI with a neutral endopeptidase inhibitor, does not
    favorably influence the primary outcome measure of the combined risk of death or
    hospitalization for heart failure requiring intravenous treatment.
    ● Sacubitril-valsartan shows a survival benefit in a large trial versus ARB alone
    EECP
    • Enhanced External Counterpulsation
    • Peripheral lower extremity therapy using graded external pneumatic compression
    at high pressure is administered in 1-h sessions for 35 treatments (7 weeks) and has
    been proposed to reduce angina symptoms and extend time to exercise-induced
    ischemia in patients with coronary artery disease.
    • Randomized trial improved exercise tolerance, QOL, and NYHA functional
    classification but without an accompanying increase in peak oxygen consumption.
    Adjunctive Tx: EXERCISE
    ● It is safe, improved patients’ sense of well-being, and correlated with a trend
    toward mortality reduction.
    ● Maximal changes in 6-min walk distance were evident at 3 months with significant
    improvements in cardiopulmonary exercise time and peak oxygen consumption
    persisting at 12 months.
    04
    Mgt of Selected
    Comorbidity
    Management of Selected Comorbidity

    ● Sleep-disordered breathing (OSA,


    CSA, Cheyne-Stokes)
    ● Anemia
    ● Depression
    ● Atrial Arrhythmias
    ● Diabetes Mellitus
    CO-MORBIDITY TREATMENT
    Nocturnal positive airway pressure improves oxygenation, LVEF, and 6-min
    walk distance.
    Sleep-disordered breathing
    However, no conclusive data exist to support this therapy as a disease-
    modifying approach with reduction in mortality.
    Oral iron supplementation does not appear to be effective in treating iron
    Anemia
    deficiency in heart failure.
    Sertraline is safe.
    Depression However, it did not provide greater reduction in depression or improve
    cardiovascular status among patients with heart failure and de
    Atrial Arrhythmias (AFIB) Amiodarone and Dofetilide,
    Thiazolidinediones is associated with worsening heart failure.
    Empagloflozin was tested in the EMPA-REG study and demonstrated a
    Diabetes Mellitus
    decrease in cardiovascular mortality as well as hospitalizations for heart
    failure.
    Neuromodulation Using Device Therapy
    ● Vagus nerve stimulation did not reduce the rate of death or hospitalization for HF.
    However, functional capacity and QOL were favorably affected by vagus nerve
    stimulation.
    05
    Cardiac
    Resynchronization
    Therapy
    Mechanical Dyssynchrony
    ● Results in an increase in wall stress and worsens functional mitral regurgitation.
    ● The single most important association of extent of dyssynchrony is a widened QRS
    interval on the ECG particularly in the presence of a left bundle branch block
    pattern.
    CRT
    ● Enables a more synchronous ventricular contraction by aligning the timing of
    activation of the opposing walls.
    ● Indication: QRS width >149ms and LBBB pattern
    06
    Sudden Cardiac
    Death Prevention
    ● Two single most important risk markers for stratification of need and benefit:
    1. Degree of residual left ventricular dysfunction despite optimal medical
    therapy (≤35%) to allow for adequate remodeling.
    2. Underlying etiology (post–myocardial infarction or ischemic cardiomyopathy)
    ● Candidates for ICD:
    1. Patients with NYHA class II or III symptoms of heart failure
    2. LVEF <35%, irrespective of etiology of heart failure,
    07
    Surgical Therapy
    Coronary Artery Bypass Grafting (CABG)
    ● Considered in patients with ischemic cardiomyopathy with multivessel coronary
    artery disease.
    ● Revascularization is most robustly supported in individuals with ongoing angina
    and left ventricular failure.
    Surgical Ventricular Restoration (SVR)
    ● a technique character ized by infarct exclusion to remodel the left ventricle by
    reshaping it surgically in patients with ischemic cardiomyopathy and dominant
    anterior left ventricular dysfunction, has been proposed.
    Mitral Regurgitation
    ● Ischemic MR (or infarct-related MR) is typically associated with leaflet tethering and
    displacement related to abnormal left ventricular wall motion and geometry.
    ● No evidence to support the use of surgical or percutaneous valve correction for
    functional MR exists as disease-modifying therapy even though MR can be
    corrected.
    08
    Disease Mgt and
    Supportive Care
    ● Nearly half of all patients readmitted to hospital within 6 months of discharge.
    ● Early postdischarge follow-up, whether by telephone or clinic-based, may be
    critical to ensuring stability because most heart failure–related readmissions tend
    to occur within the first 2 weeks after discharge.
    ● Vaccinations: Influenza and Pneumococcal vaccines,
    THANKS!
    Do you have any questions?

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