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HEART FAILURE
From Hemodynamic Subset to Appropriate Treatment
Budi Baktijasa
Riana Handayani, MD
Definition
Stage A High risk with no symptom
Stage B Structural heart disease, with no symptom
Stage C Structural heart disease, with previous or
current symptom
Stage D Refractory symptoms requiring special
intervention
Stage B
Asymptomatic
LV dysfunction NYHA Functional Class
Class I
symptoms at activity levels that
would limit normal individuals
Stage C Class II
Past or current symptoms of HF with
ordinary exertion
Symptoms of HF Class III
symptoms of HF with less
than ordinary exertion
Stage D Class IV
End-stage HF Symptoms of HF at rest
NORMAL
NORMAL
No
No Asymptomati
Asymptomati
symptoms
symptoms c
c LV
LV
Normal
Normal
exercise Dysfunction
Dysfunction
exercise
Normal
Normal LV
LV
No
No
symptoms
symptoms
Compensate
Compensate
function
function Normal
Normal d
d CHF
CHF
exercise
exercise No
No Decompensate
Decompensate
Abnormal LV
Abnormal LV symptoms
symptoms
function
function Exercise d
Exercise d CHF
CHF
Abnormal
Abnormal LVLVSymptoms
Symptoms Refractory
Refractory
function
function Exercise
Exercise
Abnormal
Abnormal LV
CHF
LV CHF
function
function Symptoms
Symptoms not
not
controlled
controlled with
with
treatment
treatment
Terminology
Final Common Pathway in Heart Failure
Diagnosis of ADHF
• Harder
Many thanconditions
you think may mimic HF
• Even
Need cardiologists
to practice,get itpractice,
wrong sometimes
practice
• No single finding is definitive
Need to integrate all the findings (history, exam,
labs, CXR, EKG)
Clinical Classification of AHF
HYPERTENSIVE
AHF
ACUTELY
DECOMPENSATED
CHRONIC HF
PULMONARY
OEDEMA
ACS AND
HF
CARDIOGENIC RIGHT HF
SHOCK
Orthopnea
Paroxysmal Nocturnal Dyspnea
Neck vein distention
Congestion Ascites, edema
Hepatojugular Reflux
Stevenson LW. Eur J Heart Fail.Rales
1999;1:251
Primary goal in making diagnosis:
Discovering signs and symptoms of high
right and left atrial pressures
The most reliable signs for elevated left-
sided filling pressures then are the
presence of an elevated JVP (>7 cmH2O)
or positive abdominojugular reflux (AJR)
Clinical Application
Hemodynamic Profile in
2
Minutes
Hemodynamic State of AHF
Evidence For Congestion
Orthopnea Edema
High Jugular Venous Pressure Ascites
Increasing S3 Rales
Loud P2 Abdominojugular reflux
Nohria A, Lewis EF and Stevenson LW. Medical Management of advanced heart failure.JAMA.2002;287:629
Hemodynamic
profiles
Relative Risk (95% CI)
(457) Ref
ICVCU Harapan Kita Hospital Registry, Asia Pacific Society of Cardiology Congress Pattaya
2012
n = 560
*
* Mean Differences:
* •Dry-Warm Ref
•Wet-Warm 1.719
•Dry-Cold 3,418
•Wet-Cold 4,654
* = p < 0.001
ICVCU Harapan Kita Hospital Registry, Asia Pacific Society of Cardiology Congress Pattaya
2012
Hemodynamic Profiles & Mortality
Six-months mortality by clinically determined hemodynamic profiles
6-mths
Patient Profile N (%)
mortality (%)
Dry – Warm (A) 123 (27) 11
Wet – Warm (B) 222 (49) 22
Wet – Cold (C) 91 (20) 40
WITHOUT CONGESTION
WITH CONGESTION Hypovolemic
(Cardiogenic Shock) Distributive shock (septic, anafilactic)
COLD-WET RV Failure
COLD-DRY
Treatment Goals
Dry Wet
Warm
A B Diuretics
Vasodilators:
Natriuretic peptides
Nitroprusside
Cold
L C Nitroglycerin
Inotropic Drugs
Dobutamine
Milrinone
Levosimendan
Enoximone
Potassium
Loop Thiazides/
Sparing
diuretics Thiazides-like
Diuretics
Thiazide
K Sparing
Diuretics
Additive effect
Cardiac Output :
Stroke Volume x Heart Rate
- Maintaining Contractility ~
Neurohormonal
(sympathetic and Vagal)
- Maintaining Preload ~ Frank-Starling
Law of The
Heart
Failing Heart
Stroke Volume
Failing Heart
Diuretics ACEi ARB
Nitrates Beta bloker
Digitalis
intotropes
Vasodilators ( Nitroglycerin )
Preload reduction
Vasodilation effect lowers preload
reduce pulmonary congestion
Should be avoided : Systolic blood
pressure <110 mmHg
Opiates
VS
Inotropes
Drugs that
stimulates smooth
muscle contraction
of the capillaries &
arteries
Cause
vasoconstriction &
a consequent rise
in blood pressure
Mixed action Inotropic +
Vasopressor
Main Goal
CO = HR x SV
Preload Contractility Afterload
Which adrenoceptor mediates
cardiac muscle contraction?
1. 1
2. 2
3. 1
4. 2
Which adrenoceptor mediates
vascular smooth muscle
contraction?
1. 1
2. 2
3. 1
4. 2
Main classes of
Adrenoceptor
receptors
1
Located in vascular smooth muscle
Mediate vasoconstriction
2
Located throughout the CNS, platelets
Mediate sedation, analgesia & platelet aggregation
Main classes of
Adrenoceptor
receptors
1
Located in vascular smooth muscle
Mediate vasoconstriction
2
Located throughout the CNS, platelets
Mediate sedation, analgesia & platelet aggregation
Main classes of
Adrenoceptor
receptors
1
Located in the heart
Mediate increased contractility & HR
2
Located mainly in the smooth muscle of bronchi
Mediate bronchodilatation
Main classes of
Adrenoceptor
receptors
1
Located in the heart
Mediate increased contractility & HR
2
Located mainly in the smooth muscle of bronchi
Mediate bronchodilatation
Located in blood vessels
Dilatation of coronary vessels
Dilatation of arteries supplying skeletal muscle
Epinephrine
Stimulates & receptors
Predominantly effects at low doses and
effects at high doses
Clinical uses
Cardiac arrest
Anaphylaxis
Low cardiac output states
Norepinephrine
Predominantly stimulates 1 receptors
Most commonly used vasopressor in
critical care
Very potent
Administered by infusion into a central
vein
Uses
Hypotension due to vasodilatation
Septic shock
Dopamine
Effect dose dependent
Direct
Low dose - 1
High dose - 1
Indirect
Stimulates norepinephrine release
D1 receptors
Vasodilatation of mesenteric & renal circulation
Dobutamine
Synthetic
Predominantly 1
Small effect at 2
Uses
Low cardiac output states
Cardiogenic shock
Intra Aortic Balloon Pump
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Dose of ACE Inhibitor/ARB
Drugs Starting Dose Target Dose
Captopril 6.25 mg t.i.d 50 mg t.i.d
Enalapril 2.5 mg b.i.d 10 – 20 mg b.i.d
Lisinopril 2.5 – 5 mg OD 20 – 35 mg OD
Ramipril 2.5 mg OD 5 mg OD
Trandolapril 0.5 mg OD 4 mg OD
Candesartan 4 or 8 mg OD 32 mg OD
Valsartan 40 mg b.i.d 160 mg b.i.d
Losartan 50 mg OD 150 mg OD
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Trials of ACE Inhibitor in Heart Failure
IA
A beta-blocker is recommended,
in addition to an ACE inhibitor (or ARB if
ACE inhibitor not tolerated),
for all patients with an EF ≤40%
to reduce the risk of HF hospitalization
and the risk of premature death
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Dose of Beta Blockers
Agent Starting Dose Target Dose
Bisoprolol 1.25 mg OD 10 mg OD
Metoprolol Succinate
12.5 / 25mg OD 200 mg OD
(CR/XL)
Nebivolol 1.25 mg OD 10 mg OD
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Trials of B-Blockers in Heart
Failure
Aldosterone Receptor Antagonist
IA
An MRA is recommended for all patients with persisting
symptoms (NYHA class II–IV) and an EF ≤35%,
despite treatment with an ACE inhibitor
(or an ARB if an ACE inhibitor is not tolerated)
and a beta-blocker, to reduce the
risk of HF hospitalization and
the risk of premature death
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Dose of MRA
Agent Starting Dose Target Dose
Eplerenone 25 OD 50 mg OD
Spironolactone 25 mg OD 25 – 50 mg OD
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Spironolactone in Heart Failure
Ivabradine
• Inhibits If current in SA node
• Slow heart rate in sinus rhytm
• Higher heart rate is associated with higher
mortality in heart failure
Ivabradine
• Should be considered to reduce the risk of HF
hospitalization in patients in sinus rhythm with an EF
≤35%, a heart rate remaining ≥70 b.p.m., and
persisting symptoms (NYHA class II–IV) despite
treatment with an evidence-based dose of beta-
IIa B
blocker (or maximum tolerated dose below that),
ACE inhibitor (or ARB), and an MRA (or ARB)
• May be considered to reduce the risk of HF
hospitalization in patients in sinus rhythm with an EF
≤35% and a heart rate ≥70 b.p.m. who are unable to
tolerate a beta-blocker. Patients should also receive IIb C
an ACE inhibitor (or ARB) and an MRA (or ARB)
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
ESC Guidelines 2012
Digoxin: Improvement in symptoms but not survival
Death or hospitalization for
worsening HF
• Digitalis investigation
group
• 6800 patients
• EF<45%
• Past or current All-cause mortality
symptoms of HF
• On ACEI and diuretics
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Diuretics
• The effects of diuretics on mortality and
morbidity have not been studied in patients with
HF
• The aim of using diuretics is to achieve and
maintain euvolaemia (the patient’s ‘dry weight’)
with the lowest achievable dose
ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
e are just ordinary women
ho incidentally become cardiologist
Thank You 92