T8 - Insuficiência Cardíaca Flashcards
What is heart failure? What do the accompaning molecular abnormalities cause?
The inability of the heart to pump blood in an amount sufficient to meet the metabolic needs of the organs.
Progressive deterioration of the failing heart and premature myocardial cell death.
HF may be accompanied by what physical signs?
- Pulmonary crackles
- Elevated jugular venous
- Peripheral oedema
- Other
HF Three subtypes according to LV ejection fraction (EF)?
- HF with preserved EF (HFpEF): LVEF ≥50%
- HF with mid-range EF (HFmrEF): LVEF 40–49%
- HF with reduced EF (HFrEF): LVEF <40%
HF-PEF vs HF-REF?
Patients with HF-PEF are older and more often female and obese than those with HF-REF.
They are less likely to have CHD and more likely to have hypertension and atrial fibrillation.
Hospitalizations?
Hospitalizations are common after HF diagnosis, with 83% patients hospitalized at least once and 43% hospitalized at least 4 times.
HF prognosis?
Worse than that of many common forms of cancer
The two main causes of HF?
Coronary Heart Disease (HF-REF) and Hypertension (HF-PEF)
Risk factors to heart failure?
Hypertension Obesity DM2 DPOC Dyslipidemia
Etiology - HFrEF?
Coronary Heart Disease
Etiology - HFpEF?
Patients with HFpEF are less likely to have CHD and more likely to have hypertension , atrial fibrillation and other comorbidities
Pathophysiology and prognosis of HF?
LVD - Hemodynamic Changes - Neurohormones, Cytokines, Cytoskeleton - Molecular Changes (LVH, necrosis, apoptosis, fibrosis) - Remodelling - LVD
Sintomas HF?
Alterações da periferia
- Alterações hemodinâmicas (vasoconstrição, ret Na e H2O)
- Miopatia (esquelética – astenia, respiratória – dispneia)
Prognóstico (alterações do coração) in HF?
- NH, citoquinas e sobrecarga
- → Alt. moleculares cardíacas (proliferação, apoptose, necrose e fibrose)
- → “cardiomiopatia de sobrecarga” (DVE e remodelagem progressiva)
What is the bad prognosis of HF linked with?
Cardiac molecular changes (induced by neurohormonal activation, and causing premature cell death and remodeling)
Insuficiência Cardíaca FE reduzida - Consequências da remodelagem?
Dilatação e Disfunção sistólica e diastólica de um ou ambos os ventrículos.
•↓ do inotropismo e do débito cardíaco (DV sistólica)
•↑da pressão telediastólica VE (DV diastólica)
•Regurgitações valvulares
•↑ da FC
Anatomopatologia de HFrEF? HFpEF?
Left ventricular dilatation (Hipertrofia excêntrica)
Interstitial fibrosis
Hipertrofia ventricular concêntrica
Ambos podem causar fibrilhação auricular.
Heart Failure - Cardinal symptoms and signs?
. Fatigue
. Dyspnea
. Edema
Insuficiência cardíaca - Sinais físicos?
. BD (baixo débito) - Hipotensão, Taquicardia, Cianose
. ICE - Crepitações
. ICD - TVJ, Refluxo Hepato-Jugular, Hepatomegalia, Ascite, Edemas pré-tibiais
Cardiomegalia, sopros (IM e IT)
Caquexia (citocinas)
Heart Failure - ECG?
- AFib , VT
- LBBB
- LVH
- Myocardial infarction
A normal ECG virtually excludes HF
HF - RX de tórax?
- I C/T
- Contorno cardíaco (Cardiomegalia)
- Congestão pulmonar
Natriuretic Peptides?
NPs levels are intimately correlated with left ventricular end-diastolic pressure.
Normal NPs in a non-treated patient BNP virtually exclude HF.
HF Diagnosis?
- Clinical History
- HF Symptoms
- Hx of CAD, HTA, other HF risk factors
- Use of Diuretics - Physical examination
- Rales
- JV dilation, JG reflux, Hepatomegalia, Ascite, Ankle edema - Any ECG Abnormality
Natriuretic Peptides (NT-proBNP >125 pg/ml e BNP >35 pg/ml) Echocardiography
If HF confirmed:
- Determine aetiology
- Start appropriate treatment
HF Diagnosis - Essential initial investigations?
- Electrocardiogram
- Natriuretic peptides
- Echocardiography
HF Diagnosis - Symptoms and signs?
Typical Symptoms: - Orthopnea - DPN - Fatigue - Ankle swelling Specific Sings: - Elevated juguar venous pressure - Hepatojugular reflex - S3 (gallop) - Laterally displaced apical impulse
Insuficiência cardíaca - Classificação da NYHA?
. Classe I – Actividade usual não causa fadiga, dispneia ou palpitações importantes
. Classe II – confortável em repouso; actividade usual causa fadiga, dispneia ou palpitações (no dia a dia)
. Classe III – confortável em repouso; actividade ligeira causa fadiga, dispneia ou palpitações (ex: vestir, lavar, pequenos esforços)
. Classe IV - sintomas em repouso
Insuficiência cardíaca - Diagnóstico diferencial?
. IR . Anemia . DPOC . Obesidade . Destreino . Varizes . Hipotiroidismo
Insuficiência cardíaca - Complicações principais?
. IC Aguda
. Arritmias: FA, TV, FV
. Alterações da condução
. Embolias
Hospitalizations in HF patients?
- Are frequent and are not decreasing
- The main cause of hospitalization above 65y
- 45% of patients with AHF will be rehospitalized at least once within 12 months
- A marker of bad prognosis
Prognosis of HF?
50% of pts will die within 5 years of HF diagnosis.
HF prognosis is worse than that of many common forms of cancer.
Heart Failure therapy - Goals?
Relieve symptoms
Prevent hospital admissions
Improve survival
Heart Failure Treatment - Never forget?
1 – Diagnose and treat the etiology
2 – Patient education
3 – Nonpharmacological treatment
HFrEF Treatment?
SNS e RAAS targets
NH blockade and Congestion Management
iCEA and B-blocker (titulandoo até doses mais altas) –> Add a MRA (ant. rect.mineralocoirticoides)
- Tolerates iECA/ARB - ARNi
- SR,QRSd >130ms - Evaluate for CRT
- SR, HR > 70bpm - Ivabradina
FA ou LVEF<35% refratária - cardiodesfribilador
HFpEF and HFmrEF Treatment?
Symptoms Relief o Diuretics HF Hospitalizations prevention o Candesartan, nevibolol, spironolactone, digoxin Survival improvement o None
Treatment strategies in HFpEF and HFmrEF?
• Address co-morbidities - Cardiovascular (HTA, CAD, AFib, PH) - Non-cardiovascular (Obesity, DM, CKD, COPD, Iron deficiency, anemia) • Address congestion (Diuretics) • Control HR, BP and myocardial ischemia • Hypoglycemic drugs: - iSGLT2: 1rst-line agent, reduced weight, BP, HF hospitalizations and CV mortality - Metformin
HF organization of care?
However it is not possible for all HF patients to receive specialist care from cardiologists due to the size of this population.
Close co-operation between cardiologists, internists and primary care physicians is necessary.
Primary care specialists: Role?
HF Diagnosis - Symptoms and signs - ECG - NPs - 2D-Echo Non-Pharmacological therapy • Diet and exercise Pharmacological therapy - NH-Blockers - ARNIs and Ivabradine - Diuretics Follow-up Patients referral
Primary care specialists: When to refer patients?
Etiological Diagnosis Non-Pharmacological therapy - Devices - Intervention - Surgery HF Decompensation - Hospital Admission - IV therapy - Mechanical support (hemodynamic, respiratory, renal)
Principles of drug therapy HF-REF?
NH blockers: highest tolerated doses ARNI: highest tolerated doses Ivabradine: highest tolerated doses Diuretics: lowest dose for effect Digoxin: low dose (0.125 mg/day)
