Heart Failure

From Diagnosis to Treatment

Andi Wahjono Adi,MD,FIHA

Department of Cardiology and Vascular Medicine, Muhammadiyah University Hospital
Medical Faculty of Muhammadiyah University

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 Qalbu = Heart

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Heart Failure…??? 3
Terms Related to Cardiac Performance

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Definitions of heart failure

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 Heart failure

The heart is unable to pump blood forward at a sufficient

rate to meet the metabolic demands of the body (forward
failure), or is able to do so only if the cardiac filling
pressures are abnormally high (backward failure), or both.

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Epidemiology
• 1–2% of the adult population in developed countries has HF
• The prevalence rising to ≥10% among persons 70 years of age or older
• Before 1990, 60–70% of patients died within 5 years of diagnosis, and
admission to hospital with worsening symptoms was frequent and
recurrent.
• Effective treatment has improved these outcomes, with a relative
reduction in hospitalization in recent years of 30–50% and smaller but
significant decreases in mortality.

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Terminology of heart failure
• Left/right sided heart failure
• Systolic/diastolic heart failure
• Backward/forward heart failure
• Acute/chronic heart failure
• Congestive heart failure
• Reduce/preserved ejection fraction heart failure

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The etiologies

1. Impaired ventricular contractility

2. Increased afterload
3. impaired ventricular relaxation and filling

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Left Sided Heart Failure

Reduced Ejection Fraction

(Systolic Dysfunction)

Heart Failure

Preserved Ejection Fraction

(Diastolic Dysfunction)

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Right Sided Heart Failure
• Cardiac causes
Left-sided heart failure, Pulmonic valve stenosis, Right ventricular
infarction

• Pulmonary parenchymal diseases

Chronic obstructive pulmonary disease, Interstitial lung disease
(e.g., sarcoidosis), Adult respiratory distress syndrome, Chronic lung
infection or bronchiectasis

• Pulmonary vascular diseases

Pulmonary embolism, Primary pulmonary hypertension

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Natural compensatory mechanisms
• The Frank–Starling mechanism
• Neurohormonal alterations
• The Development of ventricular hypertrophy and remodeling

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The Frank–Starling mechanism

Decreased
Cardiac Output

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Neurohormonal alterations

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Renin-Angiotensin-Aldosteron system

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The Development of ventricular hypertrophy and
remodeling

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Diagnosis of heart failure
The diagnosis of HF REF requires three conditions :
1. Symptoms typical of HF
2. Signs typical of HF
3. Reduced LVEF

The diagnosis of HF PEF requires four conditions :

1. Symptoms typical of HF
2. Signs typical of HF
3. Normal or only mildly reduced LVEF and LV not dilated
4. Relevant structural heart disease (LV hypertrophy/LA enlargement)
and/or diastolic dysfunction

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Criteria for Diagnosis of HF: Framingham Criteria
Major criteria Minor criteria
• Paroxysmal nocturnal dyspnea or • Ankle edema
orthopnea • Nocturnal cough
• Neck-vein distention • Dyspnea on ordinary exertion
• Rales • Hepatomegaly
• Cardiomegaly • Pleural effusion
• Acute pulmonary edema • Decrease in vital capacity by one
• Protodiastolic gallop (S3 gallop) third from maximum recorded
• Increased venous pressure (≥16 cm • Tachycardia (heart rate ≥120 bpm)
H2O at right atrium)
• Increased circulation time (≥25 sec)
• Hepatojugular reflux
Major or minor criteria
Weight loss of 4.5 kg or more in 5 days in response to treatment. When the weight
loss is attributable to the treatment of heart failure, it is considered 1 major
criterion. Otherwise it is considered a minor criterion.

Diagnosis of heart failure requires the simultaneous presence of at least 2

major criteria or 1 major criterion in conjunction with 2 minor criteria. 18
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Diagnostic flowchart for patients with suspected HF

Acute onset Non acute onset

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Cardiac imaging in the evaluation of patients with
suspected or confirmed heart failure
• Echocardiography(TTE)
• Transoesophageal echocardiography(TEE)
• Stress echocardiography
• Cardiac magnetic resonance(CMR)
• Single-photon emission computed tomography and radionuclide
Ventriculography (SPECT)
• Positron emission tomography imaging(PET)
• Coronary angiography
• Cardiac computed tomography(CT)

Other investigations
Cardiac catheterization & endomyocardial biopsy, Exercise testing, Genetic
testing, Ambulatory electrocardiographic monitoring

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Factors That May Precipitate Symptoms in Patients with
Chronic Compensated Heart Failure

• Increased metabolic demands

Fever, Infection, Anemia, Tachycardia, Hyperthyroidism, Pregnancy
• Increased circulating volume (increased preload)
Excessive sodium content in diet, Excessive fluid administration, Renal
failure
• Conditions that increase afterload
Uncontrolled hypertension, Pulmonary embolism (increased right ventricular
afterload)
• Conditions that impair contractility
Negative inotropic medications, Myocardial ischemia or infarction,
Excessive ethanol ingestion
• Failure to take prescribed heart failure medications
• Excessively slow heart rate

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New York Heart Association (NYHA) functional classification
based on severity of symptoms and physical activity

Class I No limitation of physical activity. Ordinary physical activity does

not cause undue breathlessness, fatigue, or palpitations.

Class II Slight limitation of physical activity. Comfortable at rest, but

ordinary physical activity results in undue breathlessness,
fatigue, or palpitations.

Class III Marked limitation of physical activity. Comfortable at rest, but

less than ordinary physical activity results in undue
breathlessness, fatigue, or palpitations.

Class IV Unable to carry on any physical activity without discomfort.

Symptoms at rest can be present. If any physical activity is
undertaken, discomfort is increased.

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Stages of Chronic Heart Failure
Class A Patient who is at risk of developing heart failure but has not yet
developed structural cardiac dysfunction (e.g., patient with
coronary artery disease, hypertension, or family history of
cardiomyopathy).

Class B Patient who has structural heart disease associated with heart
failure but has not yet developed symptoms.

Class C Patient who has current or prior symptoms of heart failure

associated with structural heart disease.

Class D Patient who has structural heart disease and marked heart failure
symptoms despite maximal medical therapy and requires
advanced interventions (e.g., cardiac transplantation).

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Treatment options for patients with chronic
symptomatic systolic heart failure
…………………..

The goals of treatment in

patients with established HF :
• relieve symptoms and signs
• Prevent hospital admission
• Improve survival.

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Drug doses

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Other treatments with less-certain benefits in patients with
symptomatic systolic HF

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Not Recommended treatments or combinations in patients
with symptomatic systolic HF

1. Thiazolidinediones (glitazones) should not be used as they cause III A

worsening HF and increase the risk of HF hospitalization
2 Most CCBs (with the exception of amlodipine and felodipine) should not be III B
used as they have a negative inotropic effect and can cause worsening HF.
3. NSAIDs and COX-2 inhibitors should be avoided if possible as they may III B
cause sodium and water retention, worsening renal function and worsening
HF.
4. The addition of an ARB (or renin inhibitor) to the combination of an ACE III C
inhibitor AND a mineralocorticoid antagonist is NOT recommended
because of the risk of renal dysfunction and hyperkalaemia.

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Pharmacological treatment of heart failure with ‘preserved’
ejection fraction (diastolic HF)

• Diuretics are used to control sodium and water retention and relieve
breathlessness and oedema as in HF-REF.
• Adequate treatment of hypertension and myocardial ischaemia is
also considered to be important, as is control of the ventricular rate
in patients with AF
• CCBs may also be useful for ventricular rate control in patients with
AF and in the treatment of hypertension and myocardial ischaemia
so do beta blocker.

The drugs that should be avoided in HF-REF should also be

avoided in HF-PEF, with the exception of CCBs

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Heart failure with other compelling factors

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Stable patients with heart failure and atrial fibrilation

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Thromboembolism prophylaxis
1. The CHA2DS2-VASc and HAS-BLED scores are recommended to determine I B
the likely risk–benefit (thrombo-embolism prevention vs. risk of bleeding) of
oral anticoagulation.
2. An oral anticoagulant is recommended for all patients with paroxysmal or I A
persistent/permanent AF and a CHA2DS2-VASc score ≥1, without
contraindications, and irrespective of whether a rate- or rhythm-management
strategy is used (including after successful cardioversion).
3. In patients with AF of ≥48 h duration, or when the known duration of AF is I C
unknown, an oral anticoagulant is recommended at a therapeutic dose for ≥3
weeks prior to electrical or pharmacological cardioversion.
4. Intravenous heparin or LMWH is recommended for patients who have not I C
been treated with an anticoagulant and require urgent electrical or
pharmacological cardioversion.
5. Alternative to i.v. heparin or LMWH IIa C
A TOE-guided strategy may be considered for patients who have not been
treated with an anticoagulant and require urgent electrical or pharmacological
cardioversion.
6. Combination of an oral anticoagulant and an antiplatelet agent is not III A
recommended in patients with chronic (>12 months after an acute event)
coronary or other arterial disease, because of a high risk of serious bleeding.
Single therapy with an oral anticoagulant is preferred after 12 months.
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Heart failure and ventricular arrhythmia

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Heart failure and angina

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Heart failure and hypertension

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Other co-morbidities

• Anemia • Depression
• Cachexia • Gout
• Malignancy • Hyperlipidaemia
• Angina • Iron deficiency
• Atshma • Cardio renal syndrome
• COPD • Prostatic obstruction
• Hypertension • Sleep disorder
• Diabetes • Obesity
• Erectile dysfunction

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Case#1

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A man 65 years old came to cardiology outpatient unit
presenting with shortness of breath particulary following
heavy daily activities, walking +/- 200 meter,inability to
climb stair more than 1 floor since 3 month ago. He
complain about his leg oedema and having cough at night
whenever sleep. He couldn’t sleep with thin pillows. He
also had history of uncontrolled hypertension in the last 5
years.

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Physical examination
• Cardiomegaly
• Bilateral rales
• Increased jugular venous pressure
• Hepatojugular reflux

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What is the diagnosis and how is the treatment…?

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Diagnosis
Functional : Congestive heart failure,Functional class III
Anatomi : LVH
Etiology : Hipertensive heart disease

Treatment
Fluid and salt restriction
Furosemide
Captopril, uptitration optimal doses
Bisoprolol, uptitration optimal doses
Spironolacton

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Thank You….
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