Congestive Heart Failure Flashcards
Define Atherosclerosis
The process of progressive thickening and hardening of the walls of medium and large-sized arteries as a result of cholesterol deposition
Non- Modifiable CVD risk factors (5)
Age
Male sex
Family History
Low Birth weight
Premature Birth
Modifiable CVD risk factors (6)
Hypertension
Smoking
Diabetes mellitus
Hypercholesterolemia
Obesity
Physical inactivity
CVD continuum (8)
Risk factors/ diabetes/ Hypertension
Ather + LVH
MI
Remodelling
Ventriuclar Dilation
Congestive Haert Failure
End-stage Heart disease
Death
Definition of Heart Failure (3)
“A complex of symptoms—shortness of breath, fatigue, and congestion
Due to an impairment of the heart’s ability to empty* or fill* properly, (systolic or diastolic)
= leading to inadequate perfusion of tissues during exertion, and retention of fluid”
Heart Failure facts (4)
Affects 1-2% of population
10% among persons ≥ 70 years
Prognosis 25-40% mortality ~ 5 years(similar to cancer)
Prognosis worse if (1yr ~ worse than cancer)
– severe symptoms
– high dose of diuretics
– low BP
– low sodium
Causes of Heart Failure (3)
Decreased contractility:
- Coronary heart dis.
- Cardiomyopathies
Viral myocarditis (Covid)
Infiltrations
- Drugs
ß-adrenergic blockers
Verapamil
Doxorubicin - Arrhythmias
Increased Afterload:
- Hypertension
- Valvular disease
- HOCM
Increased Output:
- Anaemia
- Hyperthyroidism
- AV shunts
Acute Decompensation (6)
One or more events
1. Discontinuation of treatment
2. ACS (new event)
3. Arrhythmias (AF)
4. Infection
5. Anaemia
6. Pulmonary Embolism
New York Heart
Association (NYHA) - 4 classes (4)
Class I:
– No limitation of physical activity
– Ordinary physical activity does not cause SOB (dyspnoea) or fatigue
Class II:
– Slight limitation of physical activity
– Ordinary physical activity result in dyspnoea or fatigue
Class III:
– Marked limitation of physical activity
– Less than ordinary physical activity result in
dyspnoea or fatigue
Class IV:
– Inability to carry out any physical activity
without discomfort
– Symptoms are present at rest
Diagnosis of HF - 5 steps (5)
- (BNP) or NT-proBNP:
if <400 ng/L HF is unlikely if <400 ng/L HF is unlikely - ECHO: HF, rEF or HF, pEF
- Cardiac MRI (CMR)
- Other tests: ECG, CXR, U&Es, ABGs, D-dimer
- Look for cause(s) of decompensation: Troponin for ACS, ECG for Arrhythmias, etc.
Ejection Fraction (3)
Is a percentage of how much blood the left
ventricle pumps out with each contraction
EF of 60% means that 60% of the total amount of blood in the left
ventricle is pushed out with each heartbeat.
EF also called Fractional shortening
Types of HF (2)
Failure of filling of blood:
– Diastolic HF
– HF (Heart failure with preserved ejection fraction >50%)
- HFpEF patients are older, female, hypertension, obesity, anaemia, and AF
Failure of ejection of blood:
–– Systolic HF
–– HFHF
(Heart failure with reduced ejection fraction ≤40%)
Aims of Treatment (4)
- Removal of the underlying or
precipitating causes - Improving survival & reducing mortality
- Relief of symptoms (& Improvement in quality of life)(& Improvement in quality of life)
- Prevention of re-admissions to hospital, recurrent ischaemic
events, and further deterioration in left ventricular function
Removal of precipitating causes (5)
Treatment of hypertension
Correction of valvular lesions
Anaemia, thyrotoxicosis, fluid
overload, increased dietary salt intake
Poor compliance with treatment
Drugs: beta-blockers, salt- retaining drugs (NSAIDs, steroids)
Standard Drug Therapy
(1st , 2nd + 3rd line) (9)
1st:
- ACE inhibitors / ARNI
- Beta Blockers
2nd:
- Angiotensin receptor antagonists (ARBs)
- Aldosterone antagonists
- Hydralazine/nitrate
3rd:
- Diuretics
- Digoxin
- Sacubitril-Valsartan (ARNI)
- SGLT2 inhibitors
RAAS + which drug is used where (4)
1) Angiotensin (+ renin)
- beta blockers + renin inhib
2) = angiotensin I (+ACE Chymase)
- ACE inhib
3) = Angiotensin II
- ARBs
4) Aldosterone + Vasoconstriction
ACE Inhibitors (4)
- Indicated in all patients with heart failure (EF<40)
(unless contraindicated)
e.g.’s
–– Captopril
–– Enalapril
–– Lisinopril
–– Perindopril
–– Ramipril
–– Trandolapril
- Documented survival benefit
- Several large controlled trials
–– CONSENSUS
–– SOLVD
–– SAVE
–– AIRE
–– TRACE
How do ACE inhib work? (8)
Reduce angiotensin II levels
Arteriolar vasodilatation
Reduce systemic vascular resistance
Reduce norepinephrine release
Decrease sympathetic activity
Decrease aldosterone secretion
Suppress
vasopressin release
Increase bradykinin levels
Acute Infarction Ramipril
Efficacy (AIRE) (5)
Effect of Ramipril on mortality and
morbidity of survivors of acute MI with HF
2006 patients, EF ≤ 35% post-MI
Follow-up average 15 months
Overall mortality significantly reduced 27%
Development of severe heart failure reduced by 23%
ACEi: other uses (6)
Heart failure
Hypertension
Post-Myocardial Infarction (LVD)
Diabetic nephropathy
Diabetic retinopathy
ACEi: side effects (6)
First dose hypotension
Cough
Angioedema
Rash
Deterioration of renal function (in RAS)
ACEi: Contraindications (3)
- Pregnancy(or risk of pregnancy)
- Renal artery stenosis (bilateral, single k)R
Caution: Peripheral vascular disease
–– Low BP
–– High dose diuretic, hypovolaemia
–– Age >70 ys
–– Creatinine >150μmol/L
–– +NSAIDs
What if ACEi are
contraindicated or untolerated? (3)
Other vasodilators
–– Angiotensin Receptor Blockers e.g. Candesartan, Losartan
–– Hydrallazine & Nitrates
– Angiotensin receptor-neprilysin inhibitor
(ARNI )
Angiotensin Receptor
Blockers (ARBs) (4)
- Block angiotensin II type 1 receptors
Examples:
–– Losartan
–– Candesartan
–– Irbesartan
–– Valsartan
–– Eprosartan
ELITE study - ARBs (4)
Evaluation of Losartan In The Elderly
722 patients with CHF
Designed to study effects of losartan
on renal function (vs
captopril)
All cause mortality was 46% lowe
Sacubitril-Valsartan
(Entresto)- ARNI (6)
Angiotensin receptor-neprilysin inhibitor
(ARNI)
Moderate to severe heart failure [NYHA
class II–IV]
LV ejection fraction of ≤35%
Already on a stable dose of ACEi or ARBs
PARADIGM-HF Trial
43% reduction in mortality
PARADIGM-HF (8)
P-rospective comparison of A-ngiotensin II
R-eceptor blocker neprilysin inhibitor
with A-ngiotensin-converting enzyme
inhibitor to D-etermine
I-mpact on Global
M-ortality and morbidity in heart failure
Beta-Blockers (7)
Reduce sympatho-adrenergic activity
Reduce afterload
Decrease myocardial oxygen demand
Reduce ventricular remodelling
Reduce renin release
Coronary and peripheral vasodilatation
Negative inotropic effect
Evidence Based Medicine
Beta-Blockers (4)
only 3 used for HF
Beta-blockers reduce mortality in mild
-to-moderate CHF, reduce hospitalization, improve symptoms
Benefit not clear in class I or class IV
Reduction in mortality may not be a
class effect (metoprolol vs atenolol)
MERIT-HF - BB (6)
39991 patients in USA & Europe
NYHA II- III
Metoprolol-XL 12.5mg up to 200mg od
Total mortality: Decreased by 34%
CV mortality: Decreased by 38%
Sudden death: Decreased by 41%
Beta-Blockers: Side
effects (8)
Fatigue
Sleep disturbances
Bradycardia
Hypotension
Heart failure
(start low, go slow)
Conduction disorders
Bronchospasm
GI disturbances
BB: Cautions &
Contraindications (7)
Asthma, COAD
Uncontrolled heart failure
Severe bradycardia
Hypotension or shock
AV block (2AV block (2nd& 3rddegrees), SSS
Pheochromocytoma (unless with alphablocker)
Peripheral vascular disease
Spironolactone- including side effects (3)
Blocks aldosterone receptors on the distal
convoluted tubule
RALES study
Side effects:
– Gynaecomastia (painful)
– Testicular atrophy
– Menstrual irregularities
– Hyperkalaemia
(esp. renal impairment)
RALES
Randomised Aldactone Evaluation Study (6)
1663 patients, severe heart failure (NYHA1663 patients, severe heart failure (NYHA
IV) (LVEF<35%)
Rx ACEi + Loop diuretic ± Digoxin
Spironolactone 25mg - 50mg od
Total mortality :Total mortality : 30% p<0.001reduction
Cardiac mortality 31% reduction
Hospitalization:35% reductionr
Epleronone - including study ( 4)
Eplerenone produces less painful gynaecomastia
than spironolactone
EPHESUS study:
13% reduction in mortality from cardiovascular
causes or hospitalization
21% reduction in sudden death
Can cause hyperkalaemia and renal dysfunction
Eplerenone produces less painful gynaecomastia
than spironolactone
EPHESUS study:
13% reduction in mortality from cardiovascular
causes or hospitalization
21% reduction in sudden death
Can cause hyperkalaemia and renal dysfunction
Digoxin (3)
Inhibits Na+-K+ ATPase pump, inactivating Na+-
Ca2+ exchanger, increasing Ca2+
Increases force of contraction
Other effects
–– dec. AV conduction
–– inc. vagal activity
–– dec. heart rate
Digoxin: uses + side effects (4)
Slowing ventricular rate in rapid AF
Treatment of heart failure in patients who
remain symptomatic despite optimal doses
of diuretics and ACEi
Side effects:
–– Nausea, vomiting, arrhythmias, confusion
–– Toxicity enhanced by hypokalaemia#
Evidence Based Medicine Digoxin (4)
- Digoxin has no effect on mortality(DIG trial)
- Clinical effects are not dramatic
- Withdrawal of digoxin may cause clinical deterioration in 1/4 of patients stable on digoxin and diuretic ±ACEi (digoxin and diuretic ±ACEi (RADIANCERADIANCE and PROVED trials)
- Reduces hospitalization rates
Diuretics (7)
Relieve symptoms
Relieve circulatory congestion and
pulmonary and peripheral oedema
Reduce atrial and ventricular diastolic
pressure
Do not improve LV dysfunction
Little impact on mortality**
Frusemide
Other loop diuretics e.g. bumetanide
Metolazone
Diuretics: side effects (2)
Metabolic effects:
–– Hypokalaemia (low K)
= (arrhythmias)
–– Hyperglycaemia (high glucose)= (diabetes)
–– Hyperuricaemia (high uric acid)= (gout)
Social disruption
–– Frequency, urgency, incontinence
Hydralazine & Nitrate (4)
Hydralazine in combination with
nitrate (especially if the patient is of African or Caribbean origin and
moderate to severe heart failure
[NYHA class III–IV]
V-HeFT (Vasodilator-Heart Failure Trial)
43% reduction in mortality
A-HeFT (African American-Heart Failure Trial)
Sodium-GLucose co-
Transporter-2 inhibitors (4)
SGLT2 inhibitors or gliflozins
Indicated in Type 2 Diabetes mellitus
Inhibit reabsorption of glucose in the kidney and lower blood sugar
Examples:
Dapagliflozin, Empagliflozin, Canagliflozin,
Ertugliflozin, Sotugliflozin
Non-Drug Therapy
of Heart Failure (2)
Cardiac-Resynchronization
Therapy (RCT)
surgery
Cardiac-Resynchronization
Therapy (RCT) (4)
Using atrial-synchronized bi-ventricular pacing
Indicated for patients with severe symptoms and intra-ventricular conduction delays i.e. QRS ≥120 msec
Leads to dys-synchronous LV contraction, contraction,
impaired emptying, MR
Can reduce symptoms, improve functional capacity, reduce hospitalizations and increase survival
Surgery (3)
Ventricular Assist Devices
Cardiac Transplantation
Xeno Cardiac
transplantation
(genetically modified
pig heart) 7th January 2022
SUMMARY 1 (Diuretics, ACEi, Digoxin) (3)
Diuretics alone alleviate symptoms but do not but do not
improve heart function or mortality
ACEiA improve LV dysfunction, CV mortality and total mortality but do not appear to protect against sudden death
Digoxinimprove symptoms, reduces
hospitalization rates but no positive effect
on survival
SUMMARY 2 (BB, Spironolactone) (2)
Beta-blockers reduce mortality in mild-to-reduce mortality in CHF, reduce hospitalization,
improve symptoms
–– Benefit not clear in class I or class IV
–– Reduction in mortality may not be a class effect
(metoprolol vs atenolol)
Spironolactone reduce CV and total
mortality and hospitalization
SUMMARY 3 (ARNI, Gliflozins) (2)
ARNI reduce mortality in HFrEF, reduce hospitalization, improve symptoms
Gliflozins (Dapagliflozin and Empagliflozin)
reduce CV mortality and hospitalization in
HFrEF and HFpEF
