CHF (Christine Dianne Pepito) CONGESTIVE HEART FAILURE Heart failure is the inability of the ventricles to deliver adequate

e blood flow to the metabolizing organs during normal activity or at rest. Why CONGESTIVE? It is a leading cause of mortality and morbidity. ETIOLOGY - Coronary artery disease - HPN - Valvular heart disease - Infections - Arrhythmias

- Alcohol--chronic - MI--acute - Diabeteschronic - Congenital - Iatrogenic

Compensatory Mechanisms in CHF Sympathetic Responses Hormonal Stimulation Concentric cardiac Hypertrophy Frank-Starling Mechanism Decomposition : Over time, the compensatory mechanisms become exhausted & increasingly ineffective. Inc. TPR & Afterload -- FLUID BACK-UP produce signs & symptoms of CHF Classifications of CHF Left-sided vs Right sided Left- pulmonary edema Right-peripheral edema (LHF: Systolic vs Diastolic ) Systolic- loss of contractility get dec. CO Diastolic- decreased filling or preload High output- hypermetabolic state Low output- metabolic demands are normal but heart is unable to meet them SYMPTOMS - Shortness of breath - Difficulty sleeping at night due to breathing problems - Increased urination at night - Chronic lack of energy - Swelling of feet & legs - Swollen / tender abdomen with loss of appetite - Cough with frothy sputum - Confusion and/or impaired memory

Left-side Heart Failure Signs and symptoms dyspnea orthopnea PND Dry, wheezing cough fatigue & weakness Nocturia Rales, Tachycardia S3 ventricular gallop S4 Atrial gallop NOTE L FOR LEFT AND L FOR LUNGS Why does this occur?? Diagnostic Test Results (Left-sided HF) Cardiomegaly LVH Pulmonary congestion Arm-to-tongue circulation prolonged Transudative pleural efflusion (x-ray & aspirated pleural fluid analysis) Cardiomegaly LVH Pulmonary congestion Arm-to-tongue circulation prolonged Transudative pleural efflusion (x-ray & aspirated pleural fluid analysis) RIGHT-SIDED HEART FAILURE Signs and Symptoms Tightness & swelling (edema) N&V, anorexia, bloating,wt. gain, inc. abd. Pain Jugular vein distension S3 ventricular & S4 atrial gallop Hepatomegaly +HJR Bilateral Leg Edema What is present in this extremity, common to right sided HF? o Coughing o Tiredness o Shortness of breath o Pumping action of the heart grows weaker o Pulmonary edema (excess fluid in lungs) o Pleural effusion (excess fluid around lungs) o Swelling in abdomen (ascites) o Swelling in ankles and legs Diagnostic Test Results (Right-sided HF) Elevated Levels of Hepatic Enzymes (e.g. SGPT) reflecting Hepatic congestion HEART FAILURE (Diagnostic Studies) Primary goal- determine underlying cause Hemodynamic assessment-Hemodynamic Monitoring-CVP- (right side) and Swan Ganz (left and right side) Echocardiogram-TEE (Transesophageal Echocardiogram) best use sound waves to produce an image of the heart Stress testing- exercise or medicine Cardiac catheterization- determine heart pressures ( inc.PAW ) Ejection fraction (EF)

Goals and drug therapy Goals Alleviation of symptoms, improve quality of life Arrest ventricular remodeling Prevent sudden death Nondrug therapy Reduce cardiac work; bed rest, Dietary Controls, Low Na+ diet Drug therapy Chronic heart failure ACE-I, -blockers, ARB, aldosterone antagonists, digoxin, diuretics Acute heart failure Intravenous diuretics, inotropic agents, PDE inhibitors, vasodilator Drugs for CHF

Vasodilators (ACE Inhibitors, Nitroprusside, Hydralazine, Prazosin, Nitrates) Diuretics Beta blockers Digitalis glycosides Other Cardiac Inotropes (Dopamine, Dobutamine, Milrinone)

Angiotensin Converting Enzyme (ACE) Inhibitors : ACE inhibitors improve mortality, morbidity, exercise tolerance, left ventricular ejection fraction. Captopril, Lisinopril, Enalapril, Ramipril, Quinapril. Angiotensin Converting Enzyme (ACE) Inhibitors : Reduction in arterial resistance (afterload) Reduction in venous tension (preload) Reduction in aldosterone secretion Inhibition of cardiac and vascular remodeling Adverse effects : Dry irritating persistent cough Hyperkalemia Angioedema Fetal toxicity Angiotensin Receptor AT-1 blockers (ARB) : Losartan, Irbesartan, Candesartan Competitive antagonists of Angiotensin II (AT-1). Vasodilators : Isosorbide dinitrate and hydralazine also used specially in patients who cannot tolerate ACE inhibitors. Amlodipine and prazosin are other vasodilators can be used in CCF.

Nitrates in CHF

Diuretics : These are useful in reducing the symptoms of volume overload by decreasing the extra cellular volume decreasing the venous return Loop diuretics like furosemide and bumetanide are the most effective and commonly used. Thiazides are effective in mild cases only. Adverse effects : Loop diuretics and thiazides cause hypokalemia. Potassium sparing diuretics help in reducing the hypokalemia due to these diuretics. Potassium Sparing Diuretics ( Spironolactone) Aldosterone inhibition minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis. Spironolactone : Aldosterone antagonist Spironolactone can be added to loop diuretics to modestly enhance the diuresis; more importantly, improve survival. Beta blockers for congestive cardiac failure : Acts primarily by inhibiting the sympathetic nervous system. Start at low dose and monitor for bradycardia Carvedilol and Metoprolol are the most commonly used for CHF amongst beta blockers Cardiac glycosides : Digoxin : Inhibition of Na/K ATPase pump increase intracellular sodium concentration eventually increase cytosolic calcium. Increase the refractoriness of AV node thus decrease ventricular response to atrial rate. Digoxin is used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation. Digoxin : Adverse effects / Precautions : Nausea, vomiting, gynecomastia, visual disturbances and psychosis. Ventricular bigeminy, AV block and bradycardia. Amiodarone and verapamil can increase the plasma concentration of digoxin by inhibiting its excretion. Digoxin toxicity treatment: Toxicity can be treated with higher than normal doses of potassium. Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose. Cardiac Inotropes : Phosphodiesterase III Inhibitors Positive inotropic and vasodilator INO-DILATOR ; Eg., Milrinone Dobutamine is a beta-1 agonist which increase contractility and cardiac output.

Heart Failure Classification Systems New York Heart Association Functional Classification of HF Classes I to IV ACC/AHA Stages of HF (newer) Stages A to D

Stage A

At high risk for developing heart failure. Includes people with: Hypertension Diabetes mellitus CAD (including heart attack) History of cardiotoxic drug therapy History of alcohol abuse History of rheumatic fever Family history of CMP

Exercise regularly Quit smoking Treat hypertension Treat lipid disorders Discourage alcohol or illicit drug use If previous heart attack/ current diabetes mellitus or HTN, use ACEInhibitors

Stage B

Those diagnosed with systolic heart failure- have never had symptoms of heart failure (usually by finding an ejection fraction of less than 40% on echocardiogram

Care measures in Stage A + Should be on ACE-I Add beta -blockers Surgical consultation for coronary artery revascularization and valve repair/replacement (as appropriate

Stage C

Patients with known heart failure with current or prior symptoms. Symptoms include: SOB, fatigue Reduced exercise intolerance

All care measures from Stage A apply, ACE-I and beta-blockers should be used + Diuretics, Digoxin, Dietary sodium restriction Weight monitoring, Fluid restriction Withdrawal drugs that worsen condition Maybe Spironolactone therapy

Stage D

Presence of advanced symptoms, after assuring optimized medical care

All therapies -Stages A, B and C + evaluation for:Cardiac transplantation, VADs, surgical options, research therapies, Continuous intravenous inotropic infusions/ End-of-life care