Thursday Education - Heart Failure Summary


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Heart Failure:

Heart Failure Julia Webster – Old Ward 11/4/13

Learning objectives:

Learning objectives Review heart failure basics Discuss the definition and staging of heart failure based on the most recent American College of Cardiology Foundation and American Heart Association (ACCF/AHA) guidelines Identify which medical therapies have been shown to reduce mortality from heart failure with reduced left ventricular ejection fraction (LVEF) Determine the appropriate sequence of medical therapy for heart failure and reduced LVEF

Definition of heart failure:

Definition of heart failure Cardiac output is inadequate for the body’s requirements

Systolic versus Diastolic:

Systolic versus Diastolic Systolic (lazy) inability of ventricle to contract normally Reduced cardiac output ( ejection fraction <40% ) Cause – IHD, MI, cardiomyopathy Diastolic (stiff) Inability of the ventricle to relax and fill normally Increased filling pressures ( ejection fraction >50% ) Cause – constrictive pericarditis , tamponade , restrictive cardiomyopathy , hypertension Usually coexist

Left-sided versus Right-sided:

Left-sided versus Right-sided Left Dyspnoea, poor exercise tolerance, fatigue, orthopnoea , paroxysmal nocturnal dyspnoea, nocturnal cough, wheeze, nocturia Right Peripheral oedema, ascites , nausea, anorexia, facial engorgement, epistaxis Causes – LVF, pulmonary stenosis , lung disease Left plus Right = Congestive Cardiac Failure

Low-output versus High-output:

Low-output versus High-output Low-output Excessive preload Mitral regurgitation, fluid overload Pump failure Reduced myocardial contraction, reduced heart rate, negatively inotropic drugs Chronic excessive afterload Aortic stenosis , hypertension High-output RARE Heart fails to meet needs Anaemia, hyperthyroidism, pregnancy

Framingham criteria – diagnosis CCF 2 major/ 1major + 2 minor :

Framingham criteria – diagnosis CCF 2 major/ 1major + 2 minor Major criteria Paroxysmal nocturnal dyspnoea Crepitations S3 gallop Cardiomegaly Increased CVP Weight loss >4.5kg in 5 days in response to Rx Neck vein distension Acute pulmonary oedema Hepatojugular reflux Minor criteria Bilateral ankle oedema Dyspnoea on ordinary exertion Tachycardia Nocturnal cough Hepatomegaly Pleural effusion


Investigations Bloods – FB, urea, creatinine , (electrolytes) CXR ECG – ischaemia , infarction, ventricular hypertrophy Echocardiography – may indicate cause, can measure ejection fraction Sequential weight measurements

CXR changes - ABCDE:

CXR changes - ABCDE A lveolar oedema – bat’s wings Kerley B lines – interstitial oedema C ardiomegaly (cardiothoracic ratio >50%) D ilated prominent upper lobe vessels Pleural E ffusion


Staging 1. American College of Cardiology Foundation (ACCF) /American Heart Association(AHA) - Heart Failure Stage 2. New York Heart Association (NYHA)- FUNCTIONAL Class A. At risk for heart failure but without structural heart disease or symptoms None B. Structural heart disease but without signs or symptoms of heart failure I. Cardiac disease - no limitation of physical activity. C. Structural heart disease with prior or current heart failure symptoms II. Cardiac disease - slight limitation of physical activity. Ordinary physical activity results in symptoms. III. Cardiac disease - marked limitation of physical activity. Less than ordinary activity results in symptoms D. Refractory heart failure despite optimum medical therapy requiring specialised interventions IV. Cardiac disease - inability to carry on any physical activity without discomfort, symptomatic at rest. If any physical activity is undertaken, discomfort increases.

Staging uses:

Staging uses Monitor patients symptoms Guide treatment Reflect progression of disease

Medical Therapies:

Medical Therapies That decrease mortality ACE inhibitors captopril , lisinopril Angiotensin receptor blockers Not available Beta blockers, LONG ACTING eg . metoprolol , carvedilol Available – propanolol and atenolol Aldosterone antagonists Spironolactone Hydralazine and isosorbide mononitrate Especially in African American patients


Digoxin Digoxin has been shown to reduce symptoms and hospitalizations in HF, but not mortality. It has a narrow therapeutic window, particularly in elderly patients. Last-line agent for the treatment of heart failure without atrial fibrillation.


Doses Furosemide (symptomatic relief) 20-40mg 80-120mg resistant oedema Captopril (6.25-)12.5mg 2-3xdaily, titrate up to 150mg/day in divided doses( eg studies used 25/50mg 3xdaily) Increase gradually at 2 week intervals Lisinopril (2.5-)5mg 1xdaily, titrate up to 35mg/day Increase maximum 10mg at 2 week intervals ACEI not suitable in severe valvular heart disease Check baseline urea and creatinine , repeat after 10days, and with every change of dose


Doses Spironolactone 25-50mg daily Digoxin 62.5-125micrograms 1xdaily Beta blocker??? Carvedilol 3.125mg 2xdaily, maximum 25mg 2xdaily, 50mg 2xdaily if over 85kg Long acting not available Hydralazine and isosorbide mononitrate 75mg and 40mg 4xdaily (combination tablet) ISMN not available

Side effects:

Side effects Furosemide Hypotension, hypokalemia , gout ACE-inhibitors renal failure, hypokalemia , cough and angioedema Beta-blocker orthostatic hypotension , bradycardia , bronchospasm , erectile dysfunction and hyperkalemia Spironolactone Hyperkalaemia Digoxin GI upset, arrhythmias/heart block, neuro /psychiatric disturbances Toxicity more likely in elderly and renal failure

Summary of treatment at Haydom:

Summary of treatment at Haydom Furosemide + ACE inhibitor ( eg captopril ) If symptoms persist Spironolactone and/or Digoxin Discuss Atenolol 50-100mg 1xdaily Hydralazine alone

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