sanfaisjfn
Post on 13-Apr-2018
217 Views
Preview:
TRANSCRIPT
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 1/16
Heart Failure
Final common pathway for many cardiovascular
diseases whose natural history results insymptomatic or asymptomatic left ventriculardysfunction
Cardinal manifestations of heart failure include
dyspnea, fatigue and fluid retention Risk of death is 5-10% annually in patients with
mild symptoms and increases to as high as 30-40% annually in patients with advanced disease
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 2/16
Main causes
Coronary artery disease
Hypertension
Valvular heart disease
Cardiomyopathy Cor pulmonale
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 3/16
Compensatory changes in heart
failure
Activation of SNS
Activation of RAS
Increased heart rate
Release of ADH
Release of atrial natriuretic peptide
Chamber enlargement
Myocardial hypertrophy
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 4/16
NYHA Classification of heart failure
Class I: No limitation of physical activity
Class II: Slight limitation of physical activity
Class III: Marked limitation of physical
activity
Class IV: Unable to carry out physical
activity without discomfort
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 5/16
New classification of heart failure
Stage A: Asymptomatic with no heart
damage but have risk factors for heart failure
Stage B: Asymptomatic but have signs ofstructural heart damage
Stage C: Have symptoms and heart damage Stage D: Endstage disease
ACC/AHA guidelines, 2001
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 6/16
Types of heart failure
Diastolic dysfunction or diastolic heart
failure
Systolic dysfunction or systolic heart failure
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 7/16
Factors aggravating heart failure
Myocardial ischemia or infarct
Dietary sodium excess Excess fluid intake
Medication noncompliance
Arrhythmias
Intercurrent illness (eg infection) Conditions associated with increased metabolic demand
(eg pregnancy, thyrotoxicosis, excessive physical activity)
Administration of drug with negative inotropic properties orfluid retaining properties (e. NSAIDs, corticosteroids)
Alcohol
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 8/16
Goals of treatment
To improve symptoms and quality of life
To decrease likelihood of disease
progression
To reduce the risk of death and need for
hospitalisation
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 9/16
Approach to the Patient with Heart Failure
Assessment of LV function (echocardiogram,radionuclide ventriculogram)
EF < 40%
Assessment of
volume status
Signs and symptoms
of fluid retention
No signs and symptoms of
fluid retention
Diuretic
(titrate to euvolemic state)
ACE Inhibitor
-blockerDigoxin
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 10/16
NEJM 1984; 311: 819-823
Cumulative mortality (%)
100
80
60
40
20
0
0 12 24 36 48 60
Months
Overall
p<0.0001
Noradrenaline > 600 pg/mland 900 pg/ml<
Noradrenaline 600 pg/ml<
Noradrenaline > 900 pg/ml
Relation between plasma noradrenaline andmortality in patients with heart failure
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 11/16
Effects of SNS Activation in Heart Failure
Dysfunction/death of cardiac myocytes
Provokes myocardial ischemia
Provokes arrhythmias
Impairs cardiac performance
These effects are mediated via stimulation
of b and a 1 receptors Am J Hypertens 1998; 11: 23S-37S
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 12/16
*
*
*p < 0.05
Idiopathic dilated cardiomyopathy
Normal myocardium
70
60
50
40
30
20
10
0
b1
a1
b
R e c e p t o r d e n s i t y ( f m o l / m g )
Receptor densities in human left ventricular myocardium
Scand Cardiovasc J 1998; Suppl 47:45-55
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 13/16
Carvedilol in Heart Failure
Effective receptor-blockade approach to heart
failure
Negative inotropic effect counteracted by
vasodilation Provides anti-proliferative, anti-arrhythmic
activity and inhibition of apoptosis
Prevents renin secretionDrugs of Today 1998; 34 (Suppl B): 1-23.
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 14/16
US Multicenter Program
Placebo Carvedilol % Risk
(n=398) (n=696) Reduction All-cause 31 22 65%
mortality (7.8%) (3.2%)
Death due to progressive 13 5
heart failure (3.3%) (0.7%)Sudden death 15 12
(3.8%) (1.7%)
Risk of hospitalization for 78 78 27%
cardiovascular reasons (19.6%) (14.1%)
Combined risk of 98 110 38%
mortality & hospitalization (25%) (16%)
NEJM 1996; 334:1349-1355
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 15/16
ANZ Multicentre Heart Failure Trial
Placebo Carvedilol % Risk
(n=208) (n=207) Reduction
All-cause 26 20 24%
mortality (12.5%) (10%)
Risk of hospitalization for 84 64 28%
cardiovascular reasons (40%) (31%)
Combined risk of 97 74 29%
mortality & hospitalization (47%) (36%)
Lancet 1997; 349: 375-380.
7/27/2019 sanfaisjfn
http://slidepdf.com/reader/full/sanfaisjfn 16/16
Effect of carvedilol on progression
of congestive heart failure
All randomized patients
Endpoint Placebo Carvedilol
(n=134) (n=232)
Primary endpoint 28 (21%) 25 (11%)*
Death due to CHF 4 (3%) 0 (0%)
Hospitalization due to worsening CHF 8 (6%) 9 (4%)
Increase in CHF medication 16 (12%) 16 (7%)
* Placebo vs. carvedilol, p = 0.008
Drugs of Today 1998; 34 (Suppl B): 1-23.
top related