Heart Failure

What is Heart Failure?

The heart is not pumping as well as it should Usually, the heart has been weakened by an underlying condition
Blocked arteries MI High blood pressure Infections Heart valve abnormalities

What is Heart Failure?

Heart failure can involve the left or right side of the heart or both Usually the left side is affected first Heart failure occurs when either side of the heart cannot keep up with the flow of blood

Heart Failure
What is Heart Failure?

What is Left Heart Failure?

Involves the left ventricle (lower chamber) of the heart Systolic failure
The heart looses its ability to contract or pump blood into the circulation

Diastolic failure
The heart looses its ability to relax because it becomes stiff Heart cannot fill properly between each beat

What is Left Heart Failure?

Systolic and diastolic heart failure are treated with different types of medications In both types, blood may back up in the lungs causing fluid to leak into the lungs (pulmonary edema) Fluid may also build up in tissues throughout the body (edema)

What is Right Heart Failure?

Usually occurs as a result of left heart failure The right ventricle pumps blood to the lungs for oxygen Occasionally isolated right heart failure can occur due to lung disease or blood clots to the lung (pulmonary embolism)

How fast does heart failure develop?

Usually a chronic disease The heart tries to compensate for the loss in pumping function by:
Developing more muscle mass Enlarging Pumping faster Worsening the HF

What Causes Heart Failure?

Health conditions that either damage the heart or make it work too hard
Coronary artery disease Heart attack High blood pressure Abnormal heart valves Heart muscle diseases (cardiomyopathy) Heart inflammation (myocarditis)

What Causes Heart Failure?

Congenital heart defects Severe lung disease Diabetes Severe anemia Overactive thyroid gland (hyperthyroidism) Abnormal heart rhythms

What Causes Heart Failure?

Coronary artery disease
Cholesterol and fatty deposits build up in the hearts arteries Less blood and oxygen reach the heart muscle This causes the heart to work harder and occasionally damages the heart muscle

What Causes Heart Failure?

Heart attack
An artery supplying blood to the heart becomes blocked Loss of oxygen and nutrients damages heart muscle tissue causing it to die Remaining healthy heart muscle must pump harder to keep up

What Causes Heart Failure?

High blood pressure
Uncontrolled high blood pressure doubles a persons risk of developing heart failure Heart must pump harder to keep blood circulating Over time, chamber first thickens, then gets larger and weaker

What Causes Heart Failure?

Abnormal heart valves Heart muscle disease
Damage to heart muscle due to drugs, alcohol or infections

Congenital heart disease Severe lung disease

What Causes Heart Failure?

Diabetes
Tend to have other conditions that make the heart work harder Obesity Hypertension High cholesterol

What Causes Heart Failure?

Severe anemia
Not enough red blood cells to carry oxygen Heart beats faster and can become overtaxed with the effort

Hyperthyroidism
Body metabolism is increased and overworks the heart

Abnormal Heart Rhythm

If the heart beats too fast, too slow or irregular it may not be able to pump enough blood to the body

Signs and symptoms of HF

Signs and Symptoms of Heart Failure

Shortness of Breath (dyspnea)
WHY?
Blood backs up in the pulmonary veins because the heart cant keep up with the supply an fluid leaks into the lungs

SYMPTOMS
Dyspnea on exertion or at rest Difficulty breathing when lying flat Waking up short of breath

Signs and Symptoms of Heart Failure

Persistent Cough or Wheezing
WHY?
Fluid backs up in the lungs

SYMPTOMS
Coughing that produces white or pink bloodtinged sputum

Signs and Symptoms of Heart Failure

Edema
WHY?
Decreased blood flow out of the weak heart Blood returning to the heart from the veins backs up causing fluid to build up in tissues

SYMPTOMS
Swelling in feet, ankles, legs or abdomen Weight gain

Signs and Symptoms of Heart Failure

Tiredness, fatigue
WHY?
Heart cant pump enough blood to meet needs of bodies tissues Body diverts blood away from less vital organs (muscles in limbs) and sends it to the heart and brain

SYMPTOMS
Constant tired feeling Difficulty with everyday activities

Signs and Symptoms of Heart Failure

Lack of appetite/ Nausea
WHY?
The digestive system receives less blood causing problems with digestion

SYMPTOMS
Feeling of being full or sick to your stomach

Signs and Symptoms of Heart Failure

Confusion/ Impaired thinking
WHY?
Changing levels of substances in the blood ( sodium) can cause confusion

SYMPTOMS
Memory loss or feeling of disorientation Relative or caregiver may notice this first

Signs and Symptoms of Heart Failure

Increased heart rate
WHY?
The heart beats faster to make up for the loss in pumping function

SYMPTOMS
Heart palpitations May feel like the heart is racing or throbbing

New York Heart Association (NYHA) Functional Classification

Class % of Symptoms patients
35% No symptoms or limitations in ordinary physical activity Mild symptoms and slight limitation during ordinary activity Marked limitation in activity even during minimal activity. Comfortable only at rest Severe limitation. Experiences symptoms even at rest

II

35%

III

25%

IV

5%

Pathophysiology

Treatment Options
The more common forms of heart failure cannot be cured, but can be treated
Lifestyle changes Medications Surgery

Lifestyle changes
Stop smoking Loose weight Avoid alcohol Avoid or limit caffeine Eat a low-fat, low-sodium diet Exercise

Lifestyle changes
Reduce stress Keep track of symptoms and weight and report any changes or concern to the doctor Limit fluid intake See the doctor more frequently

Cardiac glycoside

Positive inotropic drugs

Phosphodiesterase inhibitors

Diuretics

Beta 1 agonist

Drugs used in HF

ACE I,AT1 blockers

Vasodilators

Beat blockers

Positive inotropic agents

1. Cardiac glycosides:
Digitalis derivatives :
Digoxin Digitoxin Ouabain

Nondigitalis derivatives:

Physiology of myocyte contraction

Digoxin mechanism of action

Therapeutic Uses of Digitalis

Congestive Heart Failure Atrial fibrillation Atrial flutter

Overall Benefit of Digitalis to Myocardial Function

cardiac output cardiac efficiency heart rate cardiac size

NO survival benefit

Other Beneficial Effects

Restoration of baroreceptor sensitivity Reduction in sympathetic activity increased renal perfusion, with edema formation Increase parasympathetic outflow

Administration
Digoxin has a long enough half life (24-36 hr.) and high enough bioavailability to allow once daily dosing Digoxin has a large volume of distribution and dose must be based on lean body mass Increased cardiac performance can increase renal function and clearance of digoxin Eubacterium lentum

Adverse Effects
Cardiac
AV block Bradycardia Ventricular extrasystole Arrhythmias

CNS toxicity
Delirium Confusion and somnolence

GI
Anorexia ,nausea and vomitting

Blurred vision
Tendency to yellow-green vision Photophobia

Therapeutic index is ~ 2!

Serum Electrolytes Affect Toxicity

K+
Digitalis competes for K binding at Na/K ATPase Hypokalemia: increase toxicity Hyperkalemia: decrease toxicity

Mg2+
Hypomagnesemia: increases toxicity

Ca2+
Hypercalcemia: increases toxicity

Treatment of Digitalis Toxicity

Bile resins or activated charcoal Atropine: advanced heart block KCl: increased automaticity Antiarrythmics: ventricular arrhythmias Fab antibodies: toxic serum concentration; acute toxicity

Van Gogh

b-Adrenoceptor and Dopamine Receptor Agonists

Dobutamine Dopamine

Dobutamine
Beta 1 agonist Administered as IV infusion Used in acute HF Can induce arrhythmias

Mechanism of Action: Dobutamine

Stimulation of cardiac b1-adrenoceptors: inotropy > chronotropy peripheral vasodilatation

myocardial oxygen demand

Mechanism of Action: Dopamine

Stimulation of peripheral postjunctional D1 and prejunctional D2 receptors
Splanchnic and renal vasodilatation

Therapeutic Use
Dobutamine: management of acute failure only Dopamine: restore renal blood in acute failure

Adverse Effects
Dobutamine
Tolerance Tachycardia

Dopamine
tachycardia arrhythmias peripheral vasoconstriction if given at high doses

Phosphodiesterase inhibitors
Amrinone Milrinone PDE 3 inhibitor

Role of phosphodiesterase

Mechanism of action
inhibition of type III phosphodiesterase increase intracellular cAMP activation of protein kinase A o Ca2+ entry through L type Ca channels o inhibition of Ca2+ sequestration by SR increase cardiac output decrease peripheral vascular resistance

Phosphodiesterase Inhibitors: Therapeutic Use

short term support in advanced cardiac failure long term use not possible why?

Adverse Effects of Phosphodiesterase Inhibitors

Cardiac arrhythmias GI: Nausea and vomiting Sudden death

ACE-I
First line treatment Lower the morbidity and mortality rate among HF pts

Mechanism of Action
Afterload reduction Preload reduction Reduction of facilitation of sympathetic nervous system Reduction of cardiac hypertrophy

Diuretics
Thiazide
For mild fluid retention

Furoseamide
More effective than thiazide Rapid onset and short duration

Potassium sparing diuretics

Use to along with the above diuretics to prevent electrolyte imbalance Spironolactone have beneficial effect on heart remodeling

Diuretics: Mechanism of Action in Heart Failure

Preload reduction: reduction of excess plasma volume and edema fluid Afterload reduction: lowered blood pressure

Spironolactone
Aldosterone antagonist, K-sparing diuretic Prevention of aldosterone effects on:
Kidney Heart

Aldosterone inappropriately elevated in CHF Mobilizes edema fluid in heart failure Prevention of hypokalemia induced by loop diuretics (protection against digitalis toxicity?) Prolongs life in CHF patients

Vasodilators
Sodium nitroprusside Hydralazine Nitrates Alpha1 blocker Ca2+ channel blockers

must be avoided

Vasodilators
Mechanism of action: reduce preload and afterload

Beta blockers
Metoprolol Carvidilol Bisoprolol

b-Blockers in Heart Failure: Mechanism of Action

Standard b-blockers:
Reduction in damaging sympathetic influences in the heart (tachycardia, arrhythmias, remodeling) inhibition of renin release

Carvedilol:
Beta blockade effects peripheral vasodilatation via a1-adrenoceptor blockade (carvedilol)

Anti coagulant therapy

Not followed as standard regimen only in pts with prior embolic events

Surgery and other Medical Procedures

Treatment options
Not often used in heart failure unless there is a correctable problem Coronary artery bypass Angioplasty Valve replacement Defibrillator implantation Heart transplantation Left ventricular assist device (LVAD)

Management of heart failure

Treat the cause Combination of diuretic therapy and ACE-I
If ACE-I is contraindicated use vasodilators

Add beta blocker if the patient was stabilized

Start with low dose

Spironolactone has shown 30%reduction in mortality when administered with the conventional therapy If the above drugs dont releive the symptoms use digoxin
Positive inotropic agents must be used for short time

If the patient condition become worse make surgery intervention