Prof Univ DR Ion C.Tintoiu FESC Centrul de Cardiologie Al Armatei Universitatea Titu Maiorescu

Prof Univ Dr Ion C.
Tintoiu FESC
Centrul de Cardiologie al Armatei
Universitatea Titu Maiorescu
Outline
Outline
Definitions ,Etiology,Pathophisiology
Definitions ,Etiology,Pathophisiology
Diagnosing and classifying heart failure

Diagnosing and classifying heart failure
Approach to management of CHF

Approach to management of CHF
Drug thera!
Drug thera!
(ACE-I, AR, !eta!loc"ers,
(ACE-I, AR, !eta!loc"ers,
aldosterone !loc"ade, digo#in$
aldosterone !loc"ade, digo#in$
Device thera!
Device thera!
i%entricular (i&$ pacers i%entricular (i&$ pacers
Intracardiac defi!rillators (ICDs$ Intracardiac defi!rillators (ICDs$
'urgery and Inter%entional (reatment 'urgery and Inter%entional (reatment
Future directions
Future directions
Clinical syndrome that can result
Clinical syndrome that can result
from any structural or functional
from any structural or functional
cardiac disorder that impairs the
cardiac disorder that impairs the
ability of the ventricle to fill with
ability of the ventricle to fill with
or eject blood
or eject blood
Definition
Definition
"eart failure is a clinical s!ndrome usuall! due to

"eart failure is a clinical s!ndrome usuall! due to
left ventricular d!sfunction# resulting in acute or
left ventricular d!sfunction# resulting in acute or
chronic s!mtoms of cardiac um failure.
chronic s!mtoms of cardiac um failure.
The most common causes of heart failure are

The most common causes of heart failure are

coronary heart disease, hypertension, alcohol a!use,
coronary heart disease, hypertension, alcohol a!use,
and idiopathic dilated cardiomyopathy
and idiopathic dilated cardiomyopathy
Other causes are

Other causes are
%al%ular and pericardial disease) or
%al%ular and pericardial disease) or
non-cardiac diseases causing high-output cardiac
non-cardiac diseases causing high-output cardiac
failure, such as anaemia, thyroto#icosis, septicaemia,
failure, such as anaemia, thyroto#icosis, septicaemia,
Paget*s disease of !one, and arterio%enous fistulae+
Paget*s disease of !one, and arterio%enous fistulae+
Definition
Definition
The heart$s ina%ilit! to um enough %lood

The heart$s ina%ilit! to um enough %lood
to meet the %od!$s o&!gen and nutrient
to meet the %od!$s o&!gen and nutrient
demands
demands
Can %e
Can %e
s!stolic or diastolic
s!stolic or diastolic
#
#
left' or
left' or
right'sided#
right'sided#
acute or chronic
acute or chronic
"EA(T FAI)U(E
"EA(T FAI)U(E

Modern clinical definition
Modern clinical definition
ESC guideline ESC guideline
Typical symptoms
and signs of
heart failure
Cardiac dysfunction
confirmed
(ECG, imaging modalities)
Neurohumoral
aktivation confirmed
(BNP)
esponse to
heart failure
treatment
A normal heart pumps blood in a smooth and synchronized way. A normal heart pumps blood in a smooth and synchronized way.
Heart Failure Heart
Heart Failure Heart
A heart failure heart has a reduced ability to pump blood. A heart failure heart has a reduced ability to pump blood.
Adatation in heart failure
Adatation in heart failure
*Comensator! Mechanism+
*Comensator! Mechanism+
&entricular remodelling
LV mass, size, shape is altered

Etiology
Etiology
It is a common end point for many

It is a common end point for many
diseases of cardiovascular system
diseases of cardiovascular system
It can !e caused !y ,
It can !e caused !y ,

-
-
Inappropriate -or" load
Inappropriate -or" load ( (%olume or pressure %olume or pressure
o%erload$ o%erload$

-
-
Restricted filling
Restricted filling

-
-
.yocyte loss
.yocyte loss
ETIO)O,IES OF "EA(T FAI)U(E ETIO)O,IES OF "EA(T FAI)U(E
Deressed E-ection Fraction *./01+ Deressed E-ection Fraction *./01+
Coronar! arter! disease Coronar! arter! disease 2onischemic dilated cardiom!oath! 2onischemic dilated cardiom!oath!
M!ocardial infarction M!ocardial infarction Familial3genetic disorders Familial3genetic disorders
M!ocardial ischemia M!ocardial ischemia Infiltrative disorders Infiltrative disorders
Chronic ressure overload Chronic ressure overload To&ic3drug'induced damage To&ic3drug'induced damage
"!ertension "!ertension Meta%olic disorders Meta%olic disorders
O%structive valvular disease O%structive valvular disease 4iral 4iral
Chronic volume overload Chronic volume overload Chagas5 disease Chagas5 disease
(egurgitant valvular disease (egurgitant valvular disease Disorders of rate and rh!thm Disorders of rate and rh!thm
Intracardiac *left'to'right+ shunting Intracardiac *left'to'right+ shunting Chronic %rad!arrh!thmias Chronic %rad!arrh!thmias
E&tracardiac shunting E&tracardiac shunting Chronic tach!arrh!thmias Chronic tach!arrh!thmias
Heart Failure,
Heart Failure,
Etiologies
Etiologies
CAD CAD 671 671
Idioathic Idioathic 781 781
Undetermined Undetermined 701 701
4alve 4alve 701 701
"!ertension "!ertension 9./1 9./1
Other Other 61 61
Alcohol Alcohol /1 /1
Atrial Fi%rillation Atrial Fi%rillation 81 81
Fo# /F, Co-ie .R, 0ood DA, et al+ Coronary artery disease as the cause of incident heart Fo# /F, Co-ie .R, 0ood DA, et al+ Coronary artery disease as the cause of incident heart
failure in the population+ failure in the population+ Eur Heart J Eur Heart J+ 1223)11,114-156+ + 1223)11,114-156+
!
!
"olume overload#
"olume overload# egurgitate valve egurgitate valve
$igh output status $igh output status
!
!
Pressure overload#
Pressure overload# %ystemic hypertension %ystemic hypertension
&utflo' o(struction)*% &utflo' o(struction)*%
!
!
+oss of muscles#
+oss of muscles# Post ,-, Chronic ischemia Post ,-, Chronic ischemia
Connective tissue diseases Connective tissue diseases
-nfection, Poisons -nfection, Poisons
(alcohol,co(alt,.o/oru(icin (alcohol,co(alt,.o/oru(icin) )
!
!
estricted 0illing#
estricted 0illing# Pericardial diseases, Pericardial diseases,
estrictive estrictive cardiomyopathy cardiomyopathy
Tachyarrhythmia Tachyarrhythmia

Causes of C$0
Adapted from Cohn JN. N Engl J Med. 1996;335:9!"9#.
Pathologic
remodeling
+o' e1ection
fraction
.eath
%ymptoms#
.yspnea
0atigue
Edema
Chronic
heart
failure
$
Neurohormonal
stimulation
$ ,yocardial
to/icity
%udden
.eath
Pump
failure
Coronary artery
disease
$ypertension
Cardiomyopathy
"alvular disease
,yocardial
in1ury
Pathologic Progression of C4 Disease
.ia(etes
Pathophysiology
Hemodynamic changes
Hemodynamic changes
7eurohormonal changes
7eurohormonal changes
Cellular changes
Cellular changes
"emod!namic changes
"emod!namic changes
From hemodynamic stand point HF can be

From hemodynamic stand point HF can be
secondary to
secondary to
systolic dysfunction or
systolic dysfunction or

diastolic dysfunction
diastolic dysfunction
Cellular changes
Cellular changes

Changes in Ca
Changes in Ca
+2 +2
handling.
handling.

Changes in adrenergic receptors:
Changes in adrenergic receptors:

8 8
'light 'light in in 9 9
3 3
receptors receptors
8 8 : :
3 3
receptors desensiti;ation receptors desensiti;ation follo-ed !y do-n regulation follo-ed !y do-n regulation

Changes in contractile proteins

Changes in contractile proteins

Program cell death (

Program cell death (Aotosis Aotosis
+
+

Increase amount of fibrous tissue

Increase amount of fibrous tissue
Diagnosis of heart failure
Ph!sical e&amination
Medical histor!
)a% tests: ;2P# <
='ra!# EC,#
Echo# Siro'
Ergometr!<
Cinical symptoms and signs
Cinical symptoms and signs
dyspnoe fatigue
fluid
retention
"eart Failure: Cardinal
"eart Failure: Cardinal
S!mtoms
S!mtoms
D!snea
D!snea
Orthonea
Orthonea
Edema
Edema
Cough
Cough
)iver engorgement
)iver engorgement
&T$&PNE*
J%&%lar Veno%s 'istention J%&%lar Veno%s 'istention
not dire(tl) related to LV*+ not dire(tl) related to LV*+
E2G
Old MI or recent MI
Old MI or recent MI
Arrh!thmia
Arrh!thmia
Some forms of Cardiom!oath! are tach!cardia
Some forms of Cardiom!oath! are tach!cardia
related
related
);;;
);;;
>
>
may help in management
may help in management
"eart ;loc?
"eart ;loc?
hythm pro(lems leading to C$0
Chest X-ray
Chest X-ray
'i;e and shape of heart

'i;e and shape of heart
E%idence of pulmonary %enous congestion (dilated

E%idence of pulmonary %enous congestion (dilated
or upper lo!e %eins
or upper lo!e %eins
= peri%ascular edema$
= peri%ascular edema$
Pleural effusion
Pleural effusion
Chest 34ray
>oo" for Heart si;e
Pulmonary %ascular mar"ings
C?PD, pneumonia, Pneumothora#, -idened mediastinum
Pleural effusions
Echocardiogram
Function of %oth ventricles
Function of %oth ventricles
@all motion a%normalit! that ma! signif! CAD
4alvular a%normalit!
Intra'cardiac shunts
Pericardial effusion
Pericardial effusion
(estrictive ericarditis
(estrictive ericarditis
Pulmonar! h!ertension
DC.
DC.
HC., H?C.
HC., H?C.
Restricti%e C.P
Restricti%e C.P
Cardiac Catheteri5ation
Coronar! arter! disease
Coronar! arter! disease
Dilated ventricle
Dilated ventricle
"!erd!namic small ventricle
"!erd!namic small ventricle
+a( Tests
Anemia
Anemia
"!erth!roid
"!erth!roid
Chronic renal insuffienc!
Chronic renal insuffienc!
Electrol!te a%normalit!'2a# A# Mag# Calcium
Electrol!te a%normalit!'2a# A# Mag# Calcium
Pre'renal aBotemia
Pre'renal aBotemia
"emochromatosis
"emochromatosis
;2P
;2P
TS"
TS"
"gA7c
"gA7c
Classif!ing "eart
Classif!ing "eart
Failure:
Failure:
Terminolog! and
Terminolog! and
Staging
Staging
+ +
A Ae! Indicator for Diagnosing "eart
Failure
Failure
E-ection Fraction *EF+
E-ection Fraction *EF+
E-ection Fraction *EF+ is the ercentage of %lood

E-ection Fraction *EF+ is the ercentage of %lood
that is umed out of !our heart during each %eat
that is umed out of !our heart during each %eat
S!stolic vs. Diastolic
Diastolic d!sfunction Diastolic d!sfunction
EF normal or increased EF normal or increased
Hypertension Hypertension
Due to chronic replacement fi!rosis @ Due to chronic replacement fi!rosis @

ischemia-induced decrease in distensi!ility ischemia-induced decrease in distensi!ility
S!stolic d!sfunction S!stolic d!sfunction
EF A B2C EF A B2C
Dsually from coronary disease Dsually from coronary disease
Due to ischemia-induced decrease in Due to ischemia-induced decrease in

contractility contractility
.ost common is a com!ination of !oth .ost common is a com!ination of !oth

.iastolic C$0
-mpaired +" rela/ation -mpaired +" rela/ation
-ncrease passive +" stiffness -ncrease passive +" stiffness
Endocardial and pericardial disorders' Endocardial and pericardial disorders'
,icrovascular flo' ,icrovascular flo'
,yocardial turgor ,yocardial turgor
Neurohormonal regulation Neurohormonal regulation
.iagnosis of diastolic C$0
$
-ncreased ventricular filling pressure 'ith -ncreased ventricular filling pressure 'ith
normal systolic function normal systolic function
$
-ncresed ventricular pressure 'ith preserved -ncresed ventricular pressure 'ith preserved
systolic function and normal ventricular systolic function and normal ventricular
volumes volumes
$
-ncreased left atrial and pulmonary capillary -ncreased left atrial and pulmonary capillary
'edge pressure 'edge pressure
$
Clinical symptoms and signs6 Clinical symptoms and signs6
BE
Clinical Classifications
Acute
Acute
sudden onset -ith associated signs and symptoms

Chronic
Chronic
secondary to slo- structural changes occurring in

the stressed myocardium
Acute Decomensated
Acute Decomensated
sudden e#acer!ation or onset of symptoms in

chronic heart failure
Acute "eart Failure
Acute "eart Failure
?ften precipitated !y a myocardial infarction+

?ften precipitated !y a myocardial infarction+
Signs include:
Signs include:

'e%ere !reathlessness 'e%ere !reathlessness
Frothy pin" sputum Frothy pin" sputum
Cold clammy s"in Cold clammy s"in
(achycardia (achycardia
>o- !lood pressure >o- !lood pressure
>ung crepitations >ung crepitations
Raised Fugular %enous pressure Raised Fugular %enous pressure
(hird heart sound (hird heart sound
Confusion Confusion
70&8*. 0*-+9E: (+o' Cardiac &utput)#
.ecreased perfusion of the (rain (confusion)6
kidneys (impaired renal function),
skin (cyanosis) etc6
7
7B*C28*.
0*-+9E:
#
-ncreased
pulmonary
venous pressure,
pulmonary edema
Chronic "eart Failure
Chronic "eart Failure
Ma?ing an accurate diagnosis of heart failure and determining its Ma?ing an accurate diagnosis of heart failure and determining its
cause can %e difficult cause can %e difficult
Clinical diagnosis is confirmed to !e accurate in appro#imately half of Clinical diagnosis is confirmed to !e accurate in appro#imately half of
cases -hen in%estigated !y echocardiography+ cases -hen in%estigated !y echocardiography+
The li?elihood of heart failure in the resence of suggestive s!mtoms The li?elihood of heart failure in the resence of suggestive s!mtoms
and signs is increased if and signs is increased if there is a history of myocardial infarction (.I$ or there is a history of myocardial infarction (.I$ or
angina, an a!normal ECG, or a chest H-ray sho-ing pulmonary congestion angina, an a!normal ECG, or a chest H-ray sho-ing pulmonary congestion
or cardiomegaly+ or cardiomegaly+
S!mtoms include: S!mtoms include:
'hortness of !reath on e#ertion (sensiti%ity 66C, specificity E1C$ 'hortness of !reath on e#ertion (sensiti%ity 66C, specificity E1C$
Decreased e#ercise tolerance (often simply *fatigue*$ Decreased e#ercise tolerance (often simply *fatigue*$
Paro#ysmal nocturnal dyspnoea (sensiti%ity 55C, specificity I6C$ Paro#ysmal nocturnal dyspnoea (sensiti%ity 55C, specificity I6C$
?rthopnoea (sensiti%ity 13C, specificity 43C$ ?rthopnoea (sensiti%ity 13C, specificity 43C$
An"le s-elling (sensiti%ity 15C, specificity 42C$ An"le s-elling (sensiti%ity 15C, specificity 42C$
Acute vs. Chronic
Acute vs. Chronic
Acute
Acute
Can emergenc! situation
Can emergenc! situation
in -hich a
in -hich a
patient -as completely asymptomatic !efore
patient -as completely asymptomatic !efore
the onset of heart failure) seen in acute heart
the onset of heart failure) seen in acute heart
inFury such as .I
inFury such as .I
Chronic
Chronic
Jlong-term syndrome
Jlong-term syndrome
in -hich a
in -hich a
patient e#hi!its symptoms o%er a long period
patient e#hi!its symptoms o%er a long period
of time, usually as a result of a pree#isting
of time, usually as a result of a pree#isting
cardiac condition
cardiac condition
T!es
T!es
ystolic
ystolic
*uming ro%lem
*uming ro%lem
$Jina!ility of the heart to
$Jina!ility of the heart to
contract to pro%ide enough !lood flo- for-ard
contract to pro%ide enough !lood flo- for-ard
!iastolic
!iastolic
(filling pro!lem$J
(filling pro!lem$J
ina!ility of the left %entricle
ina!ility of the left %entricle
to rela# normally, resulting in fluid !ac" up into the
to rela# normally, resulting in fluid !ac" up into the
lungs
lungs
"eft-sided
"eft-sided
J
J
ina!ility of the left %entricle to pump enough
ina!ility of the left %entricle to pump enough
!lood, causing fluid !ac" up into the lungs
!lood, causing fluid !ac" up into the lungs
#ight-sided
#ight-sided
J
J
inefficient pumping of the right side of the
inefficient pumping of the right side of the
heart, causing fluid !uildup in the a!domen, legs, and
heart, causing fluid !uildup in the a!domen, legs, and
feet
feet
)eft'Sided "eart Failure
)eft'Sided "eart Failure
Signs D S!mtoms
Signs D S!mtoms
Dyspnea Dyspnea
Dne#plained cough Dne#plained cough
Pulmonary crac"les Pulmonary crac"les
>o- o#ygen saturation >o- o#ygen saturation
(hird heart sound (hird heart sound
Reduced urine output Reduced urine output
Altered digestion Altered digestion
Di;;iness and light- Di;;iness and light-

headedness headedness
Confusion Confusion
Restlessness and an#iety Restlessness and an#iety
Fatigue and -ea"ness Fatigue and -ea"ness

(ight'Sided "eart Failure
(ight'Sided "eart Failure
Signs D S!mtoms
Signs D S!mtoms
>o-er e#tremity edema >o-er e#tremity edema
>i%er enlargement >i%er enlargement
Ascites Ascites
Anore#ia Anore#ia
A!dominal pain A!dominal pain
7ausea 7ausea
0eight gain 0eight gain
0ea"ness 0ea"ness
Classification of stages of
Classification of stages of
heart failure
heart failure
%tage * %tage *
At hi&h ris, of
heart fail%re
-)pertension
C-'
'ia.etes
/eta.oli( s).
Cardioto0in
1ta&e 2 1ta&e 2
1tr%(t%ral heart
disease 3itho%t
s)mptoms
LV remodelin&
LV h)pertroph)
Val4e disease
%tage C %tage C
1tr%(t%ral heart
disease
3ith s)mptoms
of heart fail%re
%tage . %tage .
5efra(tor)
heart fail%re
Classification of "F: Comarison
;etEeen ACC3A"A "F Stage and
2F"A Functional Class
3
Hunt 'A et al+ J Am Coll Cardiol. 1223)54,1323K1335+

1
7e- Lor" Heart AssociationM>ittle ro-n and Company, 3N6B+ Adapted from, Farrell .H et al+ JAMA. 1221)14I,4N2K4NI+
ACC3A"A "F Stage
7
G
A At high ris? for heart failure %ut Eithout
structural heart disease or s!mtoms
of heart failure *eg# atients Eith
h!ertension or coronar! arter! disease+
; Structural heart disease %ut Eithout
s!mtoms of heart failure
C Structural heart disease Eith rior or
current s!mtoms of heart failure
D (efractor! heart failure reHuiring
secialiBed interventions
I As!mtomatic
II S!mtomatic Eith moderate e&ertion
I4 S!mtomatic at rest
III S!mtomatic Eith minimal e&ertion
2one
Current D Future Persectives
in the Treatment of "eart
Failure
Princiles of Treatment
'ystolic HF
'ystolic HF
Preload
Preload
Afterload
Afterload
Ionotropy
Ionotropy
7eurohumoral
7eurohumoral

acti%ity
acti%ity
ACE-I, eta-!loc"ers,
and aldosterone
and aldosterone
antagonist are the
antagonist are the
mainstay of treatment
O%-ectives of treatment in C"F
O%-ectives of treatment in C"F
7#
7#
Impro%e
Impro%e
rognosis
rognosis
, reduce mortality
, reduce mortality
1, Impro%e mor!idity, relie%e
1, Impro%e mor!idity, relie%e
s!mtoms
s!mtoms
- increase e#ercise capacity
- increase e#ercise capacity
- reduce fatigue and !reathlessness
- reduce fatigue and !reathlessness
- eliminate oedema and fluid retention
- eliminate oedema and fluid retention
5,
5,
Prevention
Prevention
- myocardial damage
- myocardial damage
- remodelling
- remodelling
- reoccurence of symptoms
- reoccurence of symptoms
- hospitalisation
- hospitalisation
Treatment of C$0
Correction of reversi(le causes Correction of reversi(le causes
$
,edications ,edications
.iuretics, *CE inhi(itors, (eta (lokers etc6 .iuretics, *CE inhi(itors, (eta (lokers etc6
$
-schemia -schemia
$
*rrhythmia# * fi(, flutter, P;T *rrhythmia# * fi(, flutter, P;T
$
"alvular heart disease "alvular heart disease
$
Thyroto/icosis and other high output status Thyroto/icosis and other high output status
$
%hunts %hunts
Treatment of heart failure
Pharmacologic
treatment
6ozit74 inotrop
'i&italis
Ne%roh%mor8lis
.lo,8d: 22, AC*i
'i%reti(%m
Vasodilator
Antiarrh)thmi8s
Non4pharmacologic treatment
5es)n(hronization 9C5:;
<C'
<A26
Assist de4i(e
%urgical<interventional
5e4as(%larisation
Val4e repla(ement
Ane%r)sm rese(tion
1%r&i(al remodelin&
1tem=(ell therap)
$eart transplantation
Drug Thera!
Drug Thera!
-nhi(ition of
NE9&4$9,&*+
activation
AC* inhi.itors
2eta.lo(,ers
Aldosterone
Anta&onists
'i&o0in

eduction of
%"4-ncrese
Contractility
-)dralazine
Nitrate
Ca=(hanell
2lo(,ers
<notropi( a&ents
Elimination
of oedema
'i%reti(s
"FSA G070
"FSA G070
Comrehensive "eart
Comrehensive "eart
Failure Practice
Failure Practice
,uideline
,uideline
/ey Recommendations
/ey Recommendations
Diuretics @ ACEI reduces the num!er of
sac"s on the -agon
Diuretics
Diuretics
symptoms
symptoms
, oedema
, oedema
, prognosis
, prognosis
only in case of fluid retention

RAA' acti%ation
RAA' acti%ation
add ACEi or ARO

add ACEi or ARO
(itrate, com!ine
(itrate, com!ine
Hyonatraemia, hypo"alemia, %olume

depletion, renal dysfunction
Diuretic resistance
Diuretic resistance
65 All a4aila.le for oral or <V administration
)oo Diuretics
)oo Diuretics
Agent Agent Initial Dail! Initial Dail!
Dose Dose
Ma& Total Ma& Total
Dail! Dose Dail! Dose
Elimination: Elimination:
(enal I Met. (enal I Met.
Duration of Duration of
Action Action
Furosemide Furosemide G0'/0mg Hd or G0'/0mg Hd or
%id %id
900 mg 900 mg 961('861M 961('861M /'9 hrs /'9 hrs
;umetanide ;umetanide 0.6'7.0 mg Hd 0.6'7.0 mg Hd
or %id or %id
70 mg 70 mg 9G1(38J1M 9G1(38J1M 9'J hrs 9'J hrs
Torsemide Torsemide 70'G0 mg Hd 70'G0 mg Hd G00 mg G00 mg G01('J01M G01('J01M 7G'79 hrs 7G'79 hrs
Ethacr!nic Ethacr!nic
acid acid
G6'60 mg Hd G6'60 mg Hd
or %id or %id
G00 mg G00 mg 9K1('881M 9K1('881M 9 hrs 9 hrs
Aldosterone antagonists
symptoms
symptoms
, prognosis
, prognosis
, mortality
, mortality
7LHA III, EF
7LHA III, EF
A
A
5EC
5EC
Renal dysfunction
Renal dysfunction
Hyper"alaemia
Hyper"alaemia
ACE
ACE
I and A(;
I and A(;

symptoms
symptoms
, prognosis
, prognosis
, mortality
, mortality
remodelling
remodelling
, myocardial fi!rosis
starting dose, target dose

Hypotension
Hypotension
Hyperla"aemia, renal dysfunction

Cough
Cough
Angio-oedema
Angio-oedema
L';loc?ers
>imit the don"eyPs speed, thus sa%ing energy
*ntiarrhythmics
/ost (ommon (a%se of 1C' in these patients is /ost (ommon (a%se of 1C' in these patients is
4entri(%lar ta(h)arrh)thmia 4entri(%lar ta(h)arrh)thmia
6atients 3ith h>o s%stained V: or 1C' ? <C' implant 6atients 3ith h>o s%stained V: or 1C' ? <C' implant
6atients 3ith C-+ 3ith an e@e(tion fra(tion of less than 6atients 3ith C-+ 3ith an e@e(tion fra(tion of less than
3!A ma) re(ei4e <C' implant 3!A ma) re(ei4e <C' implant
Amiodarone for patients 3ith freB%ent V6Cs and at fi. Amiodarone for patients 3ith freB%ent V6Cs and at fi.
'ranedone for patients 3ith re(%rrent paro0)smal at fi.. 'ranedone for patients 3ith re(%rrent paro0)smal at fi..
"asodilators)$ydrala5ine and Nitrates
$
(eduction of afterload
!y arteriolar %asodilatation
(
(
h!dralaBin
h!dralaBin
$
$

reduce >&EDP, ? reduce >&EDP, ?

1 1
consumption,impro%e myocardial perfusion, consumption,impro%e myocardial perfusion,
stro"e %olume stro"e %olume

and C?P and C?P
$
(eduction of reload
(eduction of reload
y
y
%enous dilation
%enous dilation

(
(
2itrate+
2itrate+
Q the %enous return Q the %enous return
Q the load on !oth Q the load on !oth

%entricles+ %entricles+
$
Dsually the ma#imum !enefit is achie%ed !y using
agents -ith !oth action+
*nticoagulation
Atrial fi!rillation
Atrial fi!rillation
HMo em!olic episodes
>eft %entricular apical throm!us
>o- >& eFection fraction
Digitalis Comounds
>i"e the carrot placed in front of the don"ey
Cardia( &l)(osides in (lini(al %se
are:
'i&o0in,
'i&ito0in
C%a.ain.
Inotroic Agents
>i"e the carrot placed in front of the don"ey
-notropic *gents
(hese are the drugs that impro%e myocardial
contractility (
contractility (: adrenergic agonists, dopaminergic agents, : adrenergic agonists, dopaminergic agents,
phosphodiesterase inhi!itors$, phosphodiesterase inhi!itors$,

.opamine .opamine
.o(utamine .o(utamine
,ilrinone, ,ilrinone,
*amrinone *amrinone
'e%eral studies sho-ed R mortality -ith oral inotropic agents 'e%eral studies sho-ed R mortality -ith oral inotropic agents
'o the only use for them no- is in acute sittings such as cardiogenic 'o the only use for them no- is in acute sittings such as cardiogenic
shoc shoc
"
"
"eart Failure: Thera!
Stage A: Stage A:
Control ris? factors# treat underl!ing chronic disease contri%utors Control ris? factors# treat underl!ing chronic disease contri%utors
Stage ;: Stage ;:
ACE3A(;3;; if aroriate ACE3A(;3;; if aroriate
Stage C: Stage C:
ACEMA(;# ;;# diuretics ACEMA(;# ;;# diuretics
Other vasodilators as aroriate Other vasodilators as aroriate
Devices *%i'4 acing# Imlanta%le defi%rillators Devices *%i'4 acing# Imlanta%le defi%rillators
Stage D: Stage D:
Mechanical assist devices Mechanical assist devices
Continuous infusion of inotroics Continuous infusion of inotroics
"eart translant "eart translant
"osice "osice
E&erimental surger! or drugs E&erimental surger! or drugs

C$0 ,anagement
2eta 2lo(,er
'i%reti(s for fl%id retention
Aldosterone anta&onists in
sele(t patient
'i&o0in to red%(e
hospitalizations
-)dralazine>nitrate or A52 if
26 allo3s D s0s
2i=V4 pa(in& if s0s C5:
AC*=< 9or A52 if AC* intolerant;
5e&%lar e0er(ise pro&ram
1odi%m restri(tion
<C'
HF'A 1232 Practice Guideline (31+E-31+12$ HF'A 1232 Practice Guideline (31+E-31+12$

OvervieE of Treatment Otions for Patients
Eith Acute Decomensated "F
Fluid and sodium restriction

Diuretics, especially loop diuretics

DltrafiltrationMrenal replacement therapy

(in selected patients only$

Parenteral %asodilators
S
S

(nitroglycerin, nitroprusside, nesiritide$
Inotropes
Inotropes
S
S
(milrinone or do!utamine$
E%ee recommendations for stipulations and restrictions6
Device Thera!
Device Thera!
Implanta!le Cardio%erter-Defi!rillators (ICD$

Cardiac Resynchroni;ation (herapy (CR($

>eft &entricular Assist De%ices (>&AD$

i%entricular Assist De%ices

i%entricular Assist De%ices
Intraaortic aloon Pump

Intraaortic aloon Pump
Cardiac (es!nchroniBation Thera!
Increase the don"eyPs (heart$ efficiency
Device Thera!:
Device Thera!:
;iventricular Pacing
#F C4er4ie3 of 'e4i(e :herap)
4entricular D!s!nchron!
A!normal %entricular conduction resulting in a

mechanical delay and dysynchronous
contraction
contraction

;i4 Pacing
;i4 Pacing
Ae! Points
Ae! Points
Indications
Indications
.oderate to se%ere CHF -ho ha%e failed .oderate to se%ere CHF -ho ha%e failed optimal optimal medical medical
therapy therapy
EFA52C EFA52C
E%idence of electrical conduction delay E%idence of electrical conduction delay
(iming of Referral Important

Patients often not on optimal .edical R# Patients often not on optimal .edical R#
Patients referred too late- 7ot a ail ?ut Patients referred too late- 7ot a ail ?ut
Defi%rillators *ICD$s+
"oE does a defi%rillator for
sudden cardiac death Eor?M
Device
Shown:
Combination
Pacemaker &
Defibrillator
Intraaortic ;alloon Pum *IA;P+
Developed in late 1960s Developed in late 1960s
Counterpulsation is synchronized to the EKG or Counterpulsation is synchronized to the EKG or

arterial waveforms arterial waveforms
Increase coronary perfusion Increase coronary perfusion
Decrease left ventricular stroke work and Decrease left ventricular stroke work and
myocardial oxygen requirements myocardial oxygen requirements
Most widely used form of mechanical circulatory Most widely used form of mechanical circulatory
support support
Indications for its use include Indications for its use include
Failure to wean from cardiopulmonary bypass Failure to wean from cardiopulmonary bypass
Cardiogenic shock after MI Cardiogenic shock after MI
Heart failure Heart failure
Refractory ventricular arrhythmias with Refractory ventricular arrhythmias with

ongoing ischemia ongoing ischemia
&AD Issues
&AD Issues
@hat is a 4ADM
@hat is a 4ADM
A single system de%ice that is surgically attached to
A single system de%ice that is surgically attached to
the left %entricle of the heart and to the aorta for left
the left %entricle of the heart and to the aorta for left
%entricular support
%entricular support
For Right &entricular support, the de%ice is attached
For Right &entricular support, the de%ice is attached
to the right atrium and to the pulmonary artery
to the right atrium and to the pulmonary artery
Thoratec p"*.
Thoratec p"*.
;arvik =>>> +"*.
;arvik =>>> +"*.
)eft 4entricular Assist Devices
*)4AD+
*)4AD+
RE.A(CH (rial- RE.A(CH (rial-
3 yr sur%i%al E1C (>&AD$ 3 yr sur%i%al E1C (>&AD$

%s 1BC (r#$ %s 1BC (r#$
1 yr sur%i%al 15C %s 4C 1 yr sur%i%al 15C %s 4C
End-'tage (Class I&$ End-'tage (Class I&$
HF pts ineligi!le for HF pts ineligi!le for

transplant due to, transplant due to,
T6Eyo T6Eyo
D. -ith E?D D. -ith E?D
CRI CRI
2eEer ,eneration Artificial "earts
%iventricular
%iventricular
Cardio0est (AH
Percutaneous -ntervention
6:CA
2alloon An&ioplast)
1tents
'r%&=el%tin& stents
Al(ohol in@e(tion for -CC/
:rans=m)o(ardial
5e4as(%larization
Earl! infarct affecting left
ventricle
thrombus
PCI and "eart Failure
%urgery
for
$eart 0ailure
.
%urgery
Coronar) 5e4as(%larization
Val4%lar 1%r&er)
Ventri(%lar 5e(onstr%(tion for

<s(haemi( Cardiom)opath)
/itral 5epair for 5e&%r&itation
LV Ane%r)sm 6li(ation>5ese(tion
Ventri(%lar 5emodellin&
6ost=infar(t V1' repair

%9GE? TE*T,ENT -N $0
)4 (econstruction *Dor+
)4 (econstruction *Dor+
Boceria et al. Eur J Cardio!thorac "urg
#$$%&#'("#)*!+".
>& Reconstruction !y Patch Plasty
Uatene, Dor, Fontan
*corn Cardiac %upport
.evice
Novel ,echanical *nti4remodeling
Novel ,echanical *nti4remodeling
Therapies in $eart 0ailure
Therapies in $eart 0ailure
*C&N *C&N
,yosplint ,yosplint
Area of revious infarct Eith ruture of ventricular
Eall
Cardiac $ransplant
Cardiac $ransplant
It has !ecome more -idely used since the ad%ances in

immunosuppressi%e treatment
'ur%i%al rate
'ur%i%al rate
3 year 42C - N2C

3 year 42C - N2C
E years I2C
E years I2C
Christian ;arnard
Christian ;arnard
Born in South Africa in 1922 Born in South Africa in 1922
Studied heart surgery at the Studied heart surgery at the

University of Minnesota then University of Minnesota then
returned to set up a cardiac unit returned to set up a cardiac unit
in Cape Town. in Cape Town.
December 1967: transplanted the December 1967: transplanted the

heart of a road accident victim heart of a road accident victim
into a 59 year old patient into a 59 year old patient
Patient only survived 18 days Patient only survived 18 days

due to infectious complications due to infectious complications
11!
$ypertension
+eft "entricular
$ypertrophy
.iastolic
.ysfunction
Post4,-
emodeling
,yocardial -schemia
*symptomatic
+eft "entricular
.ysfunction
.ia(etes
.yslipidemia
Coronary *rtery .isease
&ther C". isk 0actors
The ;est Treatment for "F: Prevention
S!mtomatic "F ' The Ti of The
Ice%erg
Ice%erg
111
Outatient Thera!
Outatient Thera!
THE END
Bine ca s-a terminat !!! Bine ca s-a terminat !!!
Ischemic "eart Disease
and
and
M!ocardial Infarction
M!ocardial Infarction
Prof Univ Dr Ion C.Tintoiu
Coronar! Arteries
Coronar! Arteries
2ormal Anatom!
2ormal Anatom!
Coronar! Angiograh!
Coronar! Angiograh!
M!ocardial Ischemia:
M!ocardial Ischemia:
Occurs Ehen m!ocardial o&!gen demand e&ceeds
Occurs Ehen m!ocardial o&!gen demand e&ceeds
m!ocardial o&!gen sul!
m!ocardial o&!gen sul!
/VC
F
G /)o(ardial C0)&en 'emand
/VC
F
determined .):
=-eart 5ate
==Contra(tilit)
=====Hall :ension
Coronar! o%struction3Cardiac
Coronar! o%struction3Cardiac
ain3Cardiac Ischemia lesion
ain3Cardiac Ischemia lesion
II$ ?cclusion
O%struction:
Impediment+
'tenosis 7arro-ing of
!lood %essle
Pain #
Angina Pectoris
Cardiac lesions
Ischemia fi!rosis .
Occlusion:
Closed
%essel
Pain :
Infarct Pain
Cardiac lesions
Infarct (necrosis ;.
I+ O%struction 7arro-
lumen
Closure
of the
lumen
(is? Factors
(is? Factors
famil! "istor!
famil! "istor!
cigarette smo?ing
cigarette smo?ing
dia%etes mellitus
dia%etes mellitus
h!ertension
h!ertension
h!erliidemia
h!erliidemia
sedentar! life'st!le
sedentar! life'st!le
o%esit!
o%esit!
elevated homoc!steine# )P'a M

elevated homoc!steine# )P'a M
Atherosclerotic PlaHue
Atherosclerotic PlaHue
Evolution from Fatt! Strea?
Evolution from Fatt! Strea?
Fatty strea"s present in Fatty strea"s present in

young adults young adults
'oft atherosclerotic 'oft atherosclerotic

plaVues most %ulnera!le plaVues most %ulnera!le
to fissuringMhemorrhage to fissuringMhemorrhage
Comple# interaction of Comple# interaction of

su!strate -ith circulating su!strate -ith circulating
cells (platelets, cells (platelets,
macrophages$ and macrophages$ and
neurohumoral factors neurohumoral factors
PlaHue rogression<.
PlaHue rogression<.
Fi!rous cap de%elops

Fi!rous cap de%elops
-hen smooth muscle
-hen smooth muscle
cells migrate to intima,
cells migrate to intima,
producing a tough
producing a tough
fi!rous matri# -hich
fi!rous matri# -hich
glues cells together
glues cells together
Screening and Diagnosis
M!ocardial Ischemia
M!ocardial Ischemia
%tress %tress
Test Test
m
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a
s
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t
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a
r
t
Coronary Coronary
*ngiography *ngiography
s
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arro
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in
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in
N
arro
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in
g
in
%
i
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e
s

o
f
%
i
t
e
s

o
f
Electro4 Electro4
cardiogram cardiogram
m
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s
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e
s
m
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C
Angina Pectoris
ISC"EMIC C"EST PAI2
ISC"EMIC C"EST PAI2
EHER(I?7A> A7GI7A
EHER(I?7A> A7GI7A

S
S RIEF EPI'?DE' R?DGH( ?7 L EHER(I?7 A7D RE>IE&ED RIEF EPI'?DE' R?DGH( ?7 L EHER(I?7 A7D RE>IE&ED
L RE'( ?7 7(G L RE'( ?7 7(G
D7'(A>E A7GI7A
D7'(A>E A7GI7A

S 7E0 ?7'E( S 7E0 ?7'E(
S CHA7GE I7 FREWDE7CLM'E&ERI(L S CHA7GE I7 FREWDE7CLM'E&ERI(L
S ?CCDR' A( RE'( S ?CCDR' A( RE'(
A.I
A.I

S 'E&ERE PER'I'(E7( 'L.P(?.' S 'E&ERE PER'I'(E7( 'L.P(?.'
S E>E&A(ED (R?P?7I7 S E>E&A(ED (R?P?7I7

ISC"EMIC C"EST PAI2: DIA,2OSIS
ISC"EMIC C"EST PAI2: DIA,2OSIS
31 >EAD E/G
31 >EAD E/G

- >oo" for '( segment ele%ation (at least
- >oo" for '( segment ele%ation (at least

3mm in t-o contiguous leads$
3mm in t-o contiguous leads$

- >oo" for '( segment depression
- >oo" for '( segment depression

- >oo" for ( -a%e in%ersions
- >oo" for ( -a%e in%ersions

- >oo" for W -a%es
- >oo" for W -a%es

- >oo" for ne- >
- >oo" for ne- >

- Al-ays compare to old E/Gs
- Al-ays compare to old E/Gs
EA, C"A2,ES I2 ISC"EMIC
EA, C"A2,ES I2 ISC"EMIC
"EA(T DISEASE
"EA(T DISEASE

'( 'EG.E7( ( 0A&E
'( 'EG.E7( ( 0A&E

DEPRE''I?7 II7&ER'I?7'
DEPRE''I?7 II7&ER'I?7'
ISC"EMIC C"EST PAI2:
ISC"EMIC C"EST PAI2:
DIA,2OSTIC TESTS
DIA,2OSTIC TESTS
CA(DIAC E2NFMES
CA(DIAC E2NFMES

' M!oglo%in
' M!oglo%in

S 0ill rise -ithin 5 hours, pea" -ithin B-N
S 0ill rise -ithin 5 hours, pea" -ithin B-N

hours, and return to !aseline -ithin 1B hrs+
hours, and return to !aseline -ithin 1B hrs+

-
-
CAM;
CAM;

S 0ill rise -ithin B hours, pea" -ithin 31- 1B
S 0ill rise -ithin B hours, pea" -ithin 31- 1B

hours and return to !aseline in 1-5 days
hours and return to !aseline in 1-5 days

-
-
T(OPO2I2 I
T(OPO2I2 I

S 0ill rise -ithin 6 hours, pea" in 31 hours
S 0ill rise -ithin 6 hours, pea" in 31 hours

and return to !aseline in 5-B days
and return to !aseline in 5-B days
$
Blood tests# %sed to e4al%ate ,idne) and th)roid
f%n(tion as 3ell as to (he(, (holesterol le4els and
the presen(e of anemia.
$
Chest 34ray# sho3s the size of )o%r heart and
3hether there is fl%id .%ild %p aro%nd the heart and
l%n&s.
$
Echocardiogram# sho3s a &raphi( o%tline of the
heartIs mo4ement
$
E1ection fraction (E0)# determines ho3 3ell )o%r
heart p%mps 3ith ea(h .eat.
Coronar! Arter! Angiograh!
Echocardiograh!
Echocardiograh!
Ischemic Heart Disease
Ischemic Heart Disease
I4US'Atherosclerotic PlaHue
I4US'Atherosclerotic PlaHue
'ta!le Angina
,*-N E3-T NE3T
Definition
T!es of Angina
Management of Angina
Antianginal drugs
Angina
Angina
Angina is a t!e of
Angina is a t!e of
chest discomfort
chest discomfort
caused %! oor %lood
caused %! oor %lood
floE through the %lood
floE through the %lood
vessels *coronar!
vessels *coronar!
vessels+ of the heart
vessels+ of the heart
muscle *m!ocardium+.
muscle *m!ocardium+.
Chest ain caused %! transient
myocardial ischemia due to an
im%alance %etEeen m!ocardial
o&!gen sul! and demand.
35N
B*C2 ,*-N E3-T -N.E3 NE3T
Transient M!ocardial Transient M!ocardial
ischemia ischemia
Severe Chest ain
Severe Chest ain
M!ocardial ;lood FloE
M!ocardial OG Demands
Angina Pectoris
3B2
$ypes of Angina
$ypes of Angina
7. Sta%le Angina.
3B3
G. Unsta%le Angina.
8. 4ariant Angina.
Sta%le Angina ' S!mtoms
Sta%le Angina ' S!mtoms
mid'su%sternal chest ain

mid'su%sternal chest ain
sHueeBing# ressure'li?e in Hualit! *closed fist O

sHueeBing# ressure'li?e in Hualit! *closed fist O
)evine$s sign+
)evine$s sign+
%uilds to a ea? and lasts G'G0 minutes

%uilds to a ea? and lasts G'G0 minutes
radiation to left arm# nec?# -aE or %ac?

radiation to left arm# nec?# -aE or %ac?
associated Eith shortness of %reath# sEeating# or

associated Eith shortness of %reath# sEeating# or
nausea
nausea
e&acer%ated %! e&ertion# cold# meals or stress

e&acer%ated %! e&ertion# cold# meals or stress
relieved %! rest# 2T,

relieved %! rest# 2T,
H?.E
%.
%.

table Angina .
(etrosternal ain
(etrosternal ain
(adiating to left arm D
(adiating to left arm D
shoulder
shoulder
The commonest cause is
The commonest cause is
AD4A2CED
AD4A2CED
AT"E(OSCE)E(OSIS
AT"E(OSCE)E(OSIS
)asting less than 76 min.
)asting less than 76 min.
3B5
E,ertion
E,ertion
Emotion
Emotion
Heavy meals
Heavy meals
E,posure to cold
E,posure to cold
-eather
-eather
Predisosing factors
(elieving
factors
.est
.est
sublingual
nitroglycerin
table Angina
3BB
E,ercise EC/ sho-ing typical severe do-n sloping
E,ercise EC/ sho-ing typical severe do-n sloping
$
$
segment
segment
(
(
Anginal ain is often associated Eith Deression
Anginal ain is often associated Eith Deression
of
of
ST
ST
segment
segment
Standing
7 min.
8 min.
K min.
P min.
table Angina
-n (et'een attacks
-n (et'een attacks
#
#
ECG is entirely
ECG is entirely
NORMAL
NORMAL
3BE
;ACA MAI2 E=IT I2DE= 2E=T
Sta%le Angina ' Diagnosis
Sta%le Angina ' Diagnosis
E&ercise Treadmill Test
E&ercise Treadmill Test
Management of Angina
Management of Sta%le Angina
Management of Unsta%le
Management of Unsta%le
Angina
Angina
Management of 4ariant Angina
3BI
Management of Sta%le
Angina
7'
7'
,eneral measures.
,eneral measures.
G'
G'
Drug Treatment.
Drug Treatment.
8'
8'
Coronar! arter!
Coronar! arter!
revasculariBation.
revasculariBation.
3B4
"top smoing "top smoing
.educe -eight .educe -eight
0reat Hypertension 1 0reat Hypertension 1
Hypercholestrolimia Hypercholestrolimia
and 2iabetes and 2iabetes
A&'I! A&'I!
"evere "evere
e,ertion e,ertion
Heavy meal Heavy meal Emotions Emotions Cold 3eather Cold 3eather
,eneral measures
3BN
8
,raduated e&ercise ma! oen neE
collaterals
a.
a.
For an acute attac?
For an acute attac?
%.
%.
For immediate re'e&ertional
For immediate re'e&ertional

roh!la&is
roh!la&is
c.
c.
For long'term roh!la&is
For long'term roh!la&is
d.
d.
Antilatelet thera!.
Antilatelet thera!.
3E2
Sta%le Angina ' Treatment
Sta%le Angina ' Treatment
(is? factor modification *"M, Co'A (eductase

(is? factor modification *"M, Co'A (eductase
inhi%itors O Statins+
inhi%itors O Statins+
Asirin'
Asirin'
Decrease throm%otic risc
Decrease throm%otic risc
Decrease M4OG
Decrease M4OG
nitrates
nitrates
%eta'%loc?ers
%eta'%loc?ers
calcium channel %loc?ers

calcium channel %loc?ers
ACE'inhi%itors
ACE'inhi%itors
Anti'o&idants *E# C# Folate# ;9+M

Anti'o&idants *E# C# Folate# ;9+M
@hat are the antianginal drugsM
Organic nitrates.
Calcium channel %loc?ers.
' adrenocetor %loc?ers.
3E1
(I$#A$) (I$#A$)
4eins 4eins
Arteries Arteries
3E5
.ela,ation of smooth .ela,ation of smooth
muscles 2ilatation muscles 2ilatation
Cellular Mechanism of 4asodilatation
2itrates
2itrates
Formation of
Formation of
2itric o&ide *2O+
2itric o&ide *2O+
Activation of
Activation of
,uan!late c!clase
,uan!late c!clase
S!nthesis of
S!nthesis of
c!clic ,MP
c!clic ,MP
(ela&ation of 4ascular
(ela&ation of 4ascular
smooth muscles
smooth muscles
3EB
2.;. *'S"+ grous are reHuired
for formation of 2O.
)ffect of (itrates :
)ffect of (itrates :
'n table Angina :
'n table Angina :
4enodilatation
Arteriolar
dilatation
Preload Preload Afterload Afterload
M!ocardial
M!ocardial
O&!gen demand
O&!gen demand
G' (edistri%ution of coronar! floE toEards
su%endocardium
8' Dilatation of coronar! collateral vessels.
7' 7'
'n &ariant Angina :
'n &ariant Angina :
(ela& smooth muscles of the
eicardial coronaries relieve
coronar! arter! sasm
'n *nstable Angina :
'n *nstable Angina :
Dilatation of eicardial coronar!
arteries Q reducing O
G
demands
3E6
Preparations :
Short acting
Short acting
For acute attac?s
For acute attac?s
)ong acting
)ong acting

For antianginal roh!la&is
For antianginal roh!la&is
2itrogl!cerin
2itrogl!cerin
*su%lingual# %uccal
*su%lingual# %uccal
sra!+
sra!+
Isosor%ide
Isosor%ide
dinitrate*su%lingual#
dinitrate*su%lingual#
%uccal sra!+
%uccal sra!+
2itrogl!cerin
2itrogl!cerin
oral S( *9.G6'7Gmg+ G'/
oral S( *9.G6'7Gmg+ G'/
times3da!
times3da!
' G1 ointment *7'7.6
' G1 ointment *7'7.6
inch3/hrs+
inch3/hrs+
' atches *7 atchOG6mg+3da!
' atches *7 atchOG6mg+3da!
Isosor%ide dinitrate *oral+ 70'
Isosor%ide dinitrate *oral+ 70'
/0mg t.d.s.
/0mg t.d.s.
Isosor%ide mononitrate *oral+
Isosor%ide mononitrate *oral+
G0mg37G hrs.
G0mg37G hrs.
3EI
Duration of Action of 4arious Prearations of
Organic 2itrates
Preparation
Duration of
action
R Short'actingR
7'2itrogl!cerin
G' Isosor%ide dinitrate
a+ Su%lingual
%+ Sra!
a+ Su%lingual
%+ Sra!
70'80 min
70'80 min
U to 90 min.
7.6 hours
R )ong'actingR
7'2itrogl!cerin
G' Isosor%ide dinitrate
8'Isosor%ide mononitrate
a+ OralS sustained release
%+ Ointment
c+ Transdermal atches

Oral
Oral
/'J hours
8'9 hours
J'7G hours
/'9 hours
9'70 hours
Ad+erse #eactions :
Ad+erse #eactions :
7' Postural "!otension D 7' Postural "!otension D
S!ncoe S!ncoe
G' Tach!cardia G' Tach!cardia
E- (hro!!ing Headache E- (hro!!ing Headache
/' Facial Flushing /' Facial Flushing
8' Drug (ash 8' Drug (ash
9' Prolonged high dose 9' Prolonged high dose
Methaemoglo%inaemia Methaemoglo%inaemia
3EN
'%loc?ers are effective in STA;)E D U2STA;)E
angina
In contrast the! are not useful for
vasosastic angina *4ariant+ TPrinBmetalUD
ma! Eorsen the condition. This deleterious
effect is li?el! due to an increase in coronar!
resistance caused %! the unoosed effects of
catecholamines acting at 'adrenocetors.
C"F C"F A'4 %loc? A'4 %loc?
Periheral Periheral
4ascular 4ascular
disease disease
"!otension "!otension
Contraindications :
Contraindications :
;ronchial ;ronchial
asthma asthma
363
4eraamil
(42-362 mg$ M4 hr
(42-362 mg$ M4 hr
DiltiaBem
(62-312 mg$ M4 hr
(62-312 mg$ M4 hr
Dih!dro!ridine grou
2ifediine *70'/0mg+ 3J hr
Amlodiine 6mg3da!
Used in treatment of all t!es of angina.
361
;loc?
;loc?
&oltage -dependent calcium
&oltage -dependent calcium
channels ("-type, in cardiac and
channels ("-type, in cardiac and
smooth muscles.
smooth muscles.
C C
A A
) )
C C
I I
U U
M M
-echanism of anti-anginal action :
-echanism of anti-anginal action :
7 ' Coronar! arter! dilatation and relief
of coronar! sasm *variant angina+
8
*4eraamil D DiltiaBem+
8
Decrease "(.
8
Decrease contractilit!
8
Decrease A4 conductivit!
8
Arteriolar
dilatation
4ascular
resistance
Afterload
G 'Decrease m!ocardial O
G
demand due to:
Ad+erse reactions :
Ad+erse reactions :
DiBBiness DiBBiness
An"le An"le
edema edema
"!otension "!otension "eadache "eadache
Flushing Flushing
Constiation Constiation
A'4 %loc? D "F A'4 %loc? D "F onl! onl!
Eith 4eraamil D Eith 4eraamil D
DiltiaBem DiltiaBem
(efle& (efle&
Tach!cardia Tach!cardia
Eith 2ifediine Eith 2ifediine
8 ' ;rad!cardia.
Contraindications of
Contraindications of
&erapamil . !iltia/em:
&erapamil . !iltia/em:
7 ' "F
G ' Sinus or A'4 node
disease.
Treatment of an acute attac? of angina
Su%lingual
Su%lingual
nitrogl!cerin *
nitrogl!cerin *
0.6 mg + or isosor%ide
0.6 mg + or isosor%ide
dinitrate *6 mg +
dinitrate *6 mg + or
Oral sra!
Oral sra!
nitrogl!cerin *
nitrogl!cerin *
0./ mg3metered
0./ mg3metered
dose+#
dose+#
isosor%ide dinitrate*7.G6 mg3metered
isosor%ide dinitrate*7.G6 mg3metered
dose+
dose+
(elief Eithin 7'8 min.
Persistence of ain
(eeat nitrogl!cerin at 6 min. (eeat nitrogl!cerin at 6 min.
interval *8 ta%. ma&.+ interval *8 ta%. ma&.+
(elief not relieved
Infarction "OSPITA)INATIO2
36I
Immediate re'e&ertional roh!la&is of Angina
Immediate re'e&ertional roh!la&is of Angina
Su%lingual nitrogl!cerin *0.6 mg+ or isor%ide
dinitrate *6 mg+ should %e ta?en 6 min.
%efore effort.
For )ong term roh!la&is:
For )ong term roh!la&is:
)ong acting nitrates# Ca
QQ
channel %loc?ers#
'%loc?ers or com%inations of these drugs.
Antilatelet thera!:
Antilatelet thera!:
Asirin in small dose *K6'760 mg dail! orall!+
Asirin in small dose *K6'760 mg dail! orall!+
or Di!ridamole *K6 mg t.d.s orall!+
or Di!ridamole *K6 mg t.d.s orall!+
364
.any people are a!le to manage coronary

.any people are a!le to manage coronary
artery disease -ith lifestyle changes and
artery disease -ith lifestyle changes and
medications+
medications+
Other eole Eith severe

Other eole Eith severe
coronar! arter! disease ma!
coronar! arter! disease ma!
need
need
angiolast!
angiolast!
or
or
surger!.
surger!.
Coronar! arter! %!ass grafting
Coronar! arter! %!ass grafting
*CA;,+
*CA;,+
Percutaneous Transluminal
Percutaneous Transluminal
coronar! Angiolast! *PTCA+
coronar! Angiolast! *PTCA+
For atients not resonding to
For atients not resonding to
adeHuate medical thera!
adeHuate medical thera!
3I2
(reatment of 'ta!le Angina
-'(E7('

Treatment (continued)
1; 1tentin&
8
a stent is introduced into a %lood vessel on a %alloon
catheter and advanced into the %loc?ed area of the arter!
8
the %alloon is then inflated and causes the stent to
e&and until it fits the inner Eall of the vessel#
conforming to contours as needed
8
the %alloon is then deflated and draEn %ac?
8
The stent sta!s in lace ermanentl!# holding the vessel
oen and imroving the floE of %lood.
Treatment (continued)
F; An&ioplast)
8
a %alloon catheter is assed through the guiding catheter to
the area near the narroEing. A guide Eire inside the %alloon
catheter is then advanced through the arter! until the ti is
%e!ond the narroEing.
8
the angiolast! catheter is moved over the guide Eire until
the %alloon is Eithin the narroEed segment.
8
%alloon is inflated# comressing the laHue against the arter!
Eall
8
once laHue has %een comressed and the arter! has %een
sufficientl! oened# the %alloon catheter Eill %e deflated and
removed.
TE*TE,ENT4C*BG
'ta!le Angina - (reatment
'ta!le Angina - (reatment
Coronary Artery ypass Grafting 'urgery (CAG$
Coronary Artery ypass Grafting 'urgery (CAG$

Acute Coronar!
Acute Coronar!
S!ndrome
S!ndrome
Acute Coronar! S!ndromes:
Acute Coronar! S!ndromes:
Terminolog!
Terminolog!
Pathoh!siolog! of all 8 is the same

Pathoh!siolog! of all 8 is the same
Unsta%le Angina *UA+ Unsta%le Angina *UA+
ST deression# T @ave inversion or normal ST deression# T @ave inversion or normal
2o enB!me release 2o enB!me release
2on'Transmural M!ocardial Infarction *2TMI or SEMI+ 2on'Transmural M!ocardial Infarction *2TMI or SEMI+
ST deression# T @ave inversion or normal ST deression# T @ave inversion or normal
2o V Eaves 2o V Eaves
CPA# )D" CPA# )D" Q Q Troonin release Troonin release
Transmural M!ocardial Infarction *AMI+ Transmural M!ocardial Infarction *AMI+
ST elevation ST elevation
Q V Eaves Q V Eaves
CPA# )D" Q Troonin release CPA# )D" Q Troonin release

The underl!ing cause is
The underl!ing cause is
8
Atheroscelerotic changes
Atheroscelerotic changes
Fissuring of atheroscelerotic laHues
Fissuring of atheroscelerotic laHues
Platelet aggregation
Platelet aggregation
Throm%osis
Throm%osis
Coronar! arter! sasm
Coronar! arter! sasm
342
JV%lnera.le 6laB%eK
Schematic of an Unstable Plaque
Schematic of an Unstable Plaque
Unstable Plaque:
More Detail.
Cross section of a
complicated plaVue
Acute Coronar! S!ndrome
Acute Coronar! S!ndrome
Ischemic Discomfort
Unsta%le S!mtoms
7o '(-segment
ele%ation
'(-segment
ele%ation
9nsta(le Non4@ @48ave
angina *,- *,-
ECG
Acute
Reperfusion
History
Physical E#am
ACC/AHA Guidelines ACC/AHA Guidelines
NSTEMI is an acute process of

NSTEMI is an acute process of
myocardial ischemia with
myocardial ischemia with
sufficient
sufficient
severity and duration to result in
severity and duration to result in
myocardial
myocardial
necrosis
necrosis
.
.
The initial
The initial
ECG in patients with
ECG in patients with
NSTEMI does not show ST-segment
NSTEMI does not show ST-segment

elevation.
elevation.
NSTEMI is distinguished from !

NSTEMI is distinguished from !
"y the
"y the
detection of cardiac
detection of cardiac
mar#ers indicative of myocardial
mar#ers indicative of myocardial

necrosis in NSTEMI and the
necrosis in NSTEMI and the
a"sence of a"normal
a"sence of a"normal
elevation of
elevation of
such "iomar#ers in patients with
such "iomar#ers in patients with

!.
!.

'efinition: N1:*/<
'efinition: N1:*/<
,*2E% ,*2E%
Test Test
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Coronary Coronary
*ngiography *ngiography
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Electro4 Electro4
cardiogram cardiogram
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MI ! 0ypes
MI ! 0ypes
Transmural
Transmural
*STEMI+
*STEMI+
Full thic"ness
Full thic"ness
'uperimposed
'uperimposed
throm!us in
throm!us in
atherosclerosis
atherosclerosis
Focal damage
Focal damage
Su%'endocardial *2STEMI+ Su%'endocardial *2STEMI+
Inner 738 to half of ventricular Inner 738 to half of ventricular

Eall Eall
Decreased circulating %lood Decreased circulating %lood

volume* shoc?# "!otension# volume* shoc?# "!otension#
)!sed throm%us+ )!sed throm%us+
Circumferential Circumferential
Heart ! 4athology
Heart ! 4athology
Ischemic "eart Disease Ischemic "eart Disease
TTC TTC
Diagnosis of .I,
Role of troponin i
:roponin < is hi&hl)

sensiti4e
:roponin < ma) .e

ele4ated after
prolon&ed
s%.endo(ardial
is(hemia
1ee e0amples .elo3

Cardiac en;ymes, o%er%ie-
+egend# *6 Early CP24,B isoforms after acute ,-
B6 Cardiac troponin after acute ,-
C6 CP24,B after acute ,-
.6 Cardiac troponin after unsta(le angina
E/G diagnosis of .I
1: se&ment
ele4ation
1: se&ment
depression
: 3a4e in4ersion
L 3a4e formation
ACUTE I2FE(IO( MI
ACUTE I2FE(IO( MI
'( E>E&A(I?7 II, III, A&F

'( E>E&A(I?7 II, III, A&F
ACUTE A2TE(IO( MI
ACUTE A2TE(IO( MI
'( 'EG.E7( E>E&A(I?7 &1-B

'( 'EG.E7( E>E&A(I?7 &1-B
0.
0.

&ariant Angina .
(Prin/metal,
Chest pain at rest due to
Chest pain at rest due to
coronary artery spasm
coronary artery spasm
EC/
EC/
changes
changes
(
(
Acute elevation of
Acute elevation of
ST
ST

segment
segment
The %aseline EC,
@ith chest ain #
mar?ed ST segment
elevation
(eturn of the ST segment to
the %aseline after
nitrogl!cerin administration
3N6
ACUTE MFOCA(DIA) I2FA(CTIO2
ACUTE MFOCA(DIA) I2FA(CTIO2
TE((ITO(F
TE((ITO(F
CO(O2A(F
CO(O2A(F
A(TE(F
A(TE(F
EA,
EA,
I7FERI?R
I7FERI?R
RCA
RCA
II, III, A&F
II, III, A&F
A7(ERI?R
A7(ERI?R
>AD
>AD
&1-B
&1-B
>A(ERA>
>A(ERA>
CIRCD.F>EH
CIRCD.F>EH
&E-6, I, A&>
&E-6, I, A&>
P?'(ERI?R
P?'(ERI?R
&ARIA>E
&ARIA>E
(A>> R 0A&E I7 &3M1 (A>> R 0A&E I7 &3M1
?R '( 'EG.E7( ?R '( 'EG.E7(
DEPRE''I?7 DEPRE''I?7
2.
2.

*nstable Angina .
Increased freHuenc!
Increased freHuenc!
#
#
severit! or duration
severit! or duration
of ain in a atient of Sta%le Angina
of ain in a atient of Sta%le Angina
-yocardial infarction may occur in %1-212 of patients.
-yocardial infarction may occur in %1-212 of patients.
2.;.
2.;.
Pain occurs Eith less e&ertion
Pain occurs Eith less e&ertion
or at rest
or at rest
3N4
Angiogram in unsta!le angina,
eccentric, ulcerated plaVue
Angiogram in unsta!le angina,
after stent deployment
Treatment of Acute M!ocardial Infarction
Treatment of Acute M!ocardial Infarction
asirin# hearin# analgesia# o&!gen

asirin# hearin# analgesia# o&!gen
reerfusion thera!
reerfusion thera!
throm%ol!tic thera! *t'PA# SA# n'PA# r' PA+ throm%ol!tic thera! *t'PA# SA# n'PA# r' PA+
neE com%inations * t'PA# r'PA Q G% 3 8a inhi%+ neE com%inations * t'PA# r'PA Q G% 3 8a inhi%+
cath la% *PTCA# stent+ cath la% *PTCA# stent+
decrease M4OG
decrease M4OG
nitrates# %eta %loc?ers and ACE inhi%itors nitrates# %eta %loc?ers and ACE inhi%itors
for high PC@P ' diuretics for high PC@P ' diuretics
for loE Cardiac Outut ' ressors *doamine# levohed# for loE Cardiac Outut ' ressors *doamine# levohed#
do%utamineS IA;PS earl! catheteriBation do%utamineS IA;PS earl! catheteriBation
Fi%rinol!tic Thera!
Fi%rinol!tic Thera!
in STEMI
in STEMI
Coagulation and Fi%rinol!sis
Coagulation and Fi%rinol!sis
0i(rinolysis 0i(rinolysis
0i(rin
Coagulation 0actors
0i(rinogen
Plasmin
Plasminogen
Tissue Plasminogen
*ctivator
0i(rinolysis
0i(rinolysis
Aside: other Anti'throm%otic drug t!es
Aside: other Anti'throm%otic drug t!es
Anti'latelet agents Anti'latelet agents include, include,
Asirin *acet!lsalic!lic acid+ Asirin *acet!lsalic!lic acid+
cloidogrel cloidogrel
di!ridamole di!ridamole
ticloidine ticloidine
gl!corotein II%3IIIa inhi%itors gl!corotein II%3IIIa inhi%itors
Throm%ol!tic *3fi%rinol!tic+ drugs Throm%ol!tic *3fi%rinol!tic+ drugs include, include,
tissue lasminogen activator ' t'PA ' altelase *Activase+ tissue lasminogen activator ' t'PA ' altelase *Activase+
retelase *(etavase+ retelase *(etavase+
tenectelase *T2Aase+ tenectelase *T2Aase+
anistrelase *Eminase+ anistrelase *Eminase+
streto?inase *Aa%i?inase# Stretase+ streto?inase *Aa%i?inase# Stretase+
uro?inase *A%%o?inase+ uro?inase *A%%o?inase+

.echanism of (hrom!olytic Drugs
.echanism of (hrom!olytic Drugs
The lasmin*ogen+ molecule has l!sine %inding sites# Ehich The lasmin*ogen+ molecule has l!sine %inding sites# Ehich
%ind to and degrade fi%rin %ind to and degrade fi%rin
Fi%rin'secific agents are much more active uon %inding to Fi%rin'secific agents are much more active uon %inding to
fi%rin# there%! increasing the affinit! for lasminogen at the fi%rin# there%! increasing the affinit! for lasminogen at the
clot surface clot surface
Throm(olytic .rugs
Throm(olytic .rugs
It is a !acterial protein produced !y group C It is a !acterial protein produced !y group C 5beta6 5beta6-hemolytic -hemolytic
streptococci streptococci
Mechanism:
Mechanism: It !inds to plasminogen producing an It !inds to plasminogen producing an Ractivator Ractivator
comle& comle&X X that lyses free plasminogen to the proteolytic en;yme that lyses free plasminogen to the proteolytic en;yme
plasmin plasmin
Plasmin degrades Plasmin degrades fi!rin fi!rin clots as -ell as clots as -ell as fi!rinogen fi!rinogen and other and other
plasma proteins (non-fi!rin specific$ plasma proteins (non-fi!rin specific$
O
Pharmaco"inetics, Pharmaco"inetics,
(he t (he t
Y Y
of the acti%ator comple# is a!out 15 minutes of the acti%ator comple# is a!out 15 minutes
(he comple# is inacti%ated !y anti-streptococcal anti!odies @ !y (he comple# is inacti%ated !y anti-streptococcal anti!odies @ !y
hepatic clearance hepatic clearance
Throm(olytic .rugs
Throm(olytic .rugs
*lteplase (rt6P*)
*lteplase (rt6P*)
O
It is It is a tissue plasminogen acti+ator (t.PA, a tissue plasminogen acti+ator (t.PA, produced !y produced !y
recom!inant D7A technology of E1I amino acids recom!inant D7A technology of E1I amino acids
O
Cost per day is around 1122 Z Cost per day is around 1122 Z
O
Mechanism: Mechanism:
It is It is an en/yme an en/yme -hich has the property of fi!rin-enhanced -hich has the property of fi!rin-enhanced
con%ersion of plasminogen to plasmin con%ersion of plasminogen to plasmin
It produces limited con%ersion of free plasminogen in the It produces limited con%ersion of free plasminogen in the
a!sence of fi!rin a!sence of fi!rin
0hen introduced into the systemic circulation it !inds to fi!rin in 0hen introduced into the systemic circulation it !inds to fi!rin in
a throm!us and con%erts the entrapped plasminogen to plasmin a throm!us and con%erts the entrapped plasminogen to plasmin
follo-ed !y acti%ated local fi!rinolysis -ith limited systemic follo-ed !y acti%ated local fi!rinolysis -ith limited systemic
proteolysis proteolysis
Throm(olytic .rugs
Throm(olytic .rugs
Theraeutic Uses
Theraeutic Uses
O
Acute M!ocardial Infarction
Acute M!ocardial Infarction
in adults for the
in adults for the
impro%ement of %entricular function follo-ing A.I
impro%ement of %entricular function follo-ing A.I
the reduction of the incidence of congesti%e heart
the reduction of the incidence of congesti%e heart
failure, and the reduction of mortality associated -ith
failure, and the reduction of mortality associated -ith
A.I
A.I
O
Acute Ischemic Stro?e
Acute Ischemic Stro?e
for impro%ing neurological
for impro%ing neurological
reco%ery and reducing the incidence of disa!ility+
reco%ery and reducing the incidence of disa!ility+
(reatment should only !e initiated -ithin 5 hours after
(reatment should only !e initiated -ithin 5 hours after
the onset of stro"e symptoms, and after e#clusion of
the onset of stro"e symptoms, and after e#clusion of
intracranial hemorrhage
intracranial hemorrhage
O
Pulmonar! Em%olism
Pulmonar! Em%olism
:
:
(reatment of acute massi%e
(reatment of acute massi%e
pulmonary em!olism
pulmonary em!olism
Reteplase & Tenectaplase
Reteplase & Tenectaplase
O
(etelase
(etelase
is another human t-PA prepared !y
is another human t-PA prepared !y
recom!inant mutation technology
recom!inant mutation technology
-
It is fi!rin-specific
It is fi!rin-specific
-
It has longer duration than alteplase
It has longer duration than alteplase
O
Tenectalase
Tenectalase
is another genetically modified
is another genetically modified
human t-PA prepared !y recom!inant
human t-PA prepared !y recom!inant
technology
technology
-
It is more fi!rin-specific @ longer duration than
It is more fi!rin-specific @ longer duration than
alteplase
alteplase
:hrom.ol)ti( 'r%&s
:hrom.ol)ti( 'r%&s

9rokinase
9rokinase
O
It is an
It is an
en;yme
en;yme
produced !y the
produced !y the
"idney
"idney
, and
, and
found in the urine
found in the urine
O
It is mainly used in the lo- molecular -eight
It is mainly used in the lo- molecular -eight
form of uro"inase o!tained from human
form of uro"inase o!tained from human
neonatal "idney cells gro-n in tissue culture
neonatal "idney cells gro-n in tissue culture
O
.echanism,
.echanism,
It acts on the endogenous
It acts on the endogenous
fi!rinolytic system con%erting plasminogen
fi!rinolytic system con%erting plasminogen
to the en;yme plasmin that degrades fi!rin
to the en;yme plasmin that degrades fi!rin
clots as -ell as fi!rinogen and some other
clots as -ell as fi!rinogen and some other
plasma proteins (
plasma proteins (
7on-fi!rin selecti%e
7on-fi!rin selecti%e
$
$
Throm(olytic .rugs
Throm(olytic .rugs

9rokinase
9rokinase
Dro"inase administered !y intra%enous infusion

Dro"inase administered !y intra%enous infusion
is rapidly cleared !y the li%er -ith an elimination
is rapidly cleared !y the li%er -ith an elimination
half-life for !iologic acti%ity of 31-12 minutes
half-life for !iologic acti%ity of 31-12 minutes
Clinical Dses,
Clinical Dses,
For the lyses of acute massi%e pulmonary em!oli

For the lyses of acute massi%e pulmonary em!oli
Contraindications to
Contraindications to
Throm(olytic Therapy
Throm(olytic Therapy
O
A%solute contraindications include:
A%solute contraindications include:
(ecent head trauma or caranial tumor

(ecent head trauma or caranial tumor
Previous hemorrhagic shoc?

Previous hemorrhagic shoc?
Stro?e or cere%ro'vascular events 7 !ear

Stro?e or cere%ro'vascular events 7 !ear
old
old
Active internal %leeding

Active internal %leeding
Ma-or surger! Eithin tEo Eee?s

Ma-or surger! Eithin tEo Eee?s
O
(elative contraindications include:
(elative contraindications include:
-
Active etic ulcer# dia%etic retinoath!#
Active etic ulcer# dia%etic retinoath!#
regnanc!# uncontrolled "T2
regnanc!# uncontrolled "T2
Fi%rinolitic Thera! in STEMI
Fi%rinolitic Thera! in STEMI
N2C of patients -M acute '(E.I ha%e complete

N2C of patients -M acute '(E.I ha%e complete
occlusion of culprit artery
occlusion of culprit artery
PCI referred if erformed E3in P0 minutes of

PCI referred if erformed E3in P0 minutes of
resentation or if transfer to neigh%oring
resentation or if transfer to neigh%oring
institution for PCI can occur E3in 80'90 min.
institution for PCI can occur E3in 80'90 min.
(hom!olytic therapy is the alternati%e treatment

(hom!olytic therapy is the alternati%e treatment
7ot as effecti%e in non-'(E.I as the infarct-related

7ot as effecti%e in non-'(E.I as the infarct-related
artery is not totally occluded in 62-4EC of cases
artery is not totally occluded in 62-4EC of cases
$ime to presentation3
$ime to presentation3
'ur%i%al !enefit
'ur%i%al !enefit
greatest
greatest
-hen lytics administered
-hen lytics administered
-ithin first B hours after onset of symptoms,
-ithin first B hours after onset of symptoms,
particularly -ithin the first I2 minutes+
particularly -ithin the first I2 minutes+
.ortality !enefit less li"ely at 35-34 hours+
.ortality !enefit less li"ely at 35-34 hours+
(here
(here
MAF
MAF
!e !enefit in patients presenting T31hours
!e !enefit in patients presenting T31hours
if patient has on-going stuttering chest pain+
if patient has on-going stuttering chest pain+
A4A recommendations (2115,:
A4A recommendations (2115,:
administer lytics if no
administer lytics if no
contraindications 67in %2 hr of symptom onset8
contraindications 67in %2 hr of symptom onset8

reasonable to administer at %2-25 hr if continuing
reasonable to administer at %2-25 hr if continuing
symptoms or persistent $ ele+ation on )9:.
symptoms or persistent $ ele+ation on )9:.
PCI after thrombolytics;;;
PCI after thrombolytics;;;
(his issue remains unresol%ed<
5 possi!le scenarios<
SFacilitated PCIJlytic drug gi%en prior to planned PCI
SFacilitated PCIJlytic drug gi%en prior to planned PCI
in attempt to achie%e an open infarct-related artery
in attempt to achie%e an open infarct-related artery
!efore arri%al of cath la!
!efore arri%al of cath la!
SAdFuncti%e PCIJPCI performed -ithin hours after
SAdFuncti%e PCIJPCI performed -ithin hours after
throm!olysis
throm!olysis
SEarly electi%e PCIJPCI performed -ithin a fe- days
SEarly electi%e PCIJPCI performed -ithin a fe- days
after throm!olysis
after throm!olysis
Heparin
Heparin
And other current Parenteral
And other current Parenteral
Anticoagulants
Anticoagulants
Unsta%le Angina
Unsta%le Angina
Anti'coagulant Thera!
"earin
"earin
recommendation is %ased on documented

recommendation is %ased on documented
efficac! in man! trials of moderate siBe
efficac! in man! trials of moderate siBe
meta'anal!ses
meta'anal!ses
*7#G+ *7#G+
of si& trials shoEed a 881
of si& trials shoEed a 881
ris? reduction in MI and death# %ut Eith a tEo
ris? reduction in MI and death# %ut Eith a tEo
fold increase in ma-or %leeding
fold increase in ma-or %leeding
titrate PTT to G& the uer limits of normal

titrate PTT to G& the uer limits of normal
3+ Circulation 3NNB)4N,43-44
1+ UA.A 3NN6)1I6,433-43E
Unsta%le Angina
Unsta%le Angina
)oE'molecular'Eeight hearin
)oE'molecular'Eeight hearin
ad%antages o%er heparin,
ad%antages o%er heparin,
%etter %io'availa%ilit!
%etter %io'availa%ilit!
higher ratio *8:7+ of anti'=a to anti'IIa

higher ratio *8:7+ of anti'=a to anti'IIa
activit!
activit!
longer anti'=a activit!# avoid re%ound

longer anti'=a activit!# avoid re%ound
induces less latelet activation

induces less latelet activation
ease of use *su%cutaneous ' Hd or %id+

ease of use *su%cutaneous ' Hd or %id+
no need for monitoring

no need for monitoring
Prehosital Throm%ol!sis
Prehosital Throm%ol!sis
Prehosital Throm%ol!sis Pro-ect:
Prehosital Throm%ol!sis Pro-ect:
Acute inferolateral infarct
Acute inferolateral infarct
Time and Mortalit!:
Time and Mortalit!:
Primar! PCI vs Throm%ol!sis
Primar! PCI vs Throm%ol!sis
A
B
C
=
>
> D = E C F B
&nset of pain to treatment (hours)
E
>
4
d
a
y

m
o
r
t
a
l
i
t
y

(
G
)
H A
D=
D>
Throm(olysis
Primary PC-
Common
total ischaemia time
$u(er 2 et al6 Eur $eart ; =>>FI=B#=>BEJ=>HC6 -%.er et al. *%r -eart J F!!5; F6: 1!63=1!M
4CI after thrombolytics777
4CI after thrombolytics777
S
S
Facilitated PCICl!tic drug given rior to lanned
Facilitated PCICl!tic drug given rior to lanned
PCI in attemt to achieve an oen infarct'related
PCI in attemt to achieve an oen infarct'related
arter! %efore arrival of cath la%
arter! %efore arrival of cath la%
S
S
Ad-unctive PCICPCI erformed Eithin hours
Ad-unctive PCICPCI erformed Eithin hours
after throm%ol!sis
after throm%ol!sis
S
S
Earl! elective PCICPCI erformed Eithin a feE
Earl! elective PCICPCI erformed Eithin a feE
da!s after throm%ol!sis
da!s after throm%ol!sis
%T %T4 4Elevation Elevation4 4
,- ,-
Clinical Finding Clinical Finding
ECG ECG
Seru Mar!ers Seru Mar!ers
Ris! Assessent Ris! Assessent
Noncardiac
Chest Pain
%ta(le
*ngina
9nsta(le
*ngina
Non4%T4
Elev6 ,-
Throm(olysis
Primary PC-
*%* K GP --(<---a -nhi(itor
K $eparin<+,8$ K
*nti4ischemic /
Early -nvasive /
.ischarge
Negative
Positive
.iagnostic
ule &ut ,-<*C%
Path'ay
%T %T4 4T T4 48ave 8ave
Changes Changes
%T %T
Elevation Elevation
Negative
+o' Pro(a(ility ,edium ,edium4 4$igh isk $igh isk %TE,- %TE,- +o' isk
*%*, $eparin<+,8$ K
*nti4ischemic /
Early Conserv6
est Pain, Post est Pain, Post4 4,-, ,-,
.,, Prior *%* .,, Prior *%*
E/ertional
Pain
*typical Pain
&ngoing &ngoing
Pain Pain
Negative Positive Positive
Cannon in 2ra%n3ald et al. Cannon in 2ra%n3ald et al. Heart Disease. Heart Disease. F!!1. F!!1.

Coronary Artery
Coronary Artery
Bypass Graft
Bypass Graft
Positive: Positive:
(elief of angina in P01 of atients (elief of angina in P01 of atients
J01 angina free after 6 !ears J01 angina free after 6 !ears
Survival a%out P61 after 7 !ear Survival a%out P61 after 7 !ear
)oE chance of restenosis )oE chance of restenosis
2egative: 2egative:
G'8 da!s in ICU# K'70 da! total hosital sta! G'8 da!s in ICU# K'70 da! total hosital sta!
8'9 month full recover! time 8'9 month full recover! time
6'701 have ost'o comlications 6'701 have ost'o comlications
"igh cost *WG6#000'W80#000+ "igh cost *WG6#000'W80#000+
)ong time on CP; )ong time on CP;
Deression of the atient5s immune s!stem Deression of the atient5s immune s!stem
Postoerative %leeding from inactivation of the %lood clotting s!stem Postoerative %leeding from inactivation of the %lood clotting s!stem
2J -arlan, et al; Manual of Cardiac Surgery, WebMD.com, American College of Cardiology Foundation
.inimally in%asi%e surgery does not use CP

.inimally in%asi%e surgery does not use CP
'maller incision
'maller incision
Emerging as a relacement for conventional

Emerging as a relacement for conventional
CA;,
CA;,
'tarting in 3NN2Ps, .IDCA has gained

'tarting in 3NN2Ps, .IDCA has gained
popularity
popularity
Dsually conducted for >I.A to >DA grafts

Dsually conducted for >I.A to >DA grafts
5N Cohen, et al; Minimally n!asi!e Cardiac Surgery
>AD e#posed >AD e#posed

Anastamosis preformed Anastamosis preformed
-ith assistance of -ith assistance of
mechanical sta!ili;er mechanical sta!ili;er
5N Cohen, et al; Minimally n!asi!e Cardiac Surgery
Completed &raft
Inoera%le Coronar! arter! disease
Inoera%le Coronar! arter! disease
"oE ma! Ee manage<
"oE ma! Ee manage<
PIC4A ' ;asic Concet
PIC4A ' ;asic Concet
Percutaneous In'Situ Coronar! 4enous ArterialiBation
Percutaneous In'Situ Coronar! 4enous ArterialiBation
Selective Coronar! 4ein Selective Coronar! 4ein

Perfuses M!ocardium Perfuses M!ocardium
Arterial Sul! From Arterial Sul! From

Pro&imal Coronar! Arter! Pro&imal Coronar! Arter!
Single Connection Single Connection

Made Percutaneousl! Made Percutaneousl!
4ein ;loc?ed Pro&imall! 4ein ;loc?ed Pro&imall!
;!asses Arter! Comletel! ;!asses Arter! Comletel!

Transvascular Inc# Eith ermission
Cardiogenic Shoc?
Cardiogenic Shoc?
Definition
Definition
.P0 mm"g
.G.G li3min.mG
X76 mm"g
Schematic
Schematic
>&EDP ele%ation
Hypotension
Decreased coronary
perfusion
Ischemia
Further myocardial
dysfunction
7eurohormonal
acti%ation
&asoconstriction
Endorgan hypoperfusion
Currently,
Currently,
stenting is recommended over surger!
stenting is recommended over surger!
for one'vessel disease
for one'vessel disease
In the future, drug-eluting stents -ill pro!a!ly !e used In the future, drug-eluting stents -ill pro!a!ly !e used
Minimall! invasive surgeries could %e used in lace of Minimall! invasive surgeries could %e used in lace of
stents in dia%etic# and other high'ris? atients stents in dia%etic# and other high'ris? atients
For more than one'vessel disease# surger! is

For more than one'vessel disease# surger! is
su%stantiall! %etter at reventing restenosis and so
su%stantiall! %etter at reventing restenosis and so
Eill li?el! continue to %e used in the future
Eill li?el! continue to %e used in the future
Minimall! invasive surgeries Eill e&and and relace Minimall! invasive surgeries Eill e&and and relace
most conventional CA;, rocedures most conventional CA;, rocedures
VUESTIO2S MMM
THE END
Bine ca s-a terminat !!! Bine ca s-a terminat !!!
,yosplint
Chan&e in radi%s
51
5F
Infarct in ventricular Eall Eith loss of muscle and
scarring
VUESTIO2S MMM
D6 $ypertrophy L
.ilatation
E6.6"
=6 %ympathetic activity#
1
1 ".(.
8 4.C
*ngiotensine
*ldosterone
Positive
Inotroics
Diuretics
ACE
inhi%itors
vasodilators
Pharmacological $reatment
!iuretics
(loop diuretics< thia/ide diuretics
and potassium sparing diuretics,

(hese act !y promoting the renal e#cretion of
salt and -ater !y !loc"ing tu!ular rea!sorption
of sodium and chloride+ (he resulting loss of
fluid reduces %entricular filling pressures
(preload$, produces consistent haemodynamic
and symptomatic !enefits and rapidly impro%es
dyspnoea and peripheral oedema+
ca
KK
*TPase
ca
QQ
Na
K
<n therape%ti( dose leads to partial inhi.ition of Na
D
>O
D

A:6ase enz)me
Na
K
Na
K
Na
K
Na
K Na
K
Na
K
O intracellular Na
K
resulting in#
2a
K
3ca
K K
e&change
ca
QQ
Na
K
A
Q
ca
QQ
ca
QQ
ca
QQ
sar(oplasmi( reti(%l%m
ca
QQ
ca
QQ
ca
QQ ca
QQ
ca
QQ
ca
QQ
ca
QQ
ca
QQ
troponin
*ctin ,yosin
0orce &f Contractility
Acute heart failure (AHF$ occurs -ith the

rapid onset of symptoms and signs of heart
failure secondary to a!normal cardiac
function, causing ele%ated cardiac filling
pressures+
(his causes se%ere dyspnoea and fluid

accumulates in the interstition and al%eolar
spaces of the lung (pulmonary oedema$+
'H?C/ is a se%ere failure of tissue perfusion,

characteri;ed !y hypotension, a lo- cardiac output and
signs of poor tissue perfusion such as oliguria, cold
e#tremities and poor cere!ral function+ Cardiogenic shoc"
is commonly due to myocardial infarction, acute massi%e
pulmonary em!olus, pericardial tamponade @ sudden-onset
%al%ular regurgitation+
(REEA(.E7(, Patients reVuire intensi%e care
General measures such as complete rest, continuous 62C

o#ygen administration and pain and an#iety relief are
essential+
(he infusion of fluid is necessary if the pulmonary capillary

-edge pressure is !elo- 34 mmHg+
'hort-acting %enous dilators such as glyceryl trinitrate or

sodium nitroprusside should !e administered intra%enously
if the -edge pressure is 1E mmHg or more+
Cardiac inotropes to increase aortic diastolic pressure+
Emergency re%asculari;ation of occluded arteries

Pathophysiology of chronic heart failure6
amani G " et al6 ,ayo Clin Proc6 =>D>IAF#DA>4DMF
P F!1! /a)o +o%ndation for /edi(al *d%(ation and 5esear(h
,odified .or Procedure
,odified .or Procedure
Prof Univ Dr Ion C.Tintoiu FESC
Cardiac 0ransplant
Cardiac 0ransplant

'ur%i%al rate
'ur%i%al rate
3 year 42C - N2C

3 year 42C - N2C
E years I2C
E years I2C
Christian ;arnard
Christian ;arnard



F5
Outatient Thera!
Outatient Thera!
6redi(tors of /ortalit) 2ased on
Anal)sis of A'-*5* 'ata.ase
Classifi(ation and 5e&ression :ree 9CA5:; anal)sis of
A'-*5* data sho3s:
:hree 4aria.les are the stron&est predi(tors of mortalit) in
hospitalized A'-+ patients:
2QN R 3 m&>dL
1)stoli( .lood press%re S 115 mm-&
1er%m (reatinine R F.M5 m&>dL
2QN R 3 m&>dL
1)stoli( .lood press%re S 115 mm-&
1er%m (reatinine R F.M5 m&>dL
+onaro3 NC et al. JA/A F!!5;F93:5MF=#!.
Continuous Heart (ransplant Perfusion
Starlings )aE
Future Tech
Future Tech
Inotroes in Cardiac Surger!
;asics
;EFO(E I2OT(OPES
Fluid
olus
>egs up
Rhythm
ECG, 'R, slo-, fast, paced on %entricle, '(Ps, ectopics
(amponade
C&P, E, D?, temp, CHR, echo
leeding
Drains, CHR, H!
Pneumothora#
CHR, e#amine, %ent alarms
Fight &entilator
Paralyse, sedate or e#tu!ate

@hich Inotroe
?hms >a-
&[I # R
P[C? # '&R
'imple terms
>o- or high cardiac output, -hat is the PA pressure

(ecetors
Atroine
Antimuscurinic ie causes tachycardia
'ome pateints ha%e muscurinic receptors on

%entricle as -ell ie inotropic
Increases HR
C?['& # HR
Ca
GQ
Inotrope and
%asoconstrictor
'hort acting
e-are radial artery

patients
0arn patient if a-a"e

Doamine
Acts on dopamine receptors on

heart and "idney
Causes a tachycardia (C?['& #

HR$
Increases urine output in some

patients
>ess meta!olic side effects

compared -ith adrenaline
e-are patients -ith tachycardia

(gi%e "
\
, .g
1\
$
Doe&amine
(achycardia
Increase splanchnic and renal !lood flo-
&A'?DI>A(?R
e-are
&asodilated patients
Do%utamine
>i"e dopamine
Has less effect on

pulmonary artery
pressure good for mitral
%al%e patients
Adrenaline
E#cellent inotrope !ut dirty
Increased heart rate and inotropy (]3-

adrenoceptor mediated$
&asoconstriction in most systemic

arteries and %eins (postFunctional a 3
and a 1 adrenoceptors$
&asodilation in muscle and li%er

%asculatures at lo- concentrations
(!1-adrenoceptor$) %asoconstriction at
high concentrations (a3-adrenoceptor
mediated$
Adrenaline
2oradrenaline
&asoconstrictor
Increased heart rate and increased

inotropy (]3-adrenoceptor mediated$
&asoconstriction occurs in most

systemic arteries and %eins
(postFunctional a 3 and a 1
adrenoceptors$
As" can I -a"e patient up to a%oid

7orad
.ust ha%e a good cardiac output

2oradrenaline
Isorenaline
Causes tachycardia and

%asodilatation
Good in patients -ith

high PA pressures
e-are %asodilated
patients
Eno&imone
6hosphodiesterase <nhi.itor
Nood in patients 3ith hi&h 6A press%re
JFnd line 3hen adrenaline ha4in& no
effe(t Jre(eptor disso(iationK
Aminoh!lline
Phosphodiesterase
inhi!itor
.ain effect on lung

compared to heart
Good in patients -ho

ha%e hypo#ic
%asoconstriction ^short
fat little smo"er -ith
poor urine output_
4assoresin
1
nd
line %asoconstrictor
.ost po-erful a%aila!le
Associated -ith organ

ischaemia
2itric O&ide
Medication
Medication
Drug treatments should %e initiated in the

Drug treatments should %e initiated in the
folloEing order:
folloEing order:

ACE inhi!itor - -ith diuretic if needed - for

ACE inhi!itor - -ith diuretic if needed - for
7LHA Grades I-I&+
7LHA Grades I-I&+
Angiotensin-II receptor antagonist - if

Angiotensin-II receptor antagonist - if
intolerant of ACE inhi!itor+
intolerant of ACE inhi!itor+
eta-!loc"er - for 7LHA Grades I-I&+

eta-!loc"er - for 7LHA Grades I-I&+
'pironolactone - for 7LHA Grades III-I&+

'pironolactone - for 7LHA Grades III-I&+
Digo#in - for 7LHA Grades II-I&+

Digo#in - for 7LHA Grades II-I&+
*ntiarrhythmics
/ost (ommon (a%se of 1C' in these patients is /ost (ommon (a%se of 1C' in these patients is
4entri(%lar ta(h)arrh)thmia 4entri(%lar ta(h)arrh)thmia
6atients 3ith h>o s%stained V: or 1C' ? <C' implant 6atients 3ith h>o s%stained V: or 1C' ? <C' implant
6atients 3ith C-+ 3ith an e@e(tion fra(tion of less than 6atients 3ith C-+ 3ith an e@e(tion fra(tion of less than
3!A ma) re(ei4e <C' implant 3!A ma) re(ei4e <C' implant
Amiodarone for patients 3ith freB%ent V6Cs and at fi. Amiodarone for patients 3ith freB%ent V6Cs and at fi.
'ranedone for patients 3ith re(%rrent paro0)smal at fi.. 'ranedone for patients 3ith re(%rrent paro0)smal at fi..
"asodilators)$ydrala5ine and Nitrates
$
(hydrala;in$
(hydrala;in$
reduce >&EDP, ? reduce >&EDP, ?

1 1
consumption,impro%e consumption,impro%e
myocardial perfusion, myocardial perfusion,
stro"e %olume and C?P stro"e %olume and C?P

$
(eduction of reload
(eduction of reload
y
y
%enous dilation
%enous dilation

( 7itrate$
( 7itrate$
Q the %enous return Q the %enous return
Q the load on !oth Q the load on !oth

%entricles+ %entricles+
$
*nticoagulation
Atrial fi!rillation
Atrial fi!rillation
-notropic *gents
contractility (
contractility (: adrenergic agonists, dopaminergic agents, : adrenergic agonists, dopaminergic agents,
phosphodiesterase inhi!itors$, phosphodiesterase inhi!itors$,

.opamine .opamine
.o(utamine .o(utamine
,ilrinone, ,ilrinone,
*amrinone *amrinone
'e%eral studies sho-ed R mortality -ith oral inotropic agents 'e%eral studies sho-ed R mortality -ith oral inotropic agents
'o the only use for them no- is in acute sittings such as cardiogenic 'o the only use for them no- is in acute sittings such as cardiogenic
shoc shoc
"
"
Ne' Treatment Choices
Imlanta%le ventricular assist devices
Imlanta%le ventricular assist devices
;iventricular acing
;iventricular acing
(only in patient -ith
(only in patient -ith
> @ CHF$
> @ CHF$
Artificial "eart
Artificial "eart
Device Thera!:
Device Thera!:
F#5 C4er4ie3 of 'e4i(e :herap)

contraction
contraction
;i4 Pacing
;i4 Pacing
Ae! Points
Ae! Points
Indications
Indications
therapy therapy
EFA52C EFA52C

E/citation4contraction
coupling
.ysrhythmias N
Electrical dyssynchrony
,echanical dyssynchrony
Future Tech
Future Tech
Stage A: Stage A:
Control ris? factors# treat underl!ing chronic disease contri%utors Control ris? factors# treat underl!ing chronic disease contri%utors
Stage ;: Stage ;:
ACE3A(;3;; if aroriate ACE3A(;3;; if aroriate
Stage C: Stage C:
ACEMA(;# ;;# diuretics ACEMA(;# ;;# diuretics
Other vasodilators as aroriate Other vasodilators as aroriate
Devices *%i'4 acing# Imlanta%le defi%rillators Devices *%i'4 acing# Imlanta%le defi%rillators
Stage D: Stage D:
Mechanical assist devices Mechanical assist devices
Continuous infusion of inotroics Continuous infusion of inotroics
"eart translant "eart translant
"osice "osice
E&erimental surger! or drugs E&erimental surger! or drugs

De%ices and 'urgical .anagement
First option if the cause of heart failure can !e treated First option if the cause of heart failure can !e treated
surgically surgically
'e%eral therapeutic options, pacing, an ICD, a %entricular 'e%eral therapeutic options, pacing, an ICD, a %entricular
assist de%ice, an artificial heart, or a heart transplant assist de%ice, an artificial heart, or a heart transplant
Pacing or resynchroni;ation therapy is recommended for Pacing or resynchroni;ation therapy is recommended for
patients -ith 7LHA Class III or I& -ith WR' prolongation patients -ith 7LHA Class III or I& -ith WR' prolongation
-ho are e#periencing symptoms despite medications -ho are e#periencing symptoms despite medications
An ICD may !e used in patients -ith arrhythmias to pre%ent An ICD may !e used in patients -ith arrhythmias to pre%ent
sudden cardiac death sudden cardiac death
A left %entricular assist de%ice may !e used as a !ridge to A left %entricular assist de%ice may !e used as a !ridge to
transplant or destination therapy transplant or destination therapy
End-stage heart failure patients may consider heart transplant End-stage heart failure patients may consider heart transplant
ECG 31 leads
ECG 31 leads
Chest H-ray
Chest H-ray
>a! tests (hyponatraemiaO$

iomar"ers of HF, 7P, pro7P, CRP,

iomar"ers of HF, 7P, pro7P, CRP,
troponins<
troponins<
Echocardiography (systolicMdiastolic
dysfunction, structural heart disease$
spiroergometry
spiroergometry
Ph!sical e&amination
Medical histor!
)a% tests: ;2P# <
='ra!# EC,#
Echo# Siro'
Ergometr!<
ACE inhi!itors
ACE inhi!itors
symptoms
symptoms
, prognosis
, prognosis
, mortality
, mortality
remodelling
remodelling

Hypotension
Hypotension

Cough
Cough
Angio-oedema
Angio-oedema
eta!loc"ers
eta!loc"ers
symptoms
symptoms
, prognosis
, prognosis
, mortality
, mortality
remodelling
remodelling
, dyssynchrony
, dyssynchrony
'CD
'CD
, antiarrhythmic effect
, antiarrhythmic effect

Hypotension
Hypotension
Fatigue
Fatigue
radycardia, !loc"
radycardia, !loc"
Reduce dose in case of decompensation

Reduce dose in case of decompensation
symptoms
symptoms
, prognosis
, prognosis
, mortality
, mortality
7LHA III, EF
7LHA III, EF
A
A
5EC
5EC
Renal dysfunction
Renal dysfunction
Hyper"alaemia
Hyper"alaemia
Diuretics
Diuretics
symptoms
symptoms
, oedema
, oedema
, prognosis
, prognosis

RAA' acti%ation
RAA' acti%ation
add ACEi or ARO

add ACEi or ARO
(itrate, com!ine
(itrate, com!ine

Diuretic resistance
Diuretic resistance
Patients 'ith acute heart failure
freOuently develop chronic heart failure6
Patients 'ith chronic heart failure
freOuently decompensate acutely6
"EA(T FAI)U(E
"EA(T FAI)U(E

52B
Multi'Discilinar!
Multi'Discilinar!
"eart Failure
"eart Failure
Management
Management
52E
S!stolic:
S!stolic:
Impaired a!ility of the heart to contract Impaired a!ility of the heart to contract
0ea"ened muscle, enlarged heart si;e 0ea"ened muscle, enlarged heart si;e
Ina!ility of heart to empty Ina!ility of heart to empty
>eft %entricular eFection fraction (>&EF$ A B2KBEC >eft %entricular eFection fraction (>&EF$ A B2KBEC
Diastolic,
Diastolic,
ina!ility of the heart to rela# is impaired ina!ility of the heart to rela# is impaired
'tiff, thic"ened myocardial -all !ut normal si;e 'tiff, thic"ened myocardial -all !ut normal si;e
Ina!ility of heart to fill Ina!ility of heart to fill
>&EF >&EF
BEC BEC
526
Acute
Acute

Chronic
Chronic

Acute Decomensated
Acute Decomensated

52I
4eart =ailure is a ymptomatic !isorder
4eart =ailure is a ymptomatic !isorder
2eE For? "eart Association'Functional
2eE For? "eart Association'Functional
Classification
Classification
Class I:
Class I:
7o a!normal symptoms -ith acti%ity
7o a!normal symptoms -ith acti%ity
Class II:
Class II:
'ymptoms -ith normal acti%ity
'ymptoms -ith normal acti%ity
Class III:
Class III:
.ar"ed limitation due to symptoms
.ar"ed limitation due to symptoms
-ith less than ordinary acti%ity
-ith less than ordinary acti%ity
Class I4:
Class I4:
'ymptoms at rest and se%ere
'ymptoms at rest and se%ere
limitations in functional acti%ity
limitations in functional acti%ity
524
4eart =ailure is a Progressi+e !isorder
4eart =ailure is a Progressi+e !isorder
ACC3A"A Stages of "F
ACC3A"A Stages of "F
Stage A'
Stage A'
-Presence of ris" factors for heart failure
-Presence of ris" factors for heart failure
Stage ;'
Stage ;'
-Presence of structural heart disease !ut no
-Presence of structural heart disease !ut no
'ymptoms
'ymptoms
Stage C''
Stage C''
Presence of structural heart disease along
Presence of structural heart disease along
-ith signs and symptoms
-ith signs and symptoms
Stage D''
Stage D''
Presence of structural heart diseases and
Presence of structural heart diseases and
ad%anced signs and symptoms
ad%anced signs and symptoms
52N
ACC3A"A G006 ,uidelines
ACC3A"A G006 ,uidelines
532
Cardiac Rhythm .anagement
8
'mall impro%ements in
hemodynamics [significant
impro%ements in HF symptoms
symptoms+
8
?ptimi;ing hemodynamics has
long !een a target of
therapy in HF+
533
Cardiac (h!thm Management
Cardiac (h!thm Management
8
Ris" Reduction
8
CR(
8
Diagnostics
8
HR (rends
8
HR &aria!ility
8
Patient Acti%ity
8
Intrathoracic Impedance
8
Arrhythmias
8
Remote .onitoring
Boceria et al. Eur J Cardio!thorac "urg
#$$%&#'("#)*!+".
>& Reconstruction !y Patch Plasty
Uatene, Dor, Fontan
>eft &entricular Assist De%ice
T!es of "eart Failure
T!es of "eart Failure
'ystolic (or sVuee;ing$ heart failure

'ystolic (or sVuee;ing$ heart failure
Decreased pumping function of the heart, -hich results in Decreased pumping function of the heart, -hich results in
fluid !ac" up in the lungs and heart failure fluid !ac" up in the lungs and heart failure
Diastolic (or rela#ation$ heart failure

Diastolic (or rela#ation$ heart failure
In%ol%es a thic"ened and stiff heart muscle In%ol%es a thic"ened and stiff heart muscle
As a result, the heart does not fill -ith !lood properly As a result, the heart does not fill -ith !lood properly
(his results in fluid !ac"up in the lungs and heart failure (his results in fluid !ac"up in the lungs and heart failure
CAD[coronary artery disease) >&H[left %entricular hypertrophy+
(is? Factors for "eart Failure
(is? Factors for "eart Failure
Coronary artery disease

Hypertension (>&H$
Hypertension (>&H$
&al%ular heart disease

&al%ular heart disease
Alcoholism
Alcoholism
Infection (%iral$
Infection (%iral$
Dia!etes
Dia!etes
Congenital heart defects

Congenital heart defects
?ther,
?ther,
?!esity ?!esity
Age Age
'mo"ing 'mo"ing
High or lo- hematocrit le%el High or lo- hematocrit le%el
?!structi%e 'leep Apnea ?!structi%e 'leep Apnea

Classif!ing "eart
Classif!ing "eart
Failure:
Failure:
Terminolog! and
Terminolog! and
Staging
Staging
Failure
Failure
EFection Fraction (EF$
EFection Fraction (EF$
EFection Fraction (EF$ is the percentage of !lood that

EFection Fraction (EF$ is the percentage of !lood that
is pumped out of your heart during each !eat
is pumped out of your heart during each !eat
3
Hunt 'A et al+ J Am Coll Cardiol. 1223)54,1323K1335+

1
7e- Lor" Heart AssociationM>ittle ro-n and Company, 3N6B+ Adapted from, Farrell .H et al+ JAMA. 1221)14I,4N2K4NI+
ACC3A"A "F Stage
7
G
A At high ris? for heart failure %ut Eithout
structural heart disease or s!mtoms
of heart failure *eg# atients Eith
h!ertension or coronar! arter! disease+
; Structural heart disease %ut Eithout
s!mtoms of heart failure
C Structural heart disease Eith rior or
current s!mtoms of heart failure
D (efractor! heart failure reHuiring
secialiBed interventions
I As!mtomatic
II S!mtomatic Eith moderate e&ertion
I4 S!mtomatic at rest
III S!mtomatic Eith minimal e&ertion
2one
"oE "eart Failure Is Diagnosed
"oE "eart Failure Is Diagnosed
.edical history is ta"en to re%eal symptoms .edical history is ta"en to re%eal symptoms
Physical e#am is done Physical e#am is done
(ests (ests
Chest H-ray Chest H-ray
lood tests lood tests
Electrical tracing of heart (Electrocardiogram or ÊCG_$ Electrical tracing of heart (Electrocardiogram or ÊCG_$
Dltrasound of heart (Echocardiogram or Êcho_$ Dltrasound of heart (Echocardiogram or Êcho_$
H-ray of the inside of !lood %essels (Angiogram$ H-ray of the inside of !lood %essels (Angiogram$
Pathoh!siolog!
Pathoh!siolog!
Adapted from Cohn JN. N Engl J Med. 1996;335:9!"9#.
Pathologic
remodeling
+o' e1ection
fraction
.eath
%ymptoms#
.yspnea
0atigue
Edema
Chronic
heart
failure
$
Neurohormonal
stimulation
$ ,yocardial
to/icity
%udden
.eath
Pump
failure
Coronary artery
disease
$ypertension
Cardiomyopathy
"alvular disease
,yocardial
in1ury
.ia(etes
Comensator! Mechanisms:
Comensator! Mechanisms:
(enin'Angiotensin'Aldosterone S!stem
(enin'Angiotensin'Aldosterone S!stem
enin K *ngiotensinogen
*ngiotensin -
*ngiotensin --
Peripheral
"asoconstriction
*fterload
Cardiac &utput
$eart 0ailure $eart 0ailure
Cardiac 8orkload
Preload
Plasma "olume
%alt L 8ater etention
Edema
*ldosterone %ecretion
*CE
2aliuresis
Beta Beta
%timulation %timulation
$
C& C&
$
Na Na
K K
0i(rosis
Drug Thera!
Drug Thera!
"eart Failure Treatments:
"eart Failure Treatments:
Medication T!es
Medication T!es
ACE inhibitor
(angiotensin-conerting
enzyme!
A"# (angiotensin receptor
bloc$ers!
#eta-bloc$er
%igo&in
%iuretic
Aldosterone
bloc$ade
'ype (hat it does
E&pands blood essels which lowers
blood pressure) neurohormonal
bloc$ade
*imilar to ACE inhibitor+lowers
blood pressure
"educes the action of stress
hormones and slows the heart rate
*lows the heart rate and improes the
heart,s pumping function (EF!
Filters sodium and e&cess fluid from the
blood to reduce the heart,s wor$load
#loc$s neurohormal actiation and controls
olume
(ational for Medications
(ational for Medications
*@h! does m! doctor have me on so
*@h! does m! doctor have me on so
man! illsMM+
man! illsMM+
Impro%e 'ymptoms
Impro%e 'ymptoms
Diuretics (-ater pills$ Diuretics (-ater pills$
digo#in digo#in
Impro%e 'ur%i%al
Impro%e 'ur%i%al
eta!loc"ers eta!loc"ers
ACE-inhi!itors ACE-inhi!itors
Aldosterone !loc"ers Aldosterone !loc"ers
Angiotensin receptor Angiotensin receptor

!loc"ers (ARPs$ !loc"ers (ARPs$
)ifest!le Changes
)ifest!le Changes
Eat a low-sodium) low-fat
diet
-ose weight
*tay physically actie
"educe or eliminate alcohol
and caffeine
.uit *mo$ing
(hat (hy
*odium is bad for high blood pressure)
causes fluid retention
E&tra weight can put a strain on
the heart
E&ercise can help reduce stress
and blood pressure
Alcohol and caffeine can wea$en an
already damaged heart
*mo$ing can damage blood essels and
ma$e the heart beat faster
3FM
Oral Medications to
Oral Medications to
Counteract<..
Counteract<..
RAA' Inhi!itors,
RAA' Inhi!itors,

ACE IMARs
ACE IMARs
Aldosterone Antagonists
eta loc"ers
eta loc"ers
'7' Inhi!itors,
'7' Inhi!itors,
eta loc"ers
eta loc"ers
&asodilatorM7itric ?#ide Agonists,

Isor!ide dinitrateMhydral;ine
3F#
ACE Inhi%itors
ACE Inhi%itors
Inhi!it the en;yme responsi!le for con%erting

Angiotensin I to Angiotensin II) counteracts
RAA'
RAA'
Decrease 'ystemic &ascular Resistance ('&R$

Enhance acti%ity of "inins and "inin-mediated

prostaglandin synthesis
.odify cardiac remodeling

Reduce P) ho- lo- is too lo-`

3F9
;eta ;loc?ers: U to 861 ((
Counteract acti%ation of RAA' and '7'

'7' acti%ation promotes catecholamine

to#icity on cardiomyocytes, increases >&
afterload and -all stress, promotes
myocardial ischemia and o#idati%e stress
7egati%e inotrope @ 7egati%e chronotrope

Rate control -ith arrhythmias

Controls HR and P
Controls HR and P
33!
;eta ;loc?ers: 8 Indicated
Metorolol =)
Metorolol =)
( !eta 3 selecti%e$, .ERI( HF
Carvedilol
Carvedilol
(!eta 3, !eta 1, alpha !loc"ade$
C?PER7ICD', C?.E(
C?PER7ICD', C?.E(
;isorolol
;isorolol

(CII' II$
(CII' II$
O2)F
O2)F

A eta !loc"er is not a !eta !loc"er is not<<+

Gi%en to all post .I andMor -ith >& dysfunction

'uperiority -ith non-selecti%e !eta !loc"ers -ith

some alpha !loc"ade`
Comet trial
Comet trial

331
"oE to give ;eta ;loc?ers
'tart lo-) go slo-<<unless s-itching

Patient should !e
Patient should !e
eu+olemic
eu+olemic
prior to starting) neg+
inotropic
inotropic
action, increased preload can e#acer!ate
fluid o%erload+
fluid o%erload+
(itrate V 1 -ee"s) can go !y Y dose

(itrate to highest tolerated doseMstudy dose) HR in

62s signifies adeVuate !3 !loc"ade
Fe- contraindications, high degree !loc"s, true

!ronchospastic Asthmatic disease
Fe- side effects) can feel -orse at first

33F
The Adverse Imact of
Aldosterone
Aldosterone
Adapted from /(/ahon. Curr "#in $%armacol. F!!1;1:19!=196.
Oorantzopo%los et al. Med Sci Monit. F!!3;9:5A1!=5A15.
Prothrom(otic
effects
Prothrom(otic
effects
,yocardial
fi(rosis
,yocardial
fi(rosis
*dverse effects
of aldosterone
*dverse effects
of aldosterone
&/idative
stress
&/idative
stress
Endothelial
dysfunction
Endothelial
dysfunction
"ascular
inflammation
"ascular
inflammation
333
Aldosterone release influenced !y Angiotension II Aldosterone release influenced !y Angiotension II
Promotes salt and -ater retention, /\ and .g loss) Promotes salt and -ater retention, /\ and .g loss)
sympathetic stimulation and parasympathetic inhi!ition, sympathetic stimulation and parasympathetic inhi!ition,
!aroreceptor dysfunction, %ascular damage and impaired !aroreceptor dysfunction, %ascular damage and impaired
arterial compliance+ arterial compliance+
(A)ES: (A)ES: ('pironolactone$, ('pironolactone$, 801 801 ris" reduction in mortality ris" reduction in mortality
and and 861 861 reduction in HF admissions as compared -ith reduction in HF admissions as compared -ith
place!o) Real -orld`` Fe- on eta loc"ers place!o) Real -orld`` Fe- on eta loc"ers
EP"ESUS EP"ESUS,Eplerenone (Inspra$, post .I) ,Eplerenone (Inspra$, post .I) 761 761 ris" reduction ris" reduction
?7 current therapy HF meds) more specific) less '+E+ ?7 current therapy HF meds) more specific) less '+E+
(gynecomastia$ (gynecomastia$
Must carefull! monitor AQ levels Must carefull! monitor AQ levels

33
2itric O&ide
2itric O&ide
Isosor!ide dinitrateMhydrala;ine (iDil$

Regulates C& processes including myocardial

hypertrophy, remodeling, su!strate use,
%ascular function, inflammation, and
throm!osis
throm!osis
335
Isosor%ide Dinitrate3"!dralaBine
A'"eFT 7 A'"eFT 7, Protecti%e role of nitric o#ide , Protecti%e role of nitric o#ide
Additional /81 reduction in mortalit! Ehen added to Additional /81 reduction in mortalit! Ehen added to
current standard thera! : *African Americans+ current standard thera! : *African Americans+
Decreased 3 Decreased 3
st st
hospitali;ation for HF !y 55C hospitali;ation for HF !y 55C
Impro%ed W?> scores Impro%ed W?> scores
Ho- it -or"s, &asodilator, alance of arterio and Ho- it -or"s, &asodilator, alance of arterio and
%enodilation %enodilation
Hydrala;ine pre%ents degredation of n+o+ and prolongs Hydrala;ine pre%ents degredation of n+o+ and prolongs
%asodilatory effects of isosor!ide %asodilatory effects of isosor!ide
'hould !e gi%en to AA -ith HF 'hould !e gi%en to AA -ith HF
A reasona!le alternati%e for any patient -ho cannot ta"e A reasona!le alternati%e for any patient -ho cannot ta"e
ACEMARs ACEMARs
ZZZZZZZZZ ZZZZZZZZZ
336
S!mtom (elief
S!mtom (elief
Digo#in,
Digo#in,
&ery mild positi%e inotrope, some

sympathoinhi!itory neurohormonal modulating
effects+
effects+
2o mortalit! data
2o mortalit! data
) data on decreased
) data on decreased
hospitali;ations
hospitali;ations
Rarely used for HF in Europe

Helpful for rate control -ith A-fi!

Dse 5
Dse 5
rd rd
line for symptom relief
4er! )oE dose

4er! )oE dose
33M
Diuretics: Fluid D 2aQ (etention
7o "no-n impact on mortality

Dseful and necessary adFunct to therapy for

congesti%e HF
congesti%e HF
s!mtoms
s!mtoms
due to sodium and -ater
retention+
retention+
Do not maintain clinical sta!ility as monotherapy

Refractoriness @ Renal Dysfunction

Inotroes
Inotroes
, 'till gi%en in ?P setting) for lo- c+o+
states) for s# relief) end stage HF only
33#
"oE Do @e Predict SCD Post'MIM
P4Cs# 2onsustained 4T Ma! 2ot "el
1 maFor types of &(

1 maFor types of &(
(ype 3, Premature (ype 3, Premature

%entricular contraction %entricular contraction
(P&C$ initiates (6+6C$ (P&C$ initiates (6+6C$
(ype 1, 7o P&C (ype 1, 7o P&C

(N3+4C$ (N3+4C$
Cannot predict -hich Cannot predict -hich

patients get (ype 3 %s (ype patients get (ype 3 %s (ype
1 1
*nderson 2P, et al6 *nderson 2P, et al6 " A Coll Cardiol " A Coll Cardiol6 DMMFI=B#CAM4CMB6 6 DMMFI=B#CAM4CMB6
"FSA G070
"FSA G070
Comrehensive "eart
Comrehensive "eart
Failure Practice
Failure Practice
,uideline
,uideline
/ey Recommendations
/ey Recommendations
"FSA G070 Practice ,uideline *K.7P+
Pharmacologic Thera!:
"!dralaBine and Oral 2itrates
A com%ination of h!dralaBine and

isosor%ide dinitrate
is recommended
is recommended
as
as
art of standard thera!# in addition to
%eta'%loc?ers and ACE'inhi%itors# for
African Americans Eith "F and reduced
)4EF:
)4EF:
2F"A III or I4 "F

2F"A III or I4 "F trength of )+idence > A trength of )+idence > A
2F"A II "F
2F"A II "F trength of )+idence > ? trength of )+idence > ?
"FSA G070 Practice ,uideline *K.G8+
Pharmacologic Thera!: Diuretics
Diuretic thera!
Diuretic thera!
is recommended
is recommended
to restore and
to restore and
maintain normal volume status in atients Eith
clinical evidence of fluid overload# generall!
manifested %!:
manifested %!:
Congestive s!mtoms
Congestive s!mtoms
Signs of elevated filling ressures

trength of )+idence > A trength of )+idence > A
)oo diuretics
)oo diuretics
rather than thiaBide't!e
diuretics are t!icall! necessar! to restore
normal volume status in atients Eith "F.

trength trength
of )+idence > ? of )+idence > ?
3F All a4aila.le for oral or <V administration
)oo Diuretics
)oo Diuretics
Dose Dose
Ma& Total Ma& Total
Action Action
%id %id
900 mg 900 mg 961('861M 961('861M /'9 hrs /'9 hrs
or %id or %id
acid acid
or %id or %id
Potassium'Saring Diuretics
Dose Dose
Ma& Total Ma& Total
Elimination Elimination Duration Duration
of Action of Action
Sironolactone Sironolactone 7G.6'G6 mg 7G.6'G6 mg
Hd Hd
60 mg 60 mg Meta%olic Meta%olic /J'KG hrs /J'KG hrs
Elerenone Elerenone G6'60 mg Hd G6'60 mg Hd 700 mg 700 mg (enal# (enal#
Meta%olic Meta%olic
Un?noEn Un?noEn
Amiloride Amiloride 6 mg Hd 6 mg Hd G0 mg G0 mg (enal (enal G/ hrs G/ hrs
Triamterene Triamterene 60'K6 mg 60'K6 mg
%id %id
G00 mg G00 mg Meta%olic Meta%olic K'P hrs K'P hrs
"FSA G070 Practice ,uideline *P.7# P./+
Device Thera!:
Device Thera!:
Proh!lactic ICD Placement
Proh!lactic ICD lacement Proh!lactic ICD lacement should %e considered should %e considered in atients in atients
Eith an )4EF Y861 and mild to moderate "F s!mtoms: Eith an )4EF Y861 and mild to moderate "F s!mtoms:

Ischemic etiolog! Ischemic etiolog! trength of )+idence > A trength of )+idence > A
2on'ischemic etiolog! 2on'ischemic etiolog! trength of )+idence > ? trength of )+idence > ?
In atients Eho are undergoing imlantation of a In atients Eho are undergoing imlantation of a
%iventricular acing device# use of a device that rovides %iventricular acing device# use of a device that rovides
defi%rillation defi%rillation should %e considered. should %e considered. trength of )+idence > ? trength of )+idence > ?
Decisions should %e made in light of functional status and Decisions should %e made in light of functional status and
rognosis %ased on severit! of underl!ing "F and comor%id rognosis %ased on severit! of underl!ing "F and comor%id
conditions# ideall! after 8'9 mos. of otimal medical thera!. conditions# ideall! after 8'9 mos. of otimal medical thera!.
trength of )+idence > C trength of )+idence > C
Adapted from:
"FSA G070 Practice ,uideline *77.7'77.G+
"F Eith Preserved )4EFC
Diagnosis
Diagnosis
Careful attention to differential diagnosis Careful attention to differential diagnosis is is

recommended recommended in atients Eith "F and reserved in atients Eith "F and reserved
)4EF. )4EF.
Treatments ma! differ %ased on cardiac disorder. Treatments ma! differ %ased on cardiac disorder.
Evaluation for ischemic disease and induci%le Evaluation for ischemic disease and induci%le
m!ocardial ischemia should %e included. m!ocardial ischemia should %e included.
(ecommended diagnostic tools: (ecommended diagnostic tools:
Echocardiograh! Echocardiograh!
Electrocardiograh! Electrocardiograh!
Stress imaging *via e&ercise or harmacologic means# using Stress imaging *via e&ercise or harmacologic means# using
m!ocardial erfusion or echocardiograhic imaging+ m!ocardial erfusion or echocardiograhic imaging+
Cardiac catheteriBation Cardiac catheteriBation

Adapted from:
Strengt# of E$idence % C
Diagnostic Algorithm
for "F Eith Preserved )4EF
$0 'ith
Preserved +"E0
.ilated +" Non4dilated +"
"alvular disease
*, ,
No valvular dis6
$igh output $0
-ncreased
thickness
Normal
Thickness
ight vent6
dysfunction
Pulmonary
hypertension
-solated pre4
dominant ",-
No mitral
o(struction
,itral o(struction
,%, atrial my/oma
Pericardial dis6
Tamponade
Constriction
No pericardial
disease
-nduci(le ischemia
-ntermittent<active
ischemia
Normal or
increased @%
$ypertrophic dis6
+o' @% voltage
-nfiltrative
myopathy
No aortic
valve disease
*ortic valve dis6
*ortic stenosis
No hypertensive
history of PE
$C,, 0a(ry dis6
$ypertensive
history of PE
$ypertensive4$C,
%ome patients 'ith "
dysfunction have +"
dysfunction due to
ventricular interaction6
No induci(le ischemia, fi(rotic, collagen4
"ascular, C,, cardinoid, dia(etes,
adiation or chemotherapy induced
heart disease, infiltrative disease, co4
mor(id conditions, reconsider diagnosis
of $0
HF'A 1232 Practice Guideline (31+5, (a!le 31+5$ HF'A 1232 Practice Guideline (31+5, (a!le 31+5$

Acute Decomensated "eart Failure *AD"F+
C
C
Treatment ,oals for "ositaliBed Patients
Impro%e symptoms, especially congestion and lo--output Impro%e symptoms, especially congestion and lo--output
symptoms symptoms
?ptimi;e %olume status ?ptimi;e %olume status
Identify etiology Identify etiology
Identify precipitating factors Identify precipitating factors
?ptimi;e chronic oral therapy) minimi;e side effects ?ptimi;e chronic oral therapy) minimi;e side effects
Identify -ho might !enefit from re%asculari;ation Identify -ho might !enefit from re%asculari;ation
Education patients concerning medication and HF self-assessment Education patients concerning medication and HF self-assessment
Consider enrollment in a disease management program Consider enrollment in a disease management program





S
S

Inotropes
Inotropes
S
S
Device Thera!:
Device Thera!:
Imlanta%le Cardiac Defri%rillators
Imlanta%le Cardiac Defri%rillators
E;M Theraies E;M Theraies (elative (is? (elative (is?
(eduction (eduction
Mortalit! Mortalit!
G !ear G !ear
ACE'I ACE'I 15C 15C 1IC 1IC
Z Z';loc?ers ';loc?ers 5EC 5EC 31C 31C
Aldosterone Aldosterone
Antagonists Antagonists
52C 52C 3NC 3NC
ICD ICD 53C 53C 4+EC 4+EC
351 C4er4ie3 of 'e4i(e :herap)

contraction
contraction
;i4 Pacing
;i4 Pacing
Ae! Points
Ae! Points
Indications
Indications
therapy therapy
EFA52C EFA52C

"eart Failure and Sudden Cardiac
"eart Failure and Sudden Cardiac
Death
Death

'udden Cardiac Death ('CD$
'udden Cardiac Death ('CD$
Lour heart Lour heart suddenly suddenly goes into a %ery fast and chaotic rhythm goes into a %ery fast and chaotic rhythm
and stops pumping !lood and stops pumping !lood
Caused !y an êlectrical_ pro!lem in your heart Caused !y an êlectrical_ pro!lem in your heart
'CD is one of the leading causes of death in the D+'+ K 'CD is one of the leading causes of death in the D+'+ K
appro#imately BE2,222 deaths a year appro#imately BE2,222 deaths a year
Patients -ith heart failure are 6-N times as li"ely to de%elop Patients -ith heart failure are 6-N times as li"ely to de%elop
sudden cardiac death as the general population sudden cardiac death as the general population
Device
Shown:
Combination
/acema$er 0
%efibrillator
@ho should Consider an ICDM
@ho should Consider an ICDM
Patients -ith -ea"end heart, 7e- Lor" Heart

Patients -ith -ea"end heart, 7e- Lor" Heart
Association (7LHA$ Class II and III heart
Association (7LHA$ Class II and III heart
failure, and measured left %entricular eFection
failure, and measured left %entricular eFection
fraction (>&EF$
fraction (>&EF$
A
A
5EC
5EC
Patients -ho meet all current reVuirements for a

Patients -ho meet all current reVuirements for a
cardiac resynchroni;ation therapy (CR($ de%ice
cardiac resynchroni;ation therapy (CR($ de%ice
and ha%e 7LHA Class I& heart failure)
and ha%e 7LHA Class I& heart failure)
Other TheraiesM
Other TheraiesM
(ransplant
(ransplant
Artificial hearts
Artificial hearts
7e- ^gadgets_ to help doctors manage heart

7e- ^gadgets_ to help doctors manage heart
failure
failure
"eart Translantation
"eart Translantation
A good solution to the failing heartK get a ne-

A good solution to the failing heartK get a ne-
heart
heart
Dnfortunately -e are limited !y supply, not

Dnfortunately -e are limited !y supply, not
demand
demand
Appro#imately 1122 transplants are performed

Appro#imately 1122 transplants are performed
yearly in the D', and this num!er has !een
yearly in the D', and this num!er has !een
sta!le for the past 12 years+
sta!le for the past 12 years+
Future Tech
Future Tech
Intrathoracic Imedance for "eart
Intrathoracic Imedance for "eart
Failure
Failure
@hat have Ee
@hat have Ee
learnedM
learnedM
In Summar!<.
In Summar!<.
Heart failure is common and has high mortality

Heart failure is common and has high mortality
Drug therapy impro%es sur%i%al

Drug therapy impro%es sur%i%al
eta!loc"ers, ACE-I, aldosterone antagonists eta!loc"ers, ACE-I, aldosterone antagonists
7e-er de%ice therapies are sho-ing promise for

7e-er de%ice therapies are sho-ing promise for
symptom relief and impro%ed sur%i%al
symptom relief and impro%ed sur%i%al
i%entricular pacing, ICDPs i%entricular pacing, ICDPs
(ransplants remain rare, !ut technology for

(ransplants remain rare, !ut technology for
mechanical assist de%ices continues to impro%e- stay
mechanical assist de%ices continues to impro%e- stay
tunedO
tunedO
EBH
"eart Failure:
"eart Failure:
Current
Current
,uidelines in
,uidelines in
Thera!
Thera!
36#
S;A(:
S;A(:

2av! 2uclear Su%marine Communications Model
2av! 2uclear Su%marine Communications Model
S
S
ituation,
ituation,
0hatPs going on -ith the patient
0hatPs going on -ith the patient
;
;
ac"ground,
ac"ground,
Pertinent clinical !ac"ground
Pertinent clinical !ac"ground
A
A
ssessment,
ssessment,
0hat
0hat
I
I
thin"
thin"
(
(
ecommendation, 0hat is needed @ time frame
ecommendation, 0hat is needed @ time frame
369
E%idence-ased
E%idence-ased
'ymptomatic Relief
'ymptomatic Relief
Chronic Heart Failure,
.edications Rationale
3M!
Evidence';ased Medications
Evidence';ased Medications
Counteract "F Comensator!
Counteract "F Comensator!
Mechanisms
Mechanisms
Goals,
Goals,
Pre%ent Remodeling and Progressi%e 0orsening

Pre%ent Remodeling and Progressi%e 0orsening
of >& function
of >& function
Decrease mor!idity and mortality

Decrease mor!idity and mortality
3M1
Oral Medications to
Oral Medications to
Counteract<..
Counteract<..
RAA' Inhi!itors,
RAA' Inhi!itors,

ACE IMARs
ACE IMARs
eta loc"ers
eta loc"ers
'7' Inhi!itors,
'7' Inhi!itors,
eta loc"ers
eta loc"ers

3MF
ACE Inhi%itors
ACE Inhi%itors

RAA'
RAA'




3M3




Controls HR and P
Controls HR and P
3M
Metorolol =)
Metorolol =)
Carvedilol
Carvedilol
C?PER7ICD', C?.E(
C?PER7ICD', C?.E(
;isorolol
;isorolol

(CII' II$
(CII' II$
O2)F
O2)F




Comet trial
Comet trial

3M5

Patient should !e
Patient should !e
eu+olemic
eu+olemic
inotropic
inotropic
fluid o%erload+
fluid o%erload+




3M6
Aldosterone
Aldosterone
Adapted from /(/ahon. Curr "#in $%armacol. F!!1;1:19!=196.
Oorantzopo%los et al. Med Sci Monit. F!!3;9:5A1!=5A15.
Prothrom(otic
effects
Prothrom(otic
effects
,yocardial
fi(rosis
,yocardial
fi(rosis
*dverse effects
of aldosterone
*dverse effects
of aldosterone
&/idative
stress
&/idative
stress
Endothelial
dysfunction
Endothelial
dysfunction
"ascular
inflammation
"ascular
inflammation
3MM
Aldosterone release influenced !y Angiotension II Aldosterone release influenced !y Angiotension II
Promotes salt and -ater retention, /\ and .g loss) Promotes salt and -ater retention, /\ and .g loss)
sympathetic stimulation and parasympathetic inhi!ition, sympathetic stimulation and parasympathetic inhi!ition,
!aroreceptor dysfunction, %ascular damage and impaired !aroreceptor dysfunction, %ascular damage and impaired
arterial compliance+ arterial compliance+
(A)ES: (A)ES: ('pironolactone$, ('pironolactone$, 801 801 ris" reduction in mortality ris" reduction in mortality
and and 861 861 reduction in HF admissions as compared -ith reduction in HF admissions as compared -ith
place!o) Real -orld`` Fe- on eta loc"ers place!o) Real -orld`` Fe- on eta loc"ers
EP"ESUS EP"ESUS,Eplerenone (Inspra$, post .I) ,Eplerenone (Inspra$, post .I) 761 761 ris" reduction ris" reduction
?7 current therapy HF meds) more specific) less '+E+ ?7 current therapy HF meds) more specific) less '+E+
(gynecomastia$ (gynecomastia$
Must carefull! monitor AQ levels Must carefull! monitor AQ levels

3M#
2itric O&ide
2itric O&ide


throm!osis
throm!osis
3M9
A'"eFT 7 A'"eFT 7, Protecti%e role of nitric o#ide , Protecti%e role of nitric o#ide
Additional /81 reduction in mortalit! Ehen added to Additional /81 reduction in mortalit! Ehen added to
current standard thera! : *African Americans+ current standard thera! : *African Americans+
Decreased 3 Decreased 3
st st
hospitali;ation for HF !y 55C hospitali;ation for HF !y 55C
Impro%ed W?> scores Impro%ed W?> scores
Ho- it -or"s, &asodilator, alance of arterio and Ho- it -or"s, &asodilator, alance of arterio and
%enodilation %enodilation
Hydrala;ine pre%ents degredation of n+o+ and prolongs Hydrala;ine pre%ents degredation of n+o+ and prolongs
%asodilatory effects of isosor!ide %asodilatory effects of isosor!ide
'hould !e gi%en to AA -ith HF 'hould !e gi%en to AA -ith HF
A reasona!le alternati%e for any patient -ho cannot ta"e A reasona!le alternati%e for any patient -ho cannot ta"e
ACEMARs ACEMARs
ZZZZZZZZZ ZZZZZZZZZ
3#!
S!mtom (elief
S!mtom (elief
Digo#in,
Digo#in,

effects+
effects+
2o mortalit! data
2o mortalit! data
) data on decreased
) data on decreased
hospitali;ations
hospitali;ations


Dse 5
Dse 5
rd rd
4er! )oE dose

4er! )oE dose
3#1


congesti%e HF
congesti%e HF
s!mtoms
s!mtoms
retention+
retention+


Inotroes
Inotroes
3#F
1 maFor types of &(

1 maFor types of &(
(ype 3, Premature (ype 3, Premature

%entricular contraction %entricular contraction
(P&C$ initiates (6+6C$ (P&C$ initiates (6+6C$
(ype 1, 7o P&C (ype 1, 7o P&C

(N3+4C$ (N3+4C$
Cannot predict -hich Cannot predict -hich

patients get (ype 3 %s (ype patients get (ype 3 %s (ype
1 1
*nderson 2P, et al6 *nderson 2P, et al6 " A Coll Cardiol " A Coll Cardiol6 DMMFI=B#CAM4CMB6 6 DMMFI=B#CAM4CMB6
3#3
@hat is ICD Thera!M
@hat is ICD Thera!M

O
Implanta!le Cardiac Defi!rillator
(ICD$ (herapy consists of pacing,
cardio%ersion, and defi!rillation
therapies to treat !rady and tachy
arrhythmias+
O
An e#ternal programmer is used to
monitor and access the de%ice
parameters and therapies for each
patient+
3#
Cardiac (es!nchroniBation
Thera!
Thera!
'tandard right atrial paceMsense lead implanted to

'tandard right atrial paceMsense lead implanted to
esta!lish A& synchrony
esta!lish A& synchrony
'tandard right %entricular paceMsenseMdefi!rillation

'tandard right %entricular paceMsenseMdefi!rillation
lead and left %entricular lead implanted to restore
lead and left %entricular lead implanted to restore
%entricular synchrony -ith !i%entricular pacing
%entricular synchrony -ith !i%entricular pacing
ight ventricular
lead
+eft ventricular
lead
*trial lead
3#5
ACC3A"A G006 ,uidelines for
ACC3A"A G006 ,uidelines for
C(T Thera!
C(T Thera!
Class I recommendation
Class I recommendation
.oderate to se%ere HF (7LHA Class III, or

.oderate to se%ere HF (7LHA Class III, or
am!ulatory Class I&$
am!ulatory Class I&$
>&EF a5EC
>&EF a5EC
WR' duration T312 ms

WR' duration T312 ms
For symptomatic patients despite optimal medical

For symptomatic patients despite optimal medical
therapy
therapy
Group at high risk of SCD from ventricular arrhythmia Group at high risk of SCD from ventricular arrhythmia
$unt %*, et al6 $unt %*, et al6 " A Coll Cardiol " A Coll Cardiol6 =>>FICB#eD4eA=6 6 =>>FICB#eD4eA=6
3#6
ACC3A"A "eart Failure Stages
ACC3A"A "eart Failure Stages
(ecommended Treatments
(ecommended Treatments
Stage Stage Treatment Treatment
"igh ris? for develoing heart "igh ris? for develoing heart
failure *"F+ failure *"F+
2o structural heart disease or 2o structural heart disease or
"F s!mtoms "F s!mtoms
Structural heart disease Eith no Structural heart disease Eith no
signs or s!mtoms of "F signs or s!mtoms of "F
Structural heart disease Eith Structural heart disease Eith
rior or current s!mtoms of "F rior or current s!mtoms of "F
(efractor! end'stage "F (efractor! end'stage "F
B B
C C
D D
Therapeutic lifestyle changes Therapeutic lifestyle changes
Optimize drug therapy Optimize drug therapy
Aspirin, AC inhi!itors, statins, Aspirin, AC inhi!itors, statins, " "
!lockers, !lockers, / /"!lockers #carvedilol$, "!lockers #carvedilol$,
dia!etic therapy dia!etic therapy
%CD #!ridge to transplantation$ %CD #!ridge to transplantation$
C&T C&T
Other devices #'(AD, pericardial Other devices #'(AD, pericardial
restraint) Class %% restraint) Class %%a a$ $
%CD if '(* +,-. and /01 days post" %CD if '(* +,-. and /01 days post"
2% #Class %% 2% #Class %%a a$ $
%CD #if '(* +,-., /01 days post"2%) %CD #if '(* +,-., /01 days post"2%)
reduced '(* and 34 of SCA, (* or (T$ reduced '(* and 34 of SCA, (* or (T$
C&T #if 5&S 6781 msec, '(* +,-.$ C&T #if 5&S 6781 msec, '(* +,-.$
$unt %*, et al6 $unt %*, et al6 " A Coll Cardiol& " A Coll Cardiol& =>>FICB#eD4eA=6 =>>FICB#eD4eA=6
A A
3#M
)atest ACC3A"A Treatment
)atest ACC3A"A Treatment
,uidelines
,uidelines
Ace Inhi!itors @ eta loc"ers for all 'ystolic HF

Ace Inhi!itors @ eta loc"ers for all 'ystolic HF
(unless contraindicated$ (he -riting committee
(unless contraindicated$ (he -riting committee
suggests that the !enefits of !eta !loc"ade are not a
suggests that the !enefits of !eta !loc"ade are not a
class effect and drugs e%aluated in clinical trials
class effect and drugs e%aluated in clinical trials
should !e utili;ed+
should !e utili;ed+
7e- data supporting the use of Ace Receptor

7e- data supporting the use of Ace Receptor
loc"ers in the management of systolic heart failure+
loc"ers in the management of systolic heart failure+
(he guidelines support the use of ICD in patients

(he guidelines support the use of ICD in patients
-ith >&EF a2+5E regardless of etiology+
-ith >&EF a2+5E regardless of etiology+
(a"e Home 'ummary,
3##
Ta?e "ome continued<
Ta?e "ome continued<
i-%entricular pacers should !e used in patients -ith

i-%entricular pacers should !e used in patients -ith
an EF a 2+5E, class III-I& symptoms and a WR' T
an EF a 2+5E, class III-I& symptoms and a WR' T
312 m'ec+
312 m'ec+
Aldosterone antagonists should !e started in patients

Aldosterone antagonists should !e started in patients
-ith moderate-se%ere symptoms and reduced >&EF
-ith moderate-se%ere symptoms and reduced >&EF
as long as the patient can !e monitored for
as long as the patient can !e monitored for
hyper"alemia+
hyper"alemia+
Hydrala;ine and nitrates can !e added on to standard

Hydrala;ine and nitrates can !e added on to standard
medical therapy in African-Americans or others -ith
medical therapy in African-Americans or others -ith
residual symptoms or used in patients -ith
residual symptoms or used in patients -ith
intolerance to ACE-I or ARs+
intolerance to ACE-I or ARs+
3#9
;ac? to the Case Stud!<..
;ac? to the Case Stud!<..
0hat 7LHA Class of HF`

0hat 7LHA Class of HF`
0hat ACC M AHA 'tage``

0hat ACC M AHA 'tage``
39!
$ypertension
+eft "entricular
$ypertrophy
.iastolic
.ysfunction
Post4,-
emodeling
,yocardial -schemia
*symptomatic
+eft "entricular
.ysfunction
.ia(etes
.yslipidemia
Coronary *rtery .isease
&ther C". isk 0actors
Ice%erg
Ice%erg
"FSA G070
"FSA G070
Comrehensive "eart
Comrehensive "eart
Failure Practice
Failure Practice
,uideline
,uideline
/ey Recommendations
/ey Recommendations

is recommended
is recommended
as
as
)4EF:
)4EF:
2F"A III or I4 "F

2F"A III or I4 "F trength of )+idence > A trength of )+idence > A
2F"A II "F
2F"A II "F trength of )+idence > ? trength of )+idence > ?
Diuretic thera!
Diuretic thera!
is recommended
is recommended
to restore and
to restore and
manifested %!:
manifested %!:
Congestive s!mtoms
Congestive s!mtoms

)oo diuretics
)oo diuretics

trength trength
of )+idence > ? of )+idence > ?
)oo Diuretics
)oo Diuretics
Dose Dose
Ma& Total Ma& Total
Action Action
%id %id
900 mg 900 mg 961('861M 961('861M /'9 hrs /'9 hrs
or %id or %id
acid acid
or %id or %id
Dose Dose
Ma& Total Ma& Total
Elimination Elimination Duration Duration
of Action of Action
Sironolactone Sironolactone 7G.6'G6 mg 7G.6'G6 mg
Hd Hd
60 mg 60 mg Meta%olic Meta%olic /J'KG hrs /J'KG hrs
Elerenone Elerenone G6'60 mg Hd G6'60 mg Hd 700 mg 700 mg (enal# (enal#
Meta%olic Meta%olic
Un?noEn Un?noEn
Amiloride Amiloride 6 mg Hd 6 mg Hd G0 mg G0 mg (enal (enal G/ hrs G/ hrs
Triamterene Triamterene 60'K6 mg 60'K6 mg
%id %id
G00 mg G00 mg Meta%olic Meta%olic K'P hrs K'P hrs
Device Thera!:
Device Thera!:
Proh!lactic ICD lacement Proh!lactic ICD lacement should %e considered should %e considered in atients in atients
Eith an )4EF Y861 and mild to moderate "F s!mtoms: Eith an )4EF Y861 and mild to moderate "F s!mtoms:

Ischemic etiolog! Ischemic etiolog! trength of )+idence > A trength of )+idence > A
2on'ischemic etiolog! 2on'ischemic etiolog! trength of )+idence > ? trength of )+idence > ?
In atients Eho are undergoing imlantation of a In atients Eho are undergoing imlantation of a
%iventricular acing device# use of a device that rovides %iventricular acing device# use of a device that rovides
defi%rillation defi%rillation should %e considered. should %e considered. trength of )+idence > ? trength of )+idence > ?
Decisions should %e made in light of functional status and Decisions should %e made in light of functional status and
rognosis %ased on severit! of underl!ing "F and comor%id rognosis %ased on severit! of underl!ing "F and comor%id
conditions# ideall! after 8'9 mos. of otimal medical thera!. conditions# ideall! after 8'9 mos. of otimal medical thera!.
Adapted from:
"FSA G070 Practice ,uideline *P.K+
"FSA G070 Practice ,uideline *P.K+
Device Thera!:
Device Thera!:
;iventricular acing thera!

;iventricular acing thera!
is recommended
is recommended
for
for
atients Eith
atients Eith
all of the follo6ing
all of the follo6ing
:
:
Sinus rh!thm
Sinus rh!thm
A Eidened V(S interval *[7G0 ms+

A Eidened V(S interval *[7G0 ms+
Severe )4 s!stolic d!sfunction *)4EF

Severe )4 s!stolic d!sfunction *)4EF
.
.

861+
861+
Persistent# moderate'to'severe "F *2F"A

Persistent# moderate'to'severe "F *2F"A
III+ desite otimal medical thera!.
III+ desite otimal medical thera!.
trength of trength of
)+idence > A )+idence > A
Diagnosis
Diagnosis
Careful attention to differential diagnosis Careful attention to differential diagnosis is is

recommended recommended in atients Eith "F and reserved in atients Eith "F and reserved
)4EF. )4EF.
Treatments ma! differ %ased on cardiac disorder. Treatments ma! differ %ased on cardiac disorder.
Evaluation for ischemic disease and induci%le Evaluation for ischemic disease and induci%le
m!ocardial ischemia should %e included. m!ocardial ischemia should %e included.
(ecommended diagnostic tools: (ecommended diagnostic tools:
Echocardiograh! Echocardiograh!
Electrocardiograh! Electrocardiograh!
Stress imaging *via e&ercise or harmacologic means# using Stress imaging *via e&ercise or harmacologic means# using
m!ocardial erfusion or echocardiograhic imaging+ m!ocardial erfusion or echocardiograhic imaging+
Cardiac catheteriBation Cardiac catheteriBation

Adapted from:
$0 'ith
Preserved +"E0
.ilated +" Non4dilated +"
"alvular disease
*, ,
No valvular dis6
$igh output $0
-ncreased
thickness
Normal
Thickness
ight vent6
dysfunction
Pulmonary
hypertension
-solated pre4
dominant ",-
No mitral
o(struction
,itral o(struction
,%, atrial my/oma
Pericardial dis6
Tamponade
Constriction
No pericardial
disease
-nduci(le ischemia
-ntermittent<active
ischemia
Normal or
increased @%
$ypertrophic dis6
+o' @% voltage
-nfiltrative
myopathy
No aortic
valve disease
*ortic valve dis6
*ortic stenosis
No hypertensive
history of PE
$C,, 0a(ry dis6
$ypertensive
history of PE
$ypertensive4$C,
%ome patients 'ith "
dysfunction have +"
dysfunction due to
ventricular interaction6
No induci(le ischemia, fi(rotic, collagen4
"ascular, C,, cardinoid, dia(etes,
adiation or chemotherapy induced
heart disease, infiltrative disease, co4
mor(id conditions, reconsider diagnosis
of $0
HF'A 1232 Practice Guideline (31+5, (a!le 31+5$ HF'A 1232 Practice Guideline (31+5, (a!le 31+5$

C
C
Impro%e symptoms, especially congestion and lo--output Impro%e symptoms, especially congestion and lo--output
symptoms symptoms
?ptimi;e %olume status ?ptimi;e %olume status
Identify etiology Identify etiology
Identify precipitating factors Identify precipitating factors
?ptimi;e chronic oral therapy) minimi;e side effects ?ptimi;e chronic oral therapy) minimi;e side effects
Identify -ho might !enefit from re%asculari;ation Identify -ho might !enefit from re%asculari;ation
Education patients concerning medication and HF self-assessment Education patients concerning medication and HF self-assessment
Consider enrollment in a disease management program Consider enrollment in a disease management program





S
S

Inotropes
Inotropes
S
S
Predictors of Mortalit! ;ased on
Predictors of Mortalit! ;ased on
Anal!sis of AD"E(E Data%ase
Anal!sis of AD"E(E Data%ase
Classification and Regression (ree (CAR($ analysis of Classification and Regression (ree (CAR($ analysis of
ADHERE data sho-s, ADHERE data sho-s,
(hree %aria!les are the strongest predictors of mortality in (hree %aria!les are the strongest predictors of mortality in
hospitali;ed ADHF patients, hospitali;ed ADHF patients,
B9N P CE mg<d+
%ystolic (lood pressure Q DDF mm$g
%erum creatinine P =6HF mg<d+
B9N P CE mg<d+
%ystolic (lood pressure Q DDF mm$g
%erum creatinine P =6HF mg<d+
0onaro' GC et al6 ;*,* =>>FI=ME#FH=4A>
Evidence';ased Treatment Across the
Evidence';ased Treatment Across the
Continuum of S!stolic )4D and "F
Continuum of S!stolic )4D and "F
Control "olume
-mprove Clinical &utcomes
.iuretics
enal eplacement
TherapyR
.igo/in
4Blocker
*CE-
or *B
*ldosterone
*ntagonist
or *B
Treat esidual %ymptoms
CT
an -C.R
$.SN<-%.NR
R-n selected patients
Heart Failure .anagement
Heart Failure .anagement
Applying the ACCMAHA
Applying the ACCMAHA
Chronic Heart Failure
Chronic Heart Failure
Guidelines
Guidelines

The Core
The Core
O
Basic management
O
Stage C
O
Beta blockers
O
ACE inhibitors
O
ARB
O
Aldosterone blocker
O
Diuretics
O
Digoxin
O
Hydralazine/Nitrate
O
Deices
O
!notro"ic agents
O
Re#ractory H$
O
Stage D
O
%rans"lantation
O
Subgrou"s
O
H$ &ith normal '(E$
The Core
The Core
Congestive "eart
Congestive "eart
Failure
Failure
O%-ectives
O%-ectives
Definition and Epidemiology

Definition and Epidemiology
Pathophysiology
Pathophysiology
Diagnosis and Classification

Diagnosis and Classification
(reatment of 'ystolic Dysfunction

(reatment of 'ystolic Dysfunction
.edical (herapy
.edical (herapy
De%ice (herapy
De%ice (herapy
@hat is C"FM
@hat is C"FM
2efinition
2efinition
A!normality of cardiac function that leads to the

A!normality of cardiac function that leads to the
ina!ility of the heart to pump !lood to meet the
ina!ility of the heart to pump !lood to meet the
!odyPs !asic meta!olic demands or -hen it can do so
!odyPs !asic meta!olic demands or -hen it can do so
only -ith an ele%ated filling pressure
only -ith an ele%ated filling pressure
Eidemiolog!
Eidemiolog!
Prevalence Prevalence
Affects nearly E million Americans currently, TE22,222 ne- cases diagnosed each year Affects nearly E million Americans currently, TE22,222 ne- cases diagnosed each year
Cost Cost
Annual direct cost in T32 !illion dollars Annual direct cost in T32 !illion dollars
Incidence increased Eith age Incidence increased Eith age
Effects 3-1C of patient from E2-EN-years-old and 32C of patient o%er the age of IE Effects 3-1C of patient from E2-EN-years-old and 32C of patient o%er the age of IE
FreHuenc! FreHuenc!
It is the most common inpatient diagnosis in the D' for patients o%er 6E years of age It is the most common inpatient diagnosis in the D' for patients o%er 6E years of age
&isits to their family practitioner on a%erage 1-5 times per year &isits to their family practitioner on a%erage 1-5 times per year
,ender ,ender
.enT -omen in those !et-een B2 and IE years of age .enT -omen in those !et-een B2 and IE years of age
(he se#es are eVual o%er IE years of age (he se#es are eVual o%er IE years of age
Pathoh!siolog! of "eart Failure
Pathoh!siolog! of "eart Failure
Hemodynamic .odel
Hemodynamic .odel
7eurohumoral Adaptations
7eurohumoral Adaptations
^
^
dou!le-edged s-ords_
dou!le-edged s-ords_
Renin-Angiotensin-Aldosterone 'ystem
Renin-Angiotensin-Aldosterone 'ystem
'ympathetic 7er%ous 'ystem

'ympathetic 7er%ous 'ystem
Antidiuretic Hormone
Antidiuretic Hormone
Atrial and -type 7atriuretic Peptides

Atrial and -type 7atriuretic Peptides
Endothelin
Endothelin
"el initiall!
"el initiall!
&asoconstriction
&asoconstriction
Redistri!utes !lood to %ital organs

Redistri!utes !lood to %ital organs
Restoration of Cardiac ?utput

Restoration of Cardiac ?utput
Increased myocardial contractility and heart rate

Increased myocardial contractility and heart rate
E#pansion of the e#tracellular fluid %olume

E#pansion of the e#tracellular fluid %olume
2eurohumoral'(AAS
2eurohumoral'(AAS
"urt long'term
"urt long'term
Preciitating Causes
Preciitating Causes
Common Common
CAD (I2C$ CAD (I2C$
'ystemic Hypertension 'ystemic Hypertension
Idiopathic Idiopathic
)ess Common )ess Common
Dia!etes .ellitus Dia!etes .ellitus
&al%ular Disease &al%ular Disease
(are (are
Anemia Anemia
Connecti%e (issue Disease Connecti%e (issue Disease
&iral .yocarditis &iral .yocarditis
Hemochromatosis Hemochromatosis
HI& HI&
HyperMHypothyroidism HyperMHypothyroidism
Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy
Infiltrati%e Disease including Infiltrati%e Disease including

amyloidosis and sarcoidosis amyloidosis and sarcoidosis
.ediastinal radiation .ediastinal radiation
Peripartum cardiomyopathy Peripartum cardiomyopathy
Restricti%e pericardial disease Restricti%e pericardial disease
(achyarrhythmias (achyarrhythmias
(o#ins (o#ins
(rypanosomiasis (ChagasP disease$ (rypanosomiasis (ChagasP disease$

Diastolic dysfunction Diastolic dysfunction
EF normal or increased EF normal or increased
Due to chronic replacement fi!rosis @ Due to chronic replacement fi!rosis @

ischemia-induced decrease in distensi!ility ischemia-induced decrease in distensi!ility
'ystolic dysfunction 'ystolic dysfunction
EF A B2C EF A B2C
Dsually from coronary disease Dsually from coronary disease
Due to ischemia-induced decrease in Due to ischemia-induced decrease in

contractility contractility
.ost common is a com!ination of !oth .ost common is a com!ination of !oth

Su%t!es of S!stolic "eart
Su%t!es of S!stolic "eart
Failure
Failure
High output
High output
'e%ere anemia 'e%ere anemia
A& malformations A& malformations
hyperthyroidism hyperthyroidism
>o- cardiac output

>o- cardiac output
Right Heart Failure

Right Heart Failure
Peripheral edema Peripheral edema
>eft Heart Failure

>eft Heart Failure
Pulmonary congestion Pulmonary congestion
i%entricular Failure
i%entricular Failure
'ystemic and pulmonary 'ystemic and pulmonary

congestion congestion
Evaluation
Evaluation
History, ris" factors for ischemic heart disease,

History, ris" factors for ischemic heart disease,
family history
family history
Physical e#am, '5, U&D more specific signs of

Physical e#am, '5, U&D more specific signs of
HF than rales, peripheral edema
HF than rales, peripheral edema
E&am
E&am
.aFor Criteria
.aFor Criteria
Paro#ysmal nocturnal Paro#ysmal nocturnal

dyspnea dyspnea
7ec" &ein Distention 7ec" &ein Distention
Rales Rales
Cardiomegaly Cardiomegaly
Pulmonary Edema Pulmonary Edema
'5 Gallop '5 Gallop
HepatoFugular Refle# HepatoFugular Refle#
.inor Criteria
.inor Criteria
An"le edema An"le edema
7octurnal Cough 7octurnal Cough
Dyspnea on ordinary Dyspnea on ordinary

e#ertion e#ertion
Hepatomegaly Hepatomegaly
Pleural Effusion Pleural Effusion
(achycardia T312!pm (achycardia T312!pm

Confirming the Presence of
Confirming the Presence of
"eart Failure
"eart Failure
CHR-cardiomegaly and pulmonary edema)
CHR-cardiomegaly and pulmonary edema)
/erleyPs >ines
/erleyPs >ines
>a!oratory &alues
>a!oratory &alues
7P
7P
.ay!e inc !y age, female gender, CRI, pulm

.ay!e inc !y age, female gender, CRI, pulm
disease, hyperthyroid, o!esity, steroid use
disease, hyperthyroid, o!esity, steroid use
ElectrocardiogramMECH?
ElectrocardiogramMECH?
Anterior W -a%es, >, >&H

Anterior W -a%es, >, >&H
2egative Prognostic Factors
2egative Prognostic Factors
Clinical
Clinical
Increased Age, Dia!etes, 'mo"ing Increased Age, Dia!etes, 'mo"ing
>a!oratory
>a!oratory
Hyponatremia, Ele%ated neurohormones Hyponatremia, Ele%ated neurohormones
Hemodynamic
Hemodynamic
Reduced EF, Increased Pulm Cap 0edge Pressure Reduced EF, Increased Pulm Cap 0edge Pressure
Electrophysiological
Electrophysiological
A-fi!, A-flutter, &entricular ectopy, &-tach A-fi!, A-flutter, &entricular ectopy, &-tach
Classification of "eart Failure: ACC3A"A Stage vs 2F"A Class Classification of "eart Failure: ACC3A"A Stage vs 2F"A Class
'ystolic HF
'ystolic HF
Preload
Preload
Afterload
Afterload
Ionotropy
Ionotropy
7eurohumoral
7eurohumoral

acti%ity
acti%ity
and aldosterone
and aldosterone
antagonist are the
antagonist are the
Treatment of S!stolic "eart
Treatment of S!stolic "eart
Failure
Failure
ACE Inhi!itors-
ACE Inhi!itors-
0or"s to inhi!it the o%er stimulation of the RA' that leads 0or"s to inhi!it the o%er stimulation of the RA' that leads
to myocardial hypertrophy and fi!rosis to myocardial hypertrophy and fi!rosis
Causes !alanced %asodilation Causes !alanced %asodilation
Decrease the rate of mor!idity @ mortality in all pts -ith Decrease the rate of mor!idity @ mortality in all pts -ith
systolic heart failure systolic heart failure
-If treating acute HF, can start after P tolerates and -If treating acute HF, can start after P tolerates and
pulmonary edema is relie%ed pulmonary edema is relie%ed
ACE'I
ACE'I
'?>&D-Enalapril '?>&D-Enalapril
12mgMday (B3 mo$ 12mgMday (B3 mo$
1E6N Patients -ith and 1E6N Patients -ith and

EF A5EC EF A5EC
Earlier stages of HF e%en Earlier stages of HF e%en

asymptomatic asymptomatic
7LHA Class II-III 7LHA Class II-III
All cause mortality dec All cause mortality dec

!y 36C !y 36C
.orality rate from HF .orality rate from HF

dec !y 36C dec !y 36C
C?7'E7'D'-Enalapril C?7'E7'D'-Enalapril
1+E-B2mg (344 days$ %s 1+E-B2mg (344 days$ %s
place!o place!o
Pts -ere already ta"ing Pts -ere already ta"ing

digo#in and diuretics digo#in and diuretics
1E5 Patient -ith 7LHA 1E5 Patient -ith 7LHA

Class I& Class I&
Dec mortality at, Dec mortality at,
6 months -B2C 6 months -B2C
3 Lear K 1IC 3 Lear K 1IC

Angiotensin'(ecetor ;loc?ers
Angiotensin'(ecetor ;loc?ers
Compara!le to ACE inhi!itors

Compara!le to ACE inhi!itors
Reduce all-cause mortality

Reduce all-cause mortality
'uita!le alternati%e for patient -ith ad%erse e%ents

'uita!le alternati%e for patient -ith ad%erse e%ents
(angioedema, cough, hyper"alemia$ occur -ith
(angioedema, cough, hyper"alemia$ occur -ith
ace-i
ace-i
;eta';loc?ers
;eta';loc?ers
5BC reduction in all mortality -ith use

5BC reduction in all mortality -ith use
of !eta-!loc"ers
of !eta-!loc"ers
Decrease Cardiac 'ympathetic Acti%ity Decrease Cardiac 'ympathetic Acti%ity
Dse in sta!le, chronic disease (start as early Dse in sta!le, chronic disease (start as early
as discharge-I.PAC(-HF$ as discharge-I.PAC(-HF$
(itrate slo-ly (itrate slo-ly
Contraindications-!radycardia, heart !loc" or Contraindications-!radycardia, heart !loc" or

hemodynamic insta!ility hemodynamic insta!ility
.ild asthma -as not a contraindication .ild asthma -as not a contraindication
0or" irrespecti%e of the etiology of the heart 0or" irrespecti%e of the etiology of the heart
failure failure
;eta'
;eta'
%loc?er thera!'Ehich to ic?M
%loc?er thera!'Ehich to ic?M
(hree !eta-!loc"ers , (hree !eta-!loc"ers ,
isoprolol (be!eta$ -(rial CII'-II isoprolol (be!eta$ -(rial CII'-II

.etoprolol ((oprol H>$ K(rial .ERI(-HF (sustained release$ .etoprolol ((oprol H>$ K(rial .ERI(-HF (sustained release$
Car%edilol (Coreg$ (rial-C?PER7ICD' Car%edilol (Coreg$ (rial-C?PER7ICD'
6 RC(Ps -ith T N,222 pts already ta"ing ACE-I sho-ed a significant reduction in 6 RC(Ps -ith T N,222 pts already ta"ing ACE-I sho-ed a significant reduction in
total mortality and sudden death (77( 1B, and 5E o%er 3-1 years$ regardless of total mortality and sudden death (77( 1B, and 5E o%er 3-1 years$ regardless of
se%erity se%erity
Carvedilol vs. Metorolol *COMET G008+ Carvedilol vs. Metorolol *COMET G008+
80GP tsS carvedilol G6mg %id vs. metorolol 60 80GP tsS carvedilol G6mg %id vs. metorolol 60 mg %id mg %id
Patient -ith 7LHA Classes II-I& Patient -ith 7LHA Classes II-I&
Car%edilol Kgreater reduction in mortality (77(, 34 o%er E years$ and Car%edilol Kgreater reduction in mortality (77(, 34 o%er E years$ and
cardio%ascular mortality (77(, 36 o%er E years$ than metoprolol !ut cardio%ascular mortality (77(, 36 o%er E years$ than metoprolol !ut
hypotension -as greater in car%edilol (3B %s 33 percent$ hypotension -as greater in car%edilol (3B %s 33 percent$
'pironolactone (Aldactone)
'pironolactone (Aldactone) RA>E' RA>E'
3NNN$
3NNN$
Pts 3,665 Class IIIMI&, ACE, >oop,Dig, EF A 5EC Pts 3,665 Class IIIMI&, ACE, >oop,Dig, EF A 5EC
Decreased all cause mortality of 52C, 77([32 Decreased all cause mortality of 52C, 77([32
Hyper"alemia, gynecomastia Hyper"alemia, gynecomastia
Eplerenone (Inspra)
Eplerenone (Inspra) EPHE'D' 1225 EPHE'D' 1225
$
$
Pts 6,6B1 asym >& dysfunction, D., or after .I Pts 6,6B1 asym >& dysfunction, D., or after .I
Dec C& mortality of 35C, 77([B5 Dec C& mortality of 35C, 77([B5
7e-er more selecti%e inhi!itor) fe-er side effects 7e-er more selecti%e inhi!itor) fe-er side effects
.ore pts on !eta-!loc"ers .ore pts on !eta-!loc"ers

"!dralaBine *Aresoline+ and
isosor%ide dinitrate *Sor%itrate+
Hydrala;ine Hydrala;ine
Reduces systemic %ascular resistance !y preferentially dilating Reduces systemic %ascular resistance !y preferentially dilating
arterioles arterioles
Isosor!ide Dinitrate Isosor!ide Dinitrate
Preferential &enodilator-reduces %entricular filling pressure Preferential &enodilator-reduces %entricular filling pressure
and treat pulmonary congestion and treat pulmonary congestion
Reduces mortality K upto 14C Reduces mortality K upto 14C
Poor tolera!ility-T52C drop out of study Poor tolera!ility-T52C drop out of study
flushing, headaches, gi upset, less freVuently can cause flushing, headaches, gi upset, less freVuently can cause
positi%e A7A titers and lupus-li"e syndrome positi%e A7A titers and lupus-li"e syndrome
African-American Heart Failure (rial (A-

African-American Heart Failure (rial (A-
HeF($
HeF($
ad%anced HF and a fi#ed dose of isosor!ide

ad%anced HF and a fi#ed dose of isosor!ide
dinitrate and hydrala;ine
dinitrate and hydrala;ine
Added to 'tandard -!loc"erMAce-I therapy

Added to 'tandard -!loc"erMAce-I therapy
'ome sur%i%al impro%ement

'ome sur%i%al impro%ement
Digo&in
Digo&in
.ay relie%e symptoms, does not reduce

.ay relie%e symptoms, does not reduce
mortality
mortality
Pts ta"ing digo#in are less li"ely to !e

Pts ta"ing digo#in are less li"ely to !e
hospitali;ed (1EC reduction$
hospitali;ed (1EC reduction$
.ore admissions for suspected digo#in

.ore admissions for suspected digo#in
to#icity
to#icity
)oo Diuretics
)oo Diuretics
.ainstay of symptomatic treatment

.ainstay of symptomatic treatment
Impro%e fluid retention

Impro%e fluid retention
Increase e#ercise tolerance

Increase e#ercise tolerance
7o effects on mor!idity or mortality

7o effects on mor!idity or mortality
Antilatelet Thera! and
Antilatelet Thera! and
Anticoagulation
Anticoagulation
Increased ris" of (hrom!oem!olic e%ents, 3+6-

Increased ris" of (hrom!oem!olic e%ents, 3+6-
5+1C per year
5+1C per year
Antiplatelet therapy (aspirin$ in not useful in

Antiplatelet therapy (aspirin$ in not useful in
patient in sinus rhythm
patient in sinus rhythm
Coumadin for patient -ith atrial fi!rillation or

Coumadin for patient -ith atrial fi!rillation or
a pre%ious throm!oem!olic e%ent
a pre%ious throm!oem!olic e%ent
2esiritide *2atrecor+
2esiritide *2atrecor+
Recom!inant form of human 7P

Recom!inant form of human 7P
Causes %enous and arterial %asodilation

Causes %enous and arterial %asodilation
has !een sho-n to impro%e dyspnea and glo!al

has !een sho-n to impro%e dyspnea and glo!al
assessments at 5 hours after initiation in pts -ith
assessments at 5 hours after initiation in pts -ith
Acute HF+
Acute HF+
Ris"s- deleterious effect on renal function and

Ris"s- deleterious effect on renal function and
decreased 52 day sur%i%al
decreased 52 day sur%i%al
2onharmacological
2onharmacological
Management
Management
'odium Restriction to 1gMday 'odium Restriction to 1gMday
Ris" Factor .anagement Ris" Factor .anagement
E#ercise E#ercise
Decreases mortality (77([B$ Decreases mortality (77([B$
Decreases hospitali;ations (77([E$ Decreases hospitali;ations (77([E$
.ultidisciplinary, Disease-.anagement Approach .ultidisciplinary, Disease-.anagement Approach
CHA.P K Cardio%ascular Hospital Atherosclerosis .anagement CHA.P K Cardio%ascular Hospital Atherosclerosis .anagement
Program Program
A'A, !eta-!loc"er, 7itrates, ACE-I, 'tatin, E#ercise, 'mo"ing A'A, !eta-!loc"er, 7itrates, ACE-I, 'tatin, E#ercise, 'mo"ing
Cessation, Dietary counseling (use increased !y 42C$ Cessation, Dietary counseling (use increased !y 42C$
Device Thera!
Device Thera!



ICD
ICD
'CD-HeF( (sudden cardiac death$

'CD-HeF( (sudden cardiac death$
1E13 patients -ith depressed >& systolic function

1E13 patients -ith depressed >& systolic function
and Class II-III HF
and Class II-III HF
Randomi;ed to standard therapy %s+ standard therapy

Randomi;ed to standard therapy %s+ standard therapy
plus ICD %s+ standard therapy plus amiodarone
plus ICD %s+ standard therapy plus amiodarone
15C reduction in mortality -ith ICD

15C reduction in mortality -ith ICD
7o difference in mortality -ith amiodarone

7o difference in mortality -ith amiodarone
Results did not %ary !ased on etiology of >&

Results did not %ary !ased on etiology of >&
dysfunction
dysfunction
ICD
ICD
Recommended in pts -ith EFA52C and mild

Recommended in pts -ith EFA52C and mild
to moderate symptoms of HF
to moderate symptoms of HF
'ur%i%al -ith good functional capacity is

'ur%i%al -ith good functional capacity is
anticipated for T 3 year
anticipated for T 3 year
*)4AD+
*)4AD+
RE.A(CH (rial- RE.A(CH (rial-
3 yr sur%i%al E1C (>&AD$ 3 yr sur%i%al E1C (>&AD$

%s 1BC (r#$ %s 1BC (r#$
1 yr sur%i%al 15C %s 4C 1 yr sur%i%al 15C %s 4C
End-'tage (Class I&$ End-'tage (Class I&$
HF pts ineligi!le for HF pts ineligi!le for

transplant due to, transplant due to,
T6Eyo T6Eyo
D. -ith E?D D. -ith E?D
CRI CRI
Diastolic D!sfunction
Acute .anagement is the 'A.E

Acute .anagement is the 'A.E
Chronic .anagement is C?7(R?&ER'IA>

Chronic .anagement is C?7(R?&ER'IA>
Diuretics-dec fluid %olume Diuretics-dec fluid %olume
CC-promote left %entricular rela#ation CC-promote left %entricular rela#ation
ACE-I-promote regression of left %entricular hypertrophy ACE-I-promote regression of left %entricular hypertrophy
eta-!loc"ersMantiarrhytmic agents-control heart rate or eta-!loc"ersMantiarrhytmic agents-control heart rate or

maintain atrial contraction maintain atrial contraction
Pathophysiology of chronic heart failure6
amani G " et al6 ,ayo Clin Proc6 =>D>IAF#DA>4DMF
P F!1! /a)o +o%ndation for /edi(al *d%(ation and 5esear(h

"eart Failure
"eart Failure
Treatment.
Treatment.
Blocing the .AA" and "ympathetic 8ervous system Blocing the .AA" and "ympathetic 8ervous system
loc"ing se%eral neurohormonal M cyto"ine systems loc"ing se%eral neurohormonal M cyto"ine systems
Enhancing compensatory mechanisms in acute heart Enhancing compensatory mechanisms in acute heart
failure) 7P failure) 7P
loc"ing meta!olic path-ays loc"ing meta!olic path-ays
(reating concomitant pro!lems (reating concomitant pro!lems
De%ices and mechanical support De%ices and mechanical support
'urgical reconstruction 'urgical reconstruction
Pharmacogenomics Pharmacogenomics
.irections in $eart 0ailure
Therapy
Therapy
loc"ing the RAA' and 'ympathetic 7er%ous loc"ing the RAA' and 'ympathetic 7er%ous
system system
Blocing several neurohormonal 9 cytoine systems Blocing several neurohormonal 9 cytoine systems
Therapy
Therapy
Does inhibition of BNP degradation (when coupled to ACE
inhibition) with omapatrilat improve survival?
Packer et al, Circulation 2002
&"ET9E# *CE<NEP -nhi(itors
&"ET9E# *CE<NEP -nhi(itors
in $eart 0ailure
in $eart 0ailure
&mapatrilat &mapatrilat
Enalapril Enalapril
P=0.187 P=0.187
% Event Free Survival % Event Free Survival
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
0.0 0.0
0 0 3 3 6 6 9 9 12 12 15 15 18 18 21 21 24 24
Months Months
Etanercept %urvival %tudy (ENE8*+)
Etanercept %urvival %tudy (ENE8*+)
(n=1500)
Mann et al, HFSA 2002
> C A D= DB => =C =B E= EB C> CC CA F= > C A D= DB => =C =B E= EB C> CC CA F= FB B> BC BA H= HB A> AC AA M= MB FB B> BC BA H= HB A> AC AA M= MB
Event Event4 4free survival G free survival G
8eeks 8eeks
Place(o Place(o
Etanercept Etanercept (i' (i' K ti' K ti'
T D6D> T D6D>
MFG C-# >6MD MFG C-# >6MD4 4D6EE D6EE
P T >6EE P T >6EE
Primary End Primary End- -Point (Death or CHF Hospitalization) Point (Death or CHF Hospitalization)
D>> D>>
A> A>
B> B>
C> C>
=> =>
> >
D>> D>>
A> A>
B> B>
C> C>
=> =>
> >
(n=1500)
Packer et al, ACC Late-Breaking Trials 2002
EN*B+E - L --# (osentan (ET
EN*B+E - L --# (osentan (ET
* *
K ET
K ET
B B
*ntagonist) -
*ntagonist) -
n $eart 0ailure (nTD,BDE)
n $eart 0ailure (nTD,BDE)
A>C A>C BA> BA> BDF BDF FHE FHE FC= FC= F>= F>= EME EME =EA =EA D=E D=E DB DB
> >
A>H A>H H=E H=E BFF BFF BDE BDE FHH FHH FD= FD= EAA EAA ==M ==M DDE DDE DM DM
> >
No6 at isk# No6 at isk#
D>> D>>
M> M>
A> A>
H> H>
B> B>
F> F>
C> C>
E> E>
=> =>
D> D>
> >
> > DE DE =B =B EM EM F= F= BF BF HA HA MD MD D>C D>C DDH DDH DE> DE>
Bosentan Bosentan
Place(o Place(o
+og rank p4value# >6AMAB +og rank p4value# >6AMAB
G of Patients (Event40ree from death<$0 hosp) G of Patients (Event40ree from death<$0 hosp)
Weeks from Weeks from
an!omi"ation an!omi"ation
system system
failure& B84 failure& B84
Therapy
Therapy
;amieson and Palade ; Cell Biol DMBCI=E#DFD ;amieson and Palade ; Cell Biol DMBCI=E#DFD
*trial<ventricular stretch *trial<ventricular stretch
receptors link (lood volume receptors link (lood volume
to renal function to renal function
$
.istension of a (alloon catheter in .istension of a (alloon catheter in
atria of dogs resulted in diuresis atria of dogs resulted in diuresis
"
$enry, et al6 (DMFB) $enry, et al6 (DMFB)
$
%ecretory granules discovered in %ecretory granules discovered in
the atria the atria
"
2isch (DMFB) 2isch (DMFB)
"
;amieson and Palade (DMBC) ;amieson and Palade (DMBC)
$
de Bold, et al (DMAD) report de Bold, et al (DMAD) report
natriuresis natriuresis
in rats after in1ection of atrial in rats after in1ection of atrial
e/tracts e/tracts
$
BNP 'as characteri5ed (y amino BNP 'as characteri5ed (y amino
acid seOuence and .N* clones acid seOuence and .N* clones
"
(%udoh, et al6 DMAA and (%udoh, et al6 DMAA and
%eilhamer, et al6 DMAM)6 %eilhamer, et al6 DMAM)6
2atriuretic Petides:
2atriuretic Petides:
The "eart as a Secretor! Organ
The "eart as a Secretor! Organ
Gly Gly
Phe Phe
Ser Ser
Leu Leu
Arg Arg
Arg Arg
Ser Ser
Ser Ser
Cys Cys
HOOC HOOC
Asn Asn
Gly Gly
H H
2 2
N N
7 7
23 23
Arg Arg
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Gin Gin
Met Met
Asp Asp
Arg Arg
Ile Ile
Gly Gly
Ala Ala
Ser Ser
Phe Phe
Arg Arg
Tyr Tyr
1 1
5 5
10 10
15 15
20 20
25 25
28 28
Ser Ser
Pro Pro
Lys Lys
Met Met
Val Val
Gin Gin
Gly Gly
Ser Ser
Phe Phe
Lys Lys
Gly Gly
Gly Gly
Cys Cys
Arg Arg
Ser Ser
Lys Lys
Met Met
Asp Asp
H H
2 2
N N
10 10
26 26
Arg Arg
Ile Ile
Ser Ser
Ser Ser
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Val Val
Leu Leu
Arg Arg
Arg Arg
His His
32 32
30 30
25 25
20 20
15 15
5 5
1 1
HOOC HOOC
Gly Gly
Leu Leu
Ser Ser
Lys Lys
Phe Phe
Gly Gly
Leu Leu
Lys Lys
Leu Leu
Gly Gly
Asp Asp
Arg Arg
Ile Ile
H H
2 2
N N
HOOC HOOC
6 6
22 22
Gly Gly
Ser Ser
Cys Cys
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Met Met
1 1
5 5
10 10
15 15
20 20
$ .iuretic
$ Natriuretic
$ "ascular rela/ation
$ -nhi(ition of **%, %N%
$ *tria
$ %ame actions as *NP
$ -n atria and ventricles
$ +onger D<= life
$ E/cellent marker
$ 9sed as therapy
$ No natriuresis
or diuresis
$ Potent vasodilator
ANP
BNP
CNP
.
i
u
r
e
t
i
c
.
i
u
r
e
t
i
c
n
a
t
r
i
u
r
e
t
i
c
n
a
t
r
i
u
r
e
t
i
c
Family of Natriuretic Peptides
Gly Gly
Phe Phe
Ser Ser
Leu Leu
Arg Arg
Arg Arg
Ser Ser
Ser Ser
Cys Cys
HOOC HOOC
Asn Asn
Gly Gly
H H
2 2
N N
7 7
23 23
Arg Arg
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Gin Gin
Met Met
Asp Asp
Arg Arg
Ile Ile
Gly Gly
Ala Ala
Ser Ser
Phe Phe
Arg Arg
Tyr Tyr
1 1
5 5
10 10
15 15
20 20
25 25
28 28
Ser Ser
Pro Pro
Lys Lys
Met Met
Val Val
Gin Gin
Gly Gly
Ser Ser
Phe Phe
Lys Lys
Gly Gly
Gly Gly
Cys Cys
Arg Arg
Ser Ser
Lys Lys
Met Met
Asp Asp
H H
2 2
N N
10 10
26 26
Arg Arg
Ile Ile
Ser Ser
Ser Ser
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Val Val
Leu Leu
Arg Arg
Arg Arg
His His
32 32
30 30
25 25
20 20
15 15
5 5
1 1
HOOC HOOC
Gly Gly
Leu Leu
Ser Ser
Lys Lys
Phe Phe
Gly Gly
Leu Leu
Lys Lys
Leu Leu
Gly Gly
Asp Asp
Arg Arg
Ile Ile
H H
2 2
N N
HOOC HOOC
6 6
22 22
Gly Gly
Ser Ser
Cys Cys
Cys Cys
Gly Gly
Leu Leu
Gly Gly
Ser Ser
Met Met
1 1
5 5
10 10
15 15
20 20
$ .iuretic
$ Natriuretic
$ "ascular rela/ation
$ -nhi(ition of **%, %N%
$ *tria
$ %ame actions as *NP
$ -n atria and ventricles
$ +onger D<= life
$ E/cellent marker
$ 9sed as therapy
$ No natriuresis
or diuresis
$ Potent vasodilator
ANP
BNP CNP
.
i
u
r
e
t
i
c
.
i
u
r
e
t
i
c
n
a
t
r
i
u
r
e
t
i
c
n
a
t
r
i
u
r
e
t
i
c
B-Type Natriuretic Peptide (nesiritide) as Therapy
N N
e e
N N
N N
e e
N N
2
2
$
$
P
P
+
+
G
G
%
%
P
P
G
G
%
%
*
*
%
%
?
?
T
T
+
+
*
*
P
P
2
2
,
,
.
.
-
-
%
%
%
%
%
%
%
%
G
G
+
+
C
C
C
C
2
2
"
"
+
+
$
$
HH
22
NN
11
10 10
70 70
76 76
90 90
100 100
108 108
Cleavage Cleavage
,
,
.
.
-
-
%
%
%
%
%
%
%
%
G
G
+
+
C
C
C
C
2
2
"
"
+
+
$
$
COOH COOH
COOH COOH
pro pro4 4BNP BNP
HH
22
NN
BNP BNP NT NT4 4proBNP proBNP
Biologically -nactive Biologically -nactive Biologically *ctive Biologically *ctive
$
$
P
P
+
+
G
G
%
%
P
P
G
G
%
%
*
*
%
%
?
?
T
T
+
+
*
*
P
P
COOH COOH
11 10 10 70 70 76 76
C
C
0
0
C
C
%
%
P
P
2
2
,
,
"
"
@
@
G
G
%
%
G
G
HH
22
NN
C
C
0
0
C
C
%
%
P
P
2
2
,
,
"
"
@
@
G
G
%
%
G
G
80 80
NT4proBNP# 5o(he >
'ade=2ehrin&
BNP# 2iosite, 2a)er, A..ott,
2e(,man=Co%lter
;'T!e 2atriuretic Petide
;'T!e 2atriuretic Petide
#oung et al, $AMA 2002
BL BL %&m %&m'0m '0m BL BL %&m %&m'0m '0m
30
28
26
24
22
20
18
1hr 2hr 3hr 1hr 2hr 3hr
-1
-4
-7
-10
#*
#*
#*
# #
#*
#*
#*
#*
#
#
Placebo
Nitroglycerin
Nesiritide
Mean Observed Value ( mmHg) Mean Change ( mmHg)
# p < .05 versus placebo
*p < .05 versus nitroglycerin
30
28
26
24
22
20
18
1hr 2hr 3hr 1hr 2hr 3hr
-1
-4
-7
-10
Mean Observed Value ( mmHg) Mean Change ( mmHg)
# p < .05 versus placebo
*p < .05 versus nitroglycerin
Primary End Point: PCWP through 3 Hours Primary End Point: PCWP through 3 Hours
Nesiritide in $eart 0ailure# ",*C
Nesiritide in $eart 0ailure# ",*C
P P
U U
L L
M M
Pulmonary Capillary Wedge Pressure (absolute and change) Pulmonary Capillary Wedge Pressure (absolute and change)
Heart Failure
Heart Failure
Ne' .iuretics4 *denosine eceptor
Ne' .iuretics4 *denosine eceptor
,odulators
,odulators
Adenosine Adenosine
1 1
re(eptor anta&onists = re(eptor anta&onists =
afferent arteriole flo3 afferent arteriole flo3
2N9M19 9CV:=1F; 2N9M19 9CV:=1F;

Furosemi!e Furosemi!e Place(o Place(o B)*+%* B)*+%*
=F> =F>
=>> =>>
DF> DF>
D>> D>>
F> F>
> >
%
o
d
i
u
m

E
/
c
r
e
t
i
o
n
%
o
d
i
u
m

E
/
c
r
e
t
i
o
n
(
m
E
O
)
(
m
E
O
)
)ottlie( et al, Circulation 2002
Francis and Tang, JAMA 2004
Conivatan andTolvatan:
Conivatan andTolvatan:
2eE AHuaretic Agents
2eE AHuaretic Agents
$
Conivaptan
Conivaptan
4 an *"P4D and *"P4= receptor
4 an *"P4D and *"P4= receptor
(lockerI promotes an aOuaresis, corrects
(lockerI promotes an aOuaresis, corrects
hyponatremia, and has vasodilator activity
hyponatremia, and has vasodilator activity
(reduces pulmonary capillary 'edge
(reduces pulmonary capillary 'edge
pressure and raises cardiac output)6
pressure and raises cardiac output)6
$
Tolvaptan
Tolvaptan
J an *"P4D receptor (locker that
J an *"P4D receptor (locker that
corrects hyponatremia in edematous patients
corrects hyponatremia in edematous patients
'ith hyponatremia via an aOuaresis)
'ith hyponatremia via an aOuaresis)
survival study under'ay (E"EE%T)
survival study under'ay (E"EE%T)
system system
Blocing metabolic path-ays Blocing metabolic path-ays
Therapy
Therapy
Partial 0atty *cid &/idation (p0&3) -nhi(ition
Partial 0atty *cid &/idation (p0&3) -nhi(ition
<nhi.it fatt) a(id o0idation onl) <nhi.it fatt) a(id o0idation onl)
at hi&h fatt) a(id (on(entrations at hi&h fatt) a(id (on(entrations
6ermit normal fatt) a(id o0idation 6ermit normal fatt) a(id o0idation
rates at ph)siolo&i( fatt) a(id rates at ph)siolo&i( fatt) a(id
(on(entrations (on(entrations
6reser4e hi&h=ener&) 6reser4e hi&h=ener&)

phosphates and (ontra(tile phosphates and (ontra(tile
f%n(tion f%n(tion
5ed%(e a((%m%lation of la(ti( 5ed%(e a((%m%lation of la(ti(

a(id and maintains tiss%e p- a(id and maintains tiss%e p-
'ela) or pre4ent onset of 'ela) or pre4ent onset of

J.io(hemi(alK m)o(ardial J.io(hemi(alK m)o(ardial
is(hemia is(hemia
Allo3 more ener&) to .e Allo3 more ener&) to .e prod%(ed prod%(ed

from ea(h C from ea(h C
F F
mole(%le (ons%med mole(%le (ons%med
Fatty Fatty
Acids Acids
Glucose Glucose
Pyruvate Pyruvate
Krebs Krebs
Cycle Cycle
Oxidative Phosphorylation Oxidative Phosphorylation
Energy ATP Energy ATP
pFOX pFOX
Inhibition Inhibition
Lactic Lactic
acid ( acid ( ) )
H H
+ +
( ( ) )
Ranolazine, Trimetazidine, and Etomoxir Ranolazine, Trimetazidine, and Etomoxir
system system
0reating concomitant problems 0reating concomitant problems
Therapy
Therapy
*nemia in *m(ulatory $eart
*nemia in *m(ulatory $eart
0ailure
0ailure
Tang et al, ACC Presentation 200'
01
701
G01
801
/01
601
Prevalence Incidence (esolution
EF.G6 EF G6'// EF /6Q
Dou!le !lind, randomi;ed, place!o-controlled

Dou!le !lind, randomi;ed, place!o-controlled
study e%aluating the safety and efficacy of
study e%aluating the safety and efficacy of
erythropoietin in the treatment of patients -ith
erythropoietin in the treatment of patients -ith
heart failure and anemia
heart failure and anemia
8
Dar!epoetin (Amgen$
Dar!epoetin (Amgen$
, '(A.I7A-HeF(- e#ercise
, '(A.I7A-HeF(- e#ercise
study) HIP?CRA(E' -sur%i%al study
study) HIP?CRA(E' -sur%i%al study
8
Concerns a!out
Concerns a!out
throm!osis
throm!osis
Erythropoietin in $eart 0ailure
Erythropoietin in $eart 0ailure
system system
2evices and mechanical support 2evices and mechanical support
"urgical reconstruction "urgical reconstruction
Therapy
Therapy
Pipeline Drug De%elopment in Heart Failure,
Pipeline Drug De%elopment in Heart Failure,
some -inners and losers
some -inners and losers
1ele(ti4e Aldosterone Anta&onists 1ele(ti4e Aldosterone Anta&onists
*plerenone 9*, *6-*1Q1; *plerenone 9*, *6-*1Q1;

*ndothelin 5e(eptor Anta&inst *ndothelin 5e(eptor Anta&inst
9*5A; 9*5A;
2osentan 95*AC-=1, *NA2L*=1 T =F; 2osentan 95*AC-=1, *NA2L*=1 T =F;
:esozantan 95<:U=1 to =5; :esozantan 95<:U=1 to =5;
'ar%sentan 9*A5:-; 'ar%sentan 9*A5:-;
*nrasentan 9*NCC5; *nrasentan 9*NCC5;

Vasopeptidase <nhi.itors 9V6<; Vasopeptidase <nhi.itors 9V6<;
Cmapatrilat 9CV*5:Q5*, CC:AV*, Cmapatrilat 9CV*5:Q5*, CC:AV*,

C6*5A; C6*5A;
Natri%reti( 6eptides Natri%reti( 6eptides
Nesiritide 965*C*'*N:, V/AC, Nesiritide 965*C*'*N:, V/AC,

F&S"N',( F&S"N',(; ;
<midazoline=1 5e(e(ptor Anta&onist <midazoline=1 5e(e(ptor Anta&onist
/o0onidine 9/CVCCN, /CV1*; /o0onidine 9/CVCCN, /CV1*;

Cal(i%m 1ensitizers Cal(i%m 1ensitizers
Le4osimendan 9L<'C, 5Q11LAN, Le4osimendan 9L<'C, 5Q11LAN,

)E**E )E**E; ;
6hosphodiesterase=3 6hosphodiesterase=3
<nhi.itor <nhi.itor
*no0imone 9 *no0imone 9EM$"WE), EM$"WE),

ESSEN+A,, EM"+E ESSEN+A,, EM"+E; ;
<mm%ne /od%lators <mm%ne /od%lators
*taner(ept 95*NA<11ANC*, *taner(ept 95*NA<11ANC*,

5*CCV*5; 5*CCV*5;
<nfli0ima. 9A::AC-; <nfli0ima. 9A::AC-;
<mm%ne mod%lator, VA1=991 <mm%ne mod%lator, VA1=991

9 9ACC,AM ACC,AM; ;
/is(ellaneo%s /is(ellaneo%s
AN* (ross=lin, .rea,er, AL:= AN* (ross=lin, .rea,er, AL:=

M11 9'<A/CN', M11 9'<A/CN', SA$$H)E, SA$$H)E,
S,*E) S,*E); ;
Ne.i4olol 9 Ne.i4olol 9SEN")S SEN")S; ;
2i'il 9 2i'il 9A-HeF+ A-HeF+; ;
dar.epoetin 9 dar.epoetin 9S+AMNA-HeF+ S+AMNA-HeF+, ,

-<6CC5A:*1; -<6CC5A:*1;
"lide courtesy of /. Francis
2onharmacologic
2onharmacologic
Management
Management
and "ealth Care
and "ealth Care
Maintenance
Maintenance
in Patients Eith Chronic
in Patients Eith Chronic
"eart Failure
"eart Failure
HF'A 1232 Recommendations
HF'A 1232 Recommendations
"FSA G070 Practice ,uideline
2onharmacologicCDiet and 2utrition
2onharmacologicCDiet and 2utrition
#ecommendation @.% #ecommendation @.%
Dietar! instruction regarding sodium inta?e

Dietar! instruction regarding sodium inta?e
is
is
recommended
recommended
in all atients Eith "F.
in all atients Eith "F.
Patients Eith "F and dia%etes# d!sliidemia or

Patients Eith "F and dia%etes# d!sliidemia or
severe o%esit! should %e given secific dietar!
severe o%esit! should %e given secific dietar!
instructions.
instructions.

trength of )+idence > ? trength of )+idence > ?

2onharmacologicCDietar! Sodium
2onharmacologicCDietar! Sodium
#ecommendation @.2 #ecommendation @.2
Dietar! sodium restriction *G'8 g dail!+

Dietar! sodium restriction *G'8 g dail!+
is
is
recommended
recommended
for atients Eith the clinical
for atients Eith the clinical
s!ndrome of "F and reserved
s!ndrome of "F and reserved
or
or

deressed )4EF.
deressed )4EF.
Further restriction *. G g dail!+

Further restriction *. G g dail!+
ma! %e considered
ma! %e considered
in moderate to severe "F.
in moderate to severe "F.

trength of )+idence trength of )+idence
> C > C
2onharmacologicCFluid Inta?e
2onharmacologicCFluid Inta?e
(estriction of dail! fluid inta?e to . G liters:

(estriction of dail! fluid inta?e to . G liters:
Is recommended
Is recommended
in atients Eith severe
in atients Eith severe
h!onatremia *serum sodium . 780 mEH3)+
h!onatremia *serum sodium . 780 mEH3)+
Should %e considered
Should %e considered
for all atients
for all atients
demonstrating fluid retention that is difficult to
demonstrating fluid retention that is difficult to
control desite high doses of diuretic and
control desite high doses of diuretic and
sodium restriction.
sodium restriction.

trength of )+idence > trength of )+idence >
C C
2onharmacologicC2utrition in Advanced "F
2onharmacologicC2utrition in Advanced "F
It It is recommended is recommended that secific attention %e aid to that secific attention %e aid to
nutritional management of atients Eith advanced "F and nutritional management of atients Eith advanced "F and
unintentional Eeight loss or muscle Easting *cardiac unintentional Eeight loss or muscle Easting *cardiac
cache&ia+. cache&ia+.
Measurement of nitrogen %alance# caloric inta?e# and Measurement of nitrogen %alance# caloric inta?e# and
real%umin ma! %e useful in determining aroriate real%umin ma! %e useful in determining aroriate
nutritional sulementation. nutritional sulementation.
Caloric sulementation Caloric sulementation is recommended is recommended. .
Ana%olic steroids are Ana%olic steroids are not recommended not recommended for cache&ic for cache&ic
atients. atients.
2onharmacologicC4itamins
2onharmacologicC4itamins
#ecommendation @.A #ecommendation @.A
Patients Eith "F# eseciall! those on diuretic

Patients Eith "F# eseciall! those on diuretic
thera! and restricted diets#
thera! and restricted diets#
should
should
%e considered
%e considered
for dail! multivitamin'mineral
for dail! multivitamin'mineral
sulementation to ensure adeHuate inta?e of the
sulementation to ensure adeHuate inta?e of the
recommended dail! value of essential nutrients.
recommended dail! value of essential nutrients.
Evaluation for secific vitamin or nutrient deficiencies Evaluation for secific vitamin or nutrient deficiencies
is rarel! necessar!. is rarel! necessar!.
C C
2onharmacologicC2utraceuticals
2onharmacologicC2utraceuticals
#ecommendation @.@ #ecommendation @.@
Documentation of the t!e and dose of naturoceutical roducts Documentation of the t!e and dose of naturoceutical roducts
utiliBed %! atients Eith "F utiliBed %! atients Eith "F is recommended is recommended. .
2aturoceutical use is 2aturoceutical use is not recommended not recommended for relief of s!mtomatic "F for relief of s!mtomatic "F
or for the secondar! revention of cardiovascular events. or for the secondar! revention of cardiovascular events.
Patients should %e instructed to avoid using natural or s!nthetic Patients should %e instructed to avoid using natural or s!nthetic
roducts containing ehedra *ma huang+# ehedrine or its roducts containing ehedra *ma huang+# ehedrine or its
meta%olites %ecause of an increased ris? of mortalit! and meta%olites %ecause of an increased ris? of mortalit! and
mor%idit!. mor%idit!.
Products should %e avoided that ma! have significant drug Products should %e avoided that ma! have significant drug
interactions Eith digo&in# vasodilators# %eta %loc?ers# interactions Eith digo&in# vasodilators# %eta %loc?ers#
antiarrh!thmic drugs and anticoagulants. antiarrh!thmic drugs and anticoagulants.
2onharmacologicCCPAP
2onharmacologicCCPAP
#ecommendation @.B
#ecommendation @.B
Continuous ositive airEa! ressure to

Continuous ositive airEa! ressure to
imrove dail! functional caacit! and
imrove dail! functional caacit! and
Hualit! of life
Hualit! of life
is recommended
is recommended
in atients
in atients
Eith "F and o%structive slee anea
Eith "F and o%structive slee anea
documented %! aroved methods of
documented %! aroved methods of
ol!somnograh!.
ol!somnograh!.

? ?
2onharmacologicCO&!gen
2onharmacologicCO&!gen
#ecommendation @.C #ecommendation @.C
Sulemental o&!gen# either at night or during

Sulemental o&!gen# either at night or during
e&ertion# is
e&ertion# is
not recommended
not recommended
for atients Eith "F
for atients Eith "F
in the a%sence of an indication due to underl!ing
in the a%sence of an indication due to underl!ing
ulmonar! disease.
ulmonar! disease.
Patients Eith resting h!o&emia or o&!gen

Patients Eith resting h!o&emia or o&!gen
desaturation during e&ercise should %e evaluated
desaturation during e&ercise should %e evaluated
for residual fluid overload or concomitant
for residual fluid overload or concomitant
ulmonar! disease.
ulmonar! disease.

2onharmacologicCInsomnia
2onharmacologicCInsomnia
#ecommendation @.D #ecommendation @.D
The identification of treata%le conditions# such as

The identification of treata%le conditions# such as
slee'disordered %reathing# urologic
slee'disordered %reathing# urologic
a%normalities# restless leg s!ndrome and
a%normalities# restless leg s!ndrome and
deression
deression
should %e considered
in atients Eith
in atients Eith
"F and chronic insomnia.
"F and chronic insomnia.
Pharmacologic aids to slee induction ma! %e Pharmacologic aids to slee induction ma! %e
necessar!. necessar!.
Agents that do not ris? h!sical deendence are Agents that do not ris? h!sical deendence are
referred. referred. trength of trength of
)+idence > C )+idence > C
2onharmacologicCDeression
2onharmacologicCDeression
#ecommendation @.%1 #ecommendation @.%1
It It is recommended is recommended that screening for endogenous or that screening for endogenous or
rolonged reactive deression in atients Eith "F %e rolonged reactive deression in atients Eith "F %e
conducted folloEing diagnosis and at eriodic intervals as conducted folloEing diagnosis and at eriodic intervals as
clinicall! indicated. clinicall! indicated.
For harmacologic treatment# selective serotonin recetor For harmacologic treatment# selective serotonin recetor
uta?e inhi%itors *SS(Is+ are referred over tric!clic uta?e inhi%itors *SS(Is+ are referred over tric!clic
antideressants# %ecause the latter have the otential to antideressants# %ecause the latter have the otential to
cause ventricular arrh!thmias# %ut the otential for drug cause ventricular arrh!thmias# %ut the otential for drug
interactions should %e considered. interactions should %e considered.
2onharmacologicCStress
2onharmacologicCStress
#ecommendation @.%%
#ecommendation @.%%
2onharmacologic techniHues for stress

2onharmacologic techniHues for stress
reduction
reduction
ma! %e considered
ma! %e considered
as a useful
as a useful
ad-unct for reducing an&iet! in atients
ad-unct for reducing an&iet! in atients
Eith "F.
Eith "F.

2onharmacologicCSe&ual D!sfunction
2onharmacologicCSe&ual D!sfunction
It
It
is recommended
is recommended
that treatment otions for
that treatment otions for
se&ual d!sfunction %e discussed oenl! Eith %oth
se&ual d!sfunction %e discussed oenl! Eith %oth
male and female atients Eith "F.
male and female atients Eith "F.
The use of hoshodiasterase'6 *PDE6+

The use of hoshodiasterase'6 *PDE6+
inhi%itors such as sildenafil
inhi%itors such as sildenafil
ma! %e considered
ma! %e considered

for use for se&ual d!sfunction in atients Eith
for use for se&ual d!sfunction in atients Eith
chronic sta%le "F.
chronic sta%le "F.
These agents are These agents are not recommended not recommended in atients in atients
ta?ing nitrate rearations. ta?ing nitrate rearations.
2onharmacologicCSmo?ing D Alcohol
2onharmacologicCSmo?ing D Alcohol
It It is recommended is recommended that atients Eith "F %e advised to that atients Eith "F %e advised to
sto smo?ing and to limit alcohol consumtion to Y G sto smo?ing and to limit alcohol consumtion to Y G
standard drin?s er da! in men or Y 7 standard drin? standard drin?s er da! in men or Y 7 standard drin?
er da! in Eomen. er da! in Eomen.
Patients susected of having an alcohol'induced Patients susected of having an alcohol'induced

cardiom!oath! should %e advised to a%stain from cardiom!oath! should %e advised to a%stain from
alcohol consumtion. alcohol consumtion.
Patients susected of using illicit drugs should %e Patients susected of using illicit drugs should %e
counseled to discontinue such use. counseled to discontinue such use.

ECG 31 leads
ECG 31 leads
Chest H-ray
Chest H-ray

iomar"ers of HF,
iomar"ers of HF,
;2P# ro;2P# C(P#
;2P# ro;2P# C(P#
troonins<
troonins<
spiroergometry
spiroergometry
Phisical e&amination
2onharmacologicC4accinations
2onharmacologicC4accinations
Pneumococcal vaccine and annual

Pneumococcal vaccine and annual
influenBa vaccination
influenBa vaccination
are recommended
are recommended

in all atients Eith "F in the a%sence of
in all atients Eith "F in the a%sence of
?noEn contraindications.
?noEn contraindications.

2onharmacologicCEndocarditis Proh!la&is
2onharmacologicCEndocarditis Proh!la&is
#ecommendation @.%A #ecommendation @.%A
Endocarditis roh!la&is Endocarditis roh!la&is is not recommended is not recommended %ased on the diagnosis of %ased on the diagnosis of
"F alone. Consistent Eith the A"A recommendation# \roh!la&is should "F alone. Consistent Eith the A"A recommendation# \roh!la&is should
%e given for onl! secific cardiac conditions# associated Eith the highest %e given for onl! secific cardiac conditions# associated Eith the highest
ris? of adverse outcome from endocarditis:$ ris? of adverse outcome from endocarditis:$
\ \rosthetic cardiac valves rosthetic cardiac valves
revious infective endocarditis revious infective endocarditis
congenital heart disease *C"D+$ such as: \unreaired c!anotic C"D# including congenital heart disease *C"D+$ such as: \unreaired c!anotic C"D# including
alliative shunts and conduits alliative shunts and conduits
comletel! reaired congenital heart defect Eith rosthetic material or device# comletel! reaired congenital heart defect Eith rosthetic material or device#
Ehether laced %! surger! or %! catheter intervention# during the first si& months Ehether laced %! surger! or %! catheter intervention# during the first si& months
after the rocedure after the rocedure
reaired C"D Eith residual defects at the site or ad-acent to the site of a rosthetic reaired C"D Eith residual defects at the site or ad-acent to the site of a rosthetic
atch or rosthetic device *Ehich inhi%it endothelialiBation+ atch or rosthetic device *Ehich inhi%it endothelialiBation+
cardiac translantation reciients Eho develo cardiac valvuloath!.$ cardiac translantation reciients Eho develo cardiac valvuloath!.$
2onharmacologicC2SAIDs
2onharmacologicC2SAIDs
#ecommendation @.%@
#ecommendation @.%@
2SAIDs# including CO='G inhi%itors# are

2SAIDs# including CO='G inhi%itors# are
not recommended
not recommended
in atients Eith chronic
in atients Eith chronic
"F.
"F.
The ris? of renal failure and fluid retention is

The ris? of renal failure and fluid retention is
mar?edl! increased in the setting of reduced
mar?edl! increased in the setting of reduced
renal function or ACE inhi%itor thera!.
renal function or ACE inhi%itor thera!.

2onharmacologicCEmlo!a%ilit!
#ecommendation @.%B
#ecommendation @.%B
It
It
is recommended
is recommended
that atients Eith neE or
that atients Eith neE or
recent'onset "F %e assessed for emlo!a%ilit!
recent'onset "F %e assessed for emlo!a%ilit!
folloEing a reasona%le eriod of clinical
folloEing a reasona%le eriod of clinical
sta%iliBation.
sta%iliBation.
An o%-ective assessment of functional e&ercise

An o%-ective assessment of functional e&ercise
caacit! is useful in this determination.
caacit! is useful in this determination.

#ecommendation @.%C #ecommendation @.%C
It It is recommended is recommended that atients Eith chronic "F Eho that atients Eith chronic "F Eho
currentl! are emlo!ed and Ehose -o% descrition is currentl! are emlo!ed and Ehose -o% descrition is
comati%le Eith their rescri%ed activit! level %e comati%le Eith their rescri%ed activit! level %e
encouraged to remain emlo!ed# even if a temorar! encouraged to remain emlo!ed# even if a temorar!
reduction in hours Eor?ed or tas? erformed is reduction in hours Eor?ed or tas? erformed is
reHuired. reHuired.
(etraining (etraining should %e considered should %e considered and suorted for and suorted for
atients Eith a -o% demanding a level of h!sical atients Eith a -o% demanding a level of h!sical
e&ertion e&ceeding recommended levels. e&ertion e&ceeding recommended levels.
? ?
2onharmacologicCE&ercise Training
2onharmacologicCE&ercise Training
#ecommendation @.%D #ecommendation @.%D (()E in 21%1, (()E in 21%1,
It is recommended It is recommended that atients Eith "F undergo that atients Eith "F undergo
e&ercise testing to determine suita%ilit! for e&ercise e&ercise testing to determine suita%ilit! for e&ercise
training *atient does not develo significant ischemia training *atient does not develo significant ischemia
or arrh!thmias+. If deemed safe# e&ercise training or arrh!thmias+. If deemed safe# e&ercise training
should %e considered for atients Eith "F in order to: should %e considered for atients Eith "F in order to:
Facilitate understanding of e&ercise e&ectations Facilitate understanding of e&ercise e&ectations

*heart rate ranges and aroriate levels of e&ercise *heart rate ranges and aroriate levels of e&ercise
training+ training+
Increase e&ercise duration and intensit! in a Increase e&ercise duration and intensit! in a
suervised setting suervised setting
Promote adherence to a general e&ercise goal of 80 Promote adherence to a general e&ercise goal of 80
minutes of moderate activit!3e&ercise# 6 da!s er Eee? minutes of moderate activit!3e&ercise# 6 da!s er Eee?
Eith Earm u and cool doEn e&ercises Eith Earm u and cool doEn e&ercises
Strengt# of E$idence % '
Drill of the Month
Drill of the Month
De%eloped !y .ichael >indsay
De%eloped !y .ichael >indsay
An Overview of Ventricular
An Overview of Ventricular
Assist Devices
Assist Devices
&
&
Pre Hospital Management
Pre Hospital Management
Student O%-ectives
Student O%-ectives
At the conclusion of this !rill tudents 6ill be
At the conclusion of this !rill tudents 6ill be
able to:
able to:
Define Heart Failure Define Heart Failure
Define &entricular Assist De%ice (&AD$ and their use in treating Define &entricular Assist De%ice (&AD$ and their use in treating
Heart Failure Heart Failure
Identify types of &entricular Assist De%ices Identify types of &entricular Assist De%ices
E#plain the difference !et-een Pulsatile and 7onpulsatile flo- E#plain the difference !et-een Pulsatile and 7onpulsatile flo-
Identify hemodynamic differences in patients -ith a &AD Identify hemodynamic differences in patients -ith a &AD
>ist &AD related complications >ist &AD related complications
Demonstrate ho- to assess a patient -ith a &AD Demonstrate ho- to assess a patient -ith a &AD
Descri!e ho- to treat &AD complications Descri!e ho- to treat &AD complications
Identify &AD resources that can !e utili;ed -hen caring for these Identify &AD resources that can !e utili;ed -hen caring for these
patients+ patients+
"eart Failure
"eart Failure
S
S
Heart failure is a condition -here the heart
Heart failure is a condition -here the heart
cannot pump enough !lood throughout the
cannot pump enough !lood throughout the
!ody+
!ody+
S
S
It de%elops o%er time as the pumping action of
It de%elops o%er time as the pumping action of
the heart gro-s -ea"er+
the heart gro-s -ea"er+
S
S
.ost cases in%ol%e the left side -here the
.ost cases in%ol%e the left side -here the
heart cannot pump enough o#ygen-rich !lood
heart cannot pump enough o#ygen-rich !lood
to the rest of the !ody+
to the rest of the !ody+
S
S
0ith right sided failure, the heart cannot
0ith right sided failure, the heart cannot
effecti%ely pump !lood to the lungs -here the
effecti%ely pump !lood to the lungs -here the
!lood pic"s up o#ygen+
!lood pic"s up o#ygen+
4entricular Assist Device *4AD+
4entricular Assist Device *4AD+
A mechanical pump that is surgically attached to one of the

A mechanical pump that is surgically attached to one of the
heartPs %entricles to augment or replace nati%e %entricular
heartPs %entricles to augment or replace nati%e %entricular
function
function
Can !e used for the left (> &AD$, right (R &AD$, or !oth
Can !e used for the left (> &AD$, right (R &AD$, or !oth
%entricles (i &AD$
%entricles (i &AD$
Are po-ered !y e#ternal po-er sources that connect to the

Are po-ered !y e#ternal po-er sources that connect to the
implanted pump %ia a percutaneous lead (dri%eline$ that
implanted pump %ia a percutaneous lead (dri%eline$ that
e#its the !ody on the right a!domen
e#its the !ody on the right a!domen
Pump output flo- can !e pulsatile or nonpulsatile

Pump output flo- can !e pulsatile or nonpulsatile
8hy .o 8e Need "*.sU
Heart disease is the leading cause of death in the 0estern

Heart disease is the leading cause of death in the 0estern
-orld
-orld
cE million people in the D' ha%e congesti%e heart failure

cE million people in the D' ha%e congesti%e heart failure
(CHF$
(CHF$
1E2,222 are in the most ad%anced stage of CHF

1E2,222 are in the most ad%anced stage of CHF
cE22,222 ne- cases each year

cE22,222 ne- cases each year
cE2,222 deaths each year

cE2,222 deaths each year
only effecti%e treatment for end stage CHF is heart

only effecti%e treatment for end stage CHF is heart
transplant
transplant
ut, in 1224,
ut, in 1224,
I534 people -ere -aiting for a heart

I534 people -ere -aiting for a heart
1132 recei%ed one

1132 recei%ed one
615 died -aiting

615 died -aiting
c3122-3E22 &AD implanted in 1224

c3122-3E22 &AD implanted in 1224
-ndications for "*.
-ndications for "*.
ridge to transplant ((($ ridge to transplant ((($
most common most common
allo- reha! from se%ere allo- reha! from se%ere

CHF -hile a-aiting donor CHF -hile a-aiting donor
ridge to reco%ery ((R$ ridge to reco%ery ((R$
unload heart, allo- unload heart, allo-

^re%erse remodeling_ ^re%erse remodeling_
can !e short- or long-term can !e short- or long-term
^ ^Destination_ therapy (D($ Destination_ therapy (D($
permanent de%ice, permanent de%ice,

instead of transplant instead of transplant
currently only in currently only in

transplant-ineligi!le transplant-ineligi!le
patients patients
ridge to candidacy ((C$M ridge to candidacy ((C$M

ridge to decision ((D$ ridge to decision ((D$
-hen eligi!ility unclear -hen eligi!ility unclear

at implant at implant
not true îndication_ !ut not true îndication_ !ut

true for many pts true for many pts
T!es of 4ADs
T!es of 4ADs
Pulsatile
Pulsatile
and
and
7on Pulsatile
7on Pulsatile
Pulsatile
Pulsatile
&entricle-li"e pumping sac de%ice+ &entricle-li"e pumping sac de%ice+
lood enters %ia the inflo- cannula and fills a fle#i!le pumping lood enters %ia the inflo- cannula and fills a fle#i!le pumping
cham!er+ cham!er+
Electric motor or pneumatic (air$ pressure collapses the cham!er Electric motor or pneumatic (air$ pressure collapses the cham!er
and forces !lood into systemic circulation %ia the outflo- cannula+ and forces !lood into systemic circulation %ia the outflo- cannula+
Can !e >&AD, R&AD, or i&AD Can !e >&AD, R&AD, or i&AD
First-generation de%ices (in use since early 3N42s$ First-generation de%ices (in use since early 3N42s$
Patients -ill ha%e a palpa!le pulse and a measura!le !lood pressure+ Patients -ill ha%e a palpa!le pulse and a measura!le !lood pressure+
oth are generated from the &AD output flo-+ oth are generated from the &AD output flo-+
Pulsatile 4AD Ae! Parameters
Pulsatile 4AD Ae! Parameters
Pump Rate,
Pump Rate,
Ho- fast the &AD is pumping (filling @ emptying$

Ho- fast the &AD is pumping (filling @ emptying$
Can !e set at a fi#ed rate or can automatically adFust

Can !e set at a fi#ed rate or can automatically adFust
Pulsatile &ADs are loud and the rate can !e assessed !y

Pulsatile &ADs are loud and the rate can !e assessed !y
listening
listening
?utput,
?utput,
(he amount of !lood eFected from the &AD

(he amount of !lood eFected from the &AD
.easured is liters per minute

.easured is liters per minute
Is dependent upon preload, afterload, and pump rate

Is dependent upon preload, afterload, and pump rate
2on'Pulsatile
2on'Pulsatile
Continuous-flo- de%ices Continuous-flo- de%ices
Impeller (spinning tur!ine-li"e rotor !lade$ propels !lood Impeller (spinning tur!ine-li"e rotor !lade$ propels !lood continuousl! continuousl! for-ard for-ard
into systemic circulation+ into systemic circulation+
A#ial flo-, !lood lea%es impeller !lades in the same direction as it enters (thin" A#ial flo-, !lood lea%es impeller !lades in the same direction as it enters (thin"
fan or !oat motor propeller$+ fan or !oat motor propeller$+
.ost implanted de%ices are >&ADs only .ost implanted de%ices are >&ADs only
Are Vuite and cannot !e heard outside of the patientPs !ody+ Assess &AD status Are Vuite and cannot !e heard outside of the patientPs !ody+ Assess &AD status
!y auscultation o%er the ape# of the >&+ (he &AD should ha%e a continuous, !y auscultation o%er the ape# of the >&+ (he &AD should ha%e a continuous,
smooth humming sound+ smooth humming sound+
(he Patient may ha%e a -ea", irregular, or non-palpa!le pulse (he Patient may ha%e a -ea", irregular, or non-palpa!le pulse
(he Patient may ha%e a narro- pulse pressure and may not !e measura!le -ith (he Patient may ha%e a narro- pulse pressure and may not !e measura!le -ith
automated !lood pressure monitors+ (his is due to the continuous for-ard automated !lood pressure monitors+ (his is due to the continuous for-ard
outflo- from the &AD+ outflo- from the &AD+
(he .ean Arterial Pressure is the "ey in monitoring hemodynamics+ Ideal range (he .ean Arterial Pressure is the "ey in monitoring hemodynamics+ Ideal range
is 6E-N2 mmHg+ is 6E-N2 mmHg+
2on Pulsatile 4AD Ae! Parameters
Flo-,
Flo-,
.easured in liters per minute

.easured in liters per minute
Correlates -ith pump speed (

Correlates -ith pump speed (
speed[
speed[
flo-,
flo-,
Qspeed[Qflo-$
Qspeed[Qflo-$
Dependent on Preload and Afterload

Dependent on Preload and Afterload
'peed,
'peed,
Ho- fast the impeller of the internal pump spins

Ho- fast the impeller of the internal pump spins
.easured in re%olutions per minute (rpm$

.easured in re%olutions per minute (rpm$
Flo- speed is set and determined !y &AD clinical team

Flo- speed is set and determined !y &AD clinical team
and usually cannot !e manipulated outside of the hospital
and usually cannot !e manipulated outside of the hospital
Po-er,
Po-er,
(he amount of po-er the &AD consumes to continually

(he amount of po-er the &AD consumes to continually
run at a set speed
run at a set speed
'udden or gradual sustained increases in the po-er can

'udden or gradual sustained increases in the po-er can
indicate throm!us inside the &AD
indicate throm!us inside the &AD
Pulsatility Inde# (PI$,

Pulsatility Inde# (PI$,
A measure of the pressure differential inside the internal

A measure of the pressure differential inside the internal
&AD pump during the nati%e heartPs cardiac cycle
&AD pump during the nati%e heartPs cardiac cycle
&aries !y patient
&aries !y patient
Indicates %olume status, right %entricle function, and

Indicates %olume status, right %entricle function, and
nati%e heart contractility
nati%e heart contractility
(he de%ice parameters are displayed numerically on the

(he de%ice parameters are displayed numerically on the
&AD console or Controller
&AD console or Controller
0ill %ary -ith each indi%idual patient and &AD de%ice

0ill %ary -ith each indi%idual patient and &AD de%ice
4AD Parameters
4AD Parameters
Parameters for pulsatile and non pulsatile de%ices

Parameters for pulsatile and non pulsatile de%ices
%ary -ith each de%ice model
%ary -ith each de%ice model
Patients and their care gi%ers "no- the e#pecta!le

Patients and their care gi%ers "no- the e#pecta!le
parameter ranges and goals for their specific de%ice
parameter ranges and goals for their specific de%ice
Contact the &AD Coordinator at the implanting

Contact the &AD Coordinator at the implanting
medical center, they -ill !e your !est resource -hen
medical center, they -ill !e your !est resource -hen
treating a &AD patient+
treating a &AD patient+
Basic "*. ,anagement
Basic "*. ,anagement
A>> &ADs are,

A>> &ADs are,
Preload-dependent
Preload-dependent
E/G-independent
E/G-independent
Afterload-sensiti%e
Afterload-sensiti%e
Anticoagulated
Anticoagulated
Prone to,
Prone to,
infection
infection
!leeding
!leeding
throm!osisMstro"e
throm!osisMstro"e
mechanical malfunction
mechanical malfunction
/ey differences depend on pulsatile %s+ non-pulsatile

/ey differences depend on pulsatile %s+ non-pulsatile
de%ice
de%ice
"*.s commonly seen in the
"*.s commonly seen in the
community
community
Thoratec "*. (p"*.<i"*.)
Thoratec "*. (p"*.<i"*.)
Pneumatic, e#ternal(p&AD$ or internal (i&AD$, Pneumatic, e#ternal(p&AD$ or internal (i&AD$, ulsatile ulsatile
pump(s$ pump(s$
right-, left-, or !i-%entricular support right-, left-, or !i-%entricular support

(R&ADM>&ADMi&AD$ (R&ADM>&ADMi&AD$
up to cI+1 lpm flo- up to cI+1 lpm flo-
'hort- to medium-term use (up to c3-1 years$ 'hort- to medium-term use (up to c3-1 years$
!ridge to reco%ery !ridge to reco%ery
!ridge to transplant !ridge to transplant
hospital discharge possi!le hospital discharge possi!le

iVA'
pVA'
Thoratec p"*.
Thoratec p"*.
$eart,ate 3"E +"*%
$eart,ate 3"E +"*%
Internally implanted, electric Internally implanted, electric ulsatile ulsatile pump pump
left heart support only left heart support only
up to 32 lpm flo- up to 32 lpm flo-
.edium- to long-term therapy (months to years$ .edium- to long-term therapy (months to years$
!ridge to transplant !ridge to transplant
destination therapy (only FDA-appro%ed D( de%ice$ destination therapy (only FDA-appro%ed D( de%ice$
$eart,ate -- +"*%
$eart,ate -- +"*%
Internally implanted, a#ial-flo- ( Internally implanted, a#ial-flo- (non'ulsatile non'ulsatile$ de%ice $ de%ice
left heart support only left heart support only
speed, 4222-3E222 rpm speed, 4222-3E222 rpm
flo-, c5-4 lpm flo-, c5-4 lpm
.edium- to long-term therapy (months to years$ .edium- to long-term therapy (months to years$
!ridge to transplant (FDA-appro%ed$ !ridge to transplant (FDA-appro%ed$
destination therapy (in%estigational$ destination therapy (in%estigational$

;arvik =>>> +"*.
;arvik =>>> +"*.
A#ial-flo- (
A#ial-flo- (
non'ulsatile
non'ulsatile
$ pump
$ pump
electric, intra-%entricular
electric, intra-%entricular
left heart support only

left heart support only
'peed, 4222-31222 rpm

'peed, 4222-31222 rpm
flo-, c5-E lpm

flo-, c5-E lpm
.edium- to long-term therapy

.edium- to long-term therapy
(months to years$
(months to years$
!ridge to transplant
!ridge to transplant
(in%estigational$
(in%estigational$
;arvik =>>> +"*.
;arvik =>>> +"*.
&AD Issues
&AD Issues
Pro(lems<Complications
.aFor &AD Complications .aFor &AD Complications
leeding leeding
(hrom!osis (hrom!osis
Infection Infection
sepsis is leading cause of death in long-term &AD support sepsis is leading cause of death in long-term &AD support
R& dysfunctionMfailure R& dysfunctionMfailure
'uc"do-n (lo- preload causes a nonpulsatle &AD to collapse the 'uc"do-n (lo- preload causes a nonpulsatle &AD to collapse the
%entricle$ %entricle$
De%ice failureMmalfunction (highly %aria!le !y de%ice type$ De%ice failureMmalfunction (highly %aria!le !y de%ice type$
Hemolysis (the &AD destroys !lood cells$ Hemolysis (the &AD destroys !lood cells$
?ther Common Issues ?ther Common Issues
Arrhythmias Arrhythmias
A patient can !e in a lethal arrhythmia and !e asymptomatic+ A patient can !e in a lethal arrhythmia and !e asymptomatic+
(reat the patient not the monitor+ (reat the patient not the monitor+
Do not cardio%ertM defi!+ unless the patient is unsta!le -ith the Do not cardio%ertM defi!+ unless the patient is unsta!le -ith the
arrhythmia+ arrhythmia+
Do not initiate chest compressions unless instructed !y a Do not initiate chest compressions unless instructed !y a
physician or &AD coordinator+ Chest compressions can disrupt physician or &AD coordinator+ Chest compressions can disrupt
the implanted eVuipment causing !leeding and death the implanted eVuipment causing !leeding and death
Electrical shoc" from cardio%ertM defi!+ -ill not damage any of Electrical shoc" from cardio%ertM defi!+ -ill not damage any of
the &AD eVuipment the &AD eVuipment
High afterload can limit &AD flo-M output High afterload can limit &AD flo-M output
Do not administer antihypertensi%e medications or nitrates Do not administer antihypertensi%e medications or nitrates
unless instructed !y a physician or &AD Coordinator unless instructed !y a physician or &AD Coordinator
HypotensionM loss of Preload HypotensionM loss of Preload
All &ADs are preload dependent+ A loss or reduction in preload All &ADs are preload dependent+ A loss or reduction in preload
-ill compromise &AD function and limit flo-M output -ill compromise &AD function and limit flo-M output
DepressionM AdFustment Disorders DepressionM AdFustment Disorders
>i%ing -ith a &AD is difficult to management for a lot of >i%ing -ith a &AD is difficult to management for a lot of
patients+ patients+
A large percentage of patients e#perience symptoms of A large percentage of patients e#perience symptoms of
depression depression
Porta!ilityM Ergonomics Porta!ilityM Ergonomics
(he e#ternal &AD eVuipment is hea%y and cum!ersome (he e#ternal &AD eVuipment is hea%y and cum!ersome
limiting a patientPs mo!ility and greatly impacting their Vuality limiting a patientPs mo!ility and greatly impacting their Vuality
of life+ of life+
leeding @ (hrom!osis
leeding @ (hrom!osis
Careful control of anticoagulation is imperati%e

Careful control of anticoagulation is imperati%e
Patients are often on !oth anticoagulants and platelet

Patients are often on !oth anticoagulants and platelet
inhi!itors
inhi!itors
De%ice throm!osis
De%ice throm!osis
rare in pulsatile de%ices rare in pulsatile de%ices
typically re%ealed !y increased po-er and signs and typically re%ealed !y increased po-er and signs and
symptoms of hemolysis symptoms of hemolysis
Alarms
Alarms
All &AD de%ices typically ha%e t-o distingue

All &AD de%ices typically ha%e t-o distingue
alarms to indicate a pro!lem and itPs se%erity
alarms to indicate a pro!lem and itPs se%erity
Ad%isory Alarms
Ad%isory Alarms
CriticalM Ha;ardous Alarms

CriticalM Ha;ardous Alarms
Alarms
Alarms
Ad%isory Alarms are intermittent !eeping

Ad%isory Alarms are intermittent !eeping
sounds that ha%e a corresponding
sounds that ha%e a corresponding
LE>>?0
LE>>?0

light that illuminates on the system controller
light that illuminates on the system controller
7ot critical !ut the de%ice reVuires attention

7ot critical !ut the de%ice reVuires attention
>i"ely due to lo- !attery, ca!le disconnected, or

>i"ely due to lo- !attery, ca!le disconnected, or
de%ice not functioning properly+
de%ice not functioning properly+
Alarms
Alarms
Ha;ardous
Ha;ardous
or
or
Critical
Critical
alarms are a loud, continuous,
alarms are a loud, continuous,
shrill sound that ha%e a corresponding
shrill sound that ha%e a corresponding
RED
RED
light
light
that illuminates on the system controller
that illuminates on the system controller
Indicating the de%ice needs immediate attention

Indicating the de%ice needs immediate attention
?ften !ecause the pump has stopped or a pro!lem is

?ften !ecause the pump has stopped or a pro!lem is
detected -ith the system controller
detected -ith the system controller
.ost li"ely inter%ention reVuired is to change out the

.ost li"ely inter%ention reVuired is to change out the
system controller
system controller
Field Management
Field Management
All &ADs are dependant on adeVuate preload

All &ADs are dependant on adeVuate preload
in order to maintain proper functioning
in order to maintain proper functioning
&olume resuscitation in an unsta!le &AD

&olume resuscitation in an unsta!le &AD
patient is the first line of therapy !efore
patient is the first line of therapy !efore
%asopressors !ut !e cautious -ith fluid as to
%asopressors !ut !e cautious -ith fluid as to
not o%er load the right %entricle in > &ADs
not o%er load the right %entricle in > &ADs
only+
only+
Field Management
Field Management
7itrates can !e detrimental to a &AD patient

7itrates can !e detrimental to a &AD patient
!ecause of the reduction in preload
!ecause of the reduction in preload
Results in decreased pump efficiency

Results in decreased pump efficiency
Consult -ith medical control !efore administering

Consult -ith medical control !efore administering
nitrates per protocol
nitrates per protocol
Field Management
Field Management
Initiate I& therapy -ith all &AD patients if

Initiate I& therapy -ith all &AD patients if
possi!le
possi!le
Dse aseptic techniVue due to the patientPs

Dse aseptic techniVue due to the patientPs
increased ris"s of infection
increased ris"s of infection
Field Management
Field Management
&AD patients are suscepti!le to other inFuries

&AD patients are suscepti!le to other inFuries
unrelated to the &AD
unrelated to the &AD
Contact the &AD Coordinator, they are your

Contact the &AD Coordinator, they are your
most %alua!le resource -hen encountering
most %alua!le resource -hen encountering
these patients
these patients
Consult -ith medical control a!out transport

Consult -ith medical control a!out transport
A# ;# C# D# Es of the
A# ;# C# D# Es of the
Management of "eart
Management of "eart
Failure
Failure
7anette /ass 0enger, .D
7anette /ass 0enger, .D
Emor! Universit! School of Medicine
Emor! Universit! School of Medicine
,rad! Memorial "osital
,rad! Memorial "osital
Atlanta# ,eorgia
Atlanta# ,eorgia
O%-ectives
O%-ectives
Understand the cornerstones of thera!
Understand the cornerstones of thera!
angiotensin'converting enB!me inhi%itors#

angiotensin'converting enB!me inhi%itors#
diuretics# and digitalis
diuretics# and digitalis
revieE the role of other theraies:

revieE the role of other theraies:
harmacotheraeutic as Eell as
harmacotheraeutic as Eell as
nonharmacotheraeutic aroaches
nonharmacotheraeutic aroaches
Eidemiolog!
Eidemiolog!
/.K million atients in the United States

/.K million atients in the United States
are estimated to have heart failure
are estimated to have heart failure
/K0#000 neE cases recogniBed annuall!

/K0#000 neE cases recogniBed annuall!
Each !ear# JK6#000 hositaliBed atients

Each !ear# JK6#000 hositaliBed atients
have a rimar! diagnosis of heart failure.
have a rimar! diagnosis of heart failure.
It is the ma-or hosital discharge
It is the ma-or hosital discharge
diagnosis for atients in the Medicare
diagnosis for atients in the Medicare
age grou.
age grou.
Eidemiolog!
Eidemiolog!
heart failure increases Eith age

heart failure increases Eith age
half of all heart failure hositaliBations

half of all heart failure hositaliBations
occur in individuals X age 96 !ears.
occur in individuals X age 96 !ears.
In the United States# the estimated costs for

In the United States# the estimated costs for
the management of atients Eith heart
the management of atients Eith heart
failure e&ceed W70 %illion annuall!.
failure e&ceed W70 %illion annuall!.
Treatment o%-ectives
Treatment o%-ectives
Decrease s!mtoms
Decrease s!mtoms
Imrove e&ercise caacit!

Imrove e&ercise caacit!
Enhance Hualit! of life

Enhance Hualit! of life
Decrease mor%idit!
Decrease mor%idit!
(etard the rogression of heart failure

(etard the rogression of heart failure
Imrove survival
Imrove survival
Cornerstones of Thera!
Cornerstones of Thera!
Angiotensin converting enB!me *ACE+

Angiotensin converting enB!me *ACE+
inhi%itors
inhi%itors
diuretics
diuretics
digitalis
digitalis
guidelines for the severit!'%ased thera! of

guidelines for the severit!'%ased thera! of
heart failure.
heart failure.
As!mtomatic Patients
For as!mtomatic atients Eith left
For as!mtomatic atients Eith left
ventricular d!sfunction *2F"A class I+#
ventricular d!sfunction *2F"A class I+#
t!icall! those Eith an e-ection fraction
t!icall! those Eith an e-ection fraction
%eloE /01#
%eloE /01#

ACE inhi%itors are recommended
ACE inhi%itors are recommended

S!mtomatic Patients
S!mtomatic Patients
2F"A class II
2F"A class II
ACE inhi%itors# mild diuretics# and digo&in#

ACE inhi%itors# mild diuretics# and digo&in#
Eith or Eithout the use of ;'%loc?er thera!
Eith or Eithout the use of ;'%loc?er thera!
2F"A class III

2F"A class III
add loo diuretics

add loo diuretics
2F"A class I4
2F"A class I4
consider ositive inotroic agents

consider ositive inotroic agents
surgical theraies ma! also %e alied

surgical theraies ma! also %e alied
Angiotensin Converting Inhi%itors
h!siologic %enefits
h!siologic %enefits

Arterio%enous &asodilatation
Arterio%enous &asodilatation
ulmonar! arterial diastolic ressure

ulmonar! arterial diastolic ressure
ulmonar! caillar! Eedge ressure

ulmonar! caillar! Eedge ressure
left ventricular end'diastolic ressure

left ventricular end'diastolic ressure
s!stemic vascular resistance

s!stemic vascular resistance
s!stemic %lood ressure

s!stemic %lood ressure
ma&imal o&!gen uta?e *M4O

ma&imal o&!gen uta?e *M4O
G G
+
+
h!siologic %enefits
h!siologic %enefits

)4 function and cardiac outut

)4 function and cardiac outut
renal# coronar!# cere%ral %lood floE

renal# coronar!# cere%ral %lood floE
2o change in heart rate or m!ocardial

2o change in heart rate or m!ocardial
contractilit!
contractilit!
no neurohormonal activation
no neurohormonal activation
resultant diuresis and natriuresis

resultant diuresis and natriuresis
clinical %enefits
clinical %enefits

Increases e&ercise caacit!

Increases e&ercise caacit!
imroves functional class

imroves functional class
attenuation of )4 remodeling ost MI

attenuation of )4 remodeling ost MI
decrease in the rogression of chronic "F

decrease in the rogression of chronic "F
decreased hositaliBation
decreased hositaliBation
enhanced Hualit! of life

enhanced Hualit! of life
imroved survival
imroved survival
Enalopril
Enalopril
'?>&D Pre%ention (rial '?>&D Pre%ention (rial
EF.861 EF.861
"F rogression# "F rogression#
hositaliBation hositaliBation
Captopril
Captopril
'A&E, GI''I-5, I'I'-B 'A&E, GI''I-5, I'I'-B
Post MI# EF ./01 Post MI# EF ./01
overall mortalit!# overall mortalit!#
re'infarction re'infarction
hositaliBation# hositaliBation#
"F rogression "F rogression

S!mtomatic Patients
S!mtomatic Patients
Hydrala;ine \ Isosor!ide dinitrate
Hydrala;ine \ Isosor!ide dinitrate
&HeF(-I &HeF(-I
mortalit!# imroved functional class mortalit!# imroved functional class

as comared Eith use of digo&in and diuretics as comared Eith use of digo&in and diuretics
&HeF(-II &HeF(-II
roved less effective than enaloril roved less effective than enaloril
S!mtomatic Patients
S!mtomatic Patients
Enalopril
Enalopril
\ digo#in \ diuretics
\ digo#in \ diuretics
'?>&D (reatment (rial '?>&D (reatment (rial
EF.861# FC III'I4 EF.861# FC III'I4
mortalit!# mortalit!#
C?7'E7'D'-II C?7'E7'D'-II
FC I4 FC I4
mortalit! */01+# mortalit! */01+#
s!mtoms# s!mtoms#
imroved functional class imroved functional class
S!mtomatic Patients
S!mtomatic Patients
>osartan
>osartan
*AT'II inhi%itor+
*AT'II inhi%itor+
E>I(E (rial E>I(E (rial
losartan imroved the survival of elderl! heart failure losartan imroved the survival of elderl! heart failure
atients treated comared Eith catoril thera! atients treated comared Eith catoril thera!
,uidelines to ACE Inhi%itor Thera!
Contraindications
Contraindications
(enal arter! stenosis (enal arter! stenosis
(enal insufficienc! *relative+ (enal insufficienc! *relative+
"!er?alemia "!er?alemia
Arterial h!otension Arterial h!otension
Cough Cough
Angioedema Angioedema
Alternatives
Alternatives
"!dralaBine Q ISD2# AT'II inhi%itor "!dralaBine Q ISD2# AT'II inhi%itor

It is imortant to titrate to the dosage regimen

It is imortant to titrate to the dosage regimen
used in the clinical trials < in the a%sence of
used in the clinical trials < in the a%sence of
s!mtoms or adverse effects on end'organ
s!mtoms or adverse effects on end'organ
erfusion
erfusion
in ver! severe heart failure# h!dralaBine and

in ver! severe heart failure# h!dralaBine and
nitrates added to ACE inhi%itor thera! can
nitrates added to ACE inhi%itor thera! can
further imrove cardiac outut
further imrove cardiac outut
Anticoagulant Thera!
Anticoagulant Thera!
(ecommended for
(ecommended for
atients Eith 2F"A III'I4 and EF .801 or atients Eith 2F"A III'I4 and EF .801 or
ventricular aneur!sm or ver! dilated )4 ventricular aneur!sm or ver! dilated )4
Indicated for
Indicated for
atients Eith heart failure Eho have atrial atients Eith heart failure Eho have atrial
fi%rillation# a rior em%olic eisode# identified fi%rillation# a rior em%olic eisode# identified
intracardiac throm%us# left ventricular aneur!sm# intracardiac throm%us# left ventricular aneur!sm#
throm%ohle%itis# or rolonged %ed rest throm%ohle%itis# or rolonged %ed rest
titrate I2( to G to 8 titrate I2( to G to 8

Arrh!thmias
Arrh!thmias
Sudden death occurs in a%out 601
Sudden death occurs in a%out 601
of atients Eith heart failure
of atients Eith heart failure
Amiodarone
Amiodarone
(andomiBed clinical trials

CHF-'(A(
CHF-'(A(

2F"A II'III atients Eith ischemic
2F"A II'III atients Eith ischemic
cardiom!oath! ' amiodarone had no affect
cardiom!oath! ' amiodarone had no affect
on survival
on survival
GE'ICA
GE'ICA
2F"A III'I4 atients Eith more non'
2F"A III'I4 atients Eith more non'
ischemic cardiom!oath! ' oen la%eled
ischemic cardiom!oath! ' oen la%eled
amiodarone decreased mortalit!
amiodarone decreased mortalit!
AICD
AICD

A&ID A&ID
amiodarone vs imlanta%le defi%rillator amiodarone vs imlanta%le defi%rillator
shoEed the AICD grou had loEer mortalit! shoEed the AICD grou had loEer mortalit!
AICD should %e considered for atients Eith

AICD should %e considered for atients Eith
ventricular fi%rillation or rior sudden death
ventricular fi%rillation or rior sudden death
;eta'%loc?ers or amiodarone ma! %e

;eta'%loc?ers or amiodarone ma! %e
aroriate for atients Eith sustained 4T#
aroriate for atients Eith sustained 4T#
Eith or Eithout s!mtoms
Eith or Eithout s!mtoms
Assist Devices
Assist Devices
a !ridge to cardiac transplantation

a !ridge to cardiac transplantation
candidates must meet the inclusion and

candidates must meet the inclusion and
e#clusion criteria for cardiac transplantation
e#clusion criteria for cardiac transplantation
'%loc?ing Drugs
'%loc?ing Drugs
Physiologic !enefits
Physiologic !enefits
increase the densit! of

increase the densit! of
'7 recetors
'7 recetors
inhi%it catecholamine to&icit!

inhi%it catecholamine to&icit!
decrease neurohormonal activation

decrease neurohormonal activation
decrease heart rate

decrease heart rate
rovide antih!ertensive# antianginal# and

rovide antih!ertensive# antianginal# and
antiarrh!thmic effects
antiarrh!thmic effects
antio&idant and antiroliferative effects

antio&idant and antiroliferative effects
'%loc?ing Drugs
'%loc?ing Drugs
Clinical !enefits
Clinical !enefits
decrease s!mtoms of "F

decrease s!mtoms of "F
imrove left ventricular function

imrove left ventricular function
imrove e&ercise tolerance

imrove e&ercise tolerance
'%loc?ing Drugs ' Clinical Trials
HA(
HA(
*
*
';loc?er "eart Attac? Trial+

';loc?er "eart Attac? Trial+
roranolol decreased cardiovascular

roranolol decreased cardiovascular
mortalit!# sudden death# and reinfarction in
mortalit!# sudden death# and reinfarction in
ost'MI atients
ost'MI atients
%enefit is greatest in atients Eho also had left

%enefit is greatest in atients Eho also had left
ventricular d!sfunction
ventricular d!sfunction
'A&E
'A&E
(
(
Survival and 4entricular
Survival and 4entricular
Enlargement
Enlargement
$
$
ost'MI atients Eith an EF ./01

ost'MI atients Eith an EF ./01
' %loc?ers reduced mortalit! %oth in the ACE

' %loc?ers reduced mortalit! %oth in the ACE
inhi%itor and the lace%o grou
inhi%itor and the lace%o grou
loEest mortalit! occurred in atients receiving

loEest mortalit! occurred in atients receiving
%oth ACE and
%oth ACE and
'%loc?ing thera!
'%loc?ing thera!
.DC
.DC
(
(
Metorolol in Dilated
Metorolol in Dilated
Cardiom!oath!
Cardiom!oath!
$
$
2F"A II'III Eith dilated cardiom!oath!

2F"A II'III Eith dilated cardiom!oath!
no decrease in mortalit!
no decrease in mortalit!
significant decrease in s!mtoms

significant decrease in s!mtoms
significant increase in e&ercise tolerance# )4

significant increase in e&ercise tolerance# )4
e-ection fraction# Hualit! of life
e-ection fraction# Hualit! of life
.?CHA
.?CHA
(
(
Multicenter Oral Carvedilol
Multicenter Oral Carvedilol
"eart Failure Assessment Trial
"eart Failure Assessment Trial
$
$
2F"A II'III heart failure

2F"A II'III heart failure
Huadrule thera! *QACE# diuretic# digo&in+

Huadrule thera! *QACE# diuretic# digo&in+
/P1 decrease in the com%ined endoints of

/P1 decrease in the com%ined endoints of
mortalit! and hositaliBation
mortalit! and hositaliBation
no imrovements in e&ercise tolerance

no imrovements in e&ercise tolerance
PRECI'E
PRECI'E
(
(
Prosective (andomiBed Evaluation of
Prosective (andomiBed Evaluation of
Carvedilol on S!mtoms and E&ercise
Carvedilol on S!mtoms and E&ercise
$
$
decrease in mortalit! from J1 to 81

decrease in mortalit! from J1 to 81
/01 decrease in hositaliBation

/01 decrease in hositaliBation
decrease in s!mtoms
decrease in s!mtoms
imrovement in )4 e-ection fraction

imrovement in )4 e-ection fraction
no affect on e&ercise tolerance

no affect on e&ercise tolerance
Calcium Channel ;loc?ing Drugs
Potential !enefit,
Potential !enefit,
anti'ischemic and vasodilator! effects

anti'ischemic and vasodilator! effects
Ad%erse effect,
Ad%erse effect,
negative inotroic roerties

negative inotroic roerties
.DPI( M 'PRI7( trials

.DPI( M 'PRI7( trials
diltiaBem# veraamil# and nifediine are not

diltiaBem# veraamil# and nifediine are not
recommended for atients Eith "F
recommended for atients Eith "F
PRAI'E-3
PRAI'E-3
*Prosective (andomiBed
*Prosective (andomiBed
Amlodiine Survival Evaluation+
Amlodiine Survival Evaluation+
2F"A III'I4 heart failure

2F"A III'I4 heart failure
ACE# digo&in# diuretics ] amlodiine

ACE# digo&in# diuretics ] amlodiine
no change in total mortalit!

no change in total mortalit!
no survival %enefit in ischemics
no survival %enefit in ischemics
imroved survival in non'ischemics
imroved survival in non'ischemics
no change in e&ercise tolerance

no change in e&ercise tolerance
Coronar! (evasculariBation
Coronar! (evasculariBation
J01 of atients Eith heart failure have coronar!

J01 of atients Eith heart failure have coronar!
disease
disease
Patients should %e evaluated for the resence of

Patients should %e evaluated for the resence of
m!ocardial ischemia and the otential %enefit of
m!ocardial ischemia and the otential %enefit of
revaculariBation
revaculariBation
Survival Eas imroved %! revasculariBation

Survival Eas imroved %! revasculariBation
comared Eith medical thera!# even in the
comared Eith medical thera!# even in the
a%sence of angina ectoris *Du?e data%ase+
a%sence of angina ectoris *Du?e data%ase+
Cardiac Translantation
Cardiac Translantation
Survival of 901'P01 at 7'!r# K01 at 6'!r

Survival of 901'P01 at 7'!r# K01 at 6'!r
Inclusion Criteria:
Inclusion Criteria:
must first e&clude remedia%le m!ocardial ischemia must first e&clude remedia%le m!ocardial ischemia
heart failure refractor! to otimal medical (& heart failure refractor! to otimal medical (&
left ventricular e-ection fraction .G01 left ventricular e-ection fraction .G01
4O 4O
G G
ma& ma&
7/ m)3?g3min 7/ m)3?g3min
Pro%lems:
Pro%lems:
re-ection# graft atherosclerosis# neolasia# re-ection# graft atherosclerosis# neolasia#

cost3availa%ilit! cost3availa%ilit!
Cardiom!olast!
Cardiom!olast!
Cardiac (eduction Surger!
Cardiac (eduction Surger!
currentl! considered e&erimental

currentl! considered e&erimental
Diet
Diet
(raditional approach non-pharmacologic

(raditional approach non-pharmacologic
management is sodium and -ater restriction
management is sodium and -ater restriction
'odium e#cess is the main reason for heart

'odium e#cess is the main reason for heart
failure e#acer!ation
failure e#acer!ation
Restrict sodium to 1 to 5 grams M day

Restrict sodium to 1 to 5 grams M day
Diuretics
Diuretics
sodium and -ater retention

sodium and -ater retention
symptoms of %olume o%erload

symptoms of %olume o%erload
thia;ide diuretics are not acti%e -ith GFR A52

thia;ide diuretics are not acti%e -ith GFR A52
m>Mmin
m>Mmin
in resistant edema, loop diuretics, /

in resistant edema, loop diuretics, /
\ \
-sparing
-sparing
diuretics, and metola;one are indicated
diuretics, and metola;one are indicated
Digitalis
Digitalis
eneficial hemodynamic effects

eneficial hemodynamic effects
cardiac outut
cardiac outut
left ventricular e-ection fraction

left ventricular e-ection fraction
left ventricular diastolic ressure

left ventricular diastolic ressure
e&ercise tolerance
e&ercise tolerance
natriuresis
natriuresis
neurohormonal activation
neurohormonal activation
Digitalis ' Clinical Trials
DIG
DIG
(Digitalis In%estigation Group$
(Digitalis In%estigation Group$
2F"A class I'I4 heart failure

2F"A class I'I4 heart failure
no change in mortalit! comared Eith lace%o

no change in mortalit! comared Eith lace%o
thera!
thera!
com%ined endoint of hositaliBations and

com%ined endoint of hositaliBations and
death
death
serious arrh!thmia and MI

serious arrh!thmia and MI
RADIA7CE
RADIA7CE
(
(
(andomiBed Assessment of the
(andomiBed Assessment of the
effect of Digo&in on Inhi%itors of ACE
effect of Digo&in on Inhi%itors of ACE
$
$
e-ection fraction .861

e-ection fraction .861
ACE# diuretics# digo&in

ACE# diuretics# digo&in
associated Eith
associated Eith
e&ercise tolerance in atients

e&ercise tolerance in atients
Eith normal sinus rh!thm
Eith normal sinus rh!thm
EithdraEal of digo&in resulted in


e&ercise
e&ercise
tolerance# and
tolerance# and

in hositaliBation
in hositaliBation
PR?&ED
PR?&ED
*Prosective (andomiBed Stud! of
*Prosective (andomiBed Stud! of
4entricular Function and Efficac! of Digo&in+
4entricular Function and Efficac! of Digo&in+
mild'to'moderate "F Eith EF .861

mild'to'moderate "F Eith EF .861
in 2S( and not on ACE inhi%itor thera!

in 2S( and not on ACE inhi%itor thera!

e&ercise
e&ercise
tolerance and
tolerance and
in hositaliBation
in hositaliBation
Do%utamine
Do%utamine
L'7 recetor agonist

L'7 recetor agonist
loE'dose do%utamine *G'8 ug3?g3min+

loE'dose do%utamine *G'8 ug3?g3min+
m!ocardial contractilit! and cardiac

m!ocardial contractilit! and cardiac
outut# arteriovenous dilatation
outut# arteriovenous dilatation
high'dose do%utamine *6'76 ug3?g3min+

high'dose do%utamine *6'76 ug3?g3min+
tach!cardia# arrh!thmia# slanchnic and

tach!cardia# arrh!thmia# slanchnic and
renal vasoconstriction
renal vasoconstriction
associated Eith s!mtomatic %enefit

associated Eith s!mtomatic %enefit
continuous home um infusion

continuous home um infusion
E&ercise Training
E&ercise Training

AHCPR
AHCPR
Cardiac Reha!ilitation Guidelines
Cardiac Reha!ilitation Guidelines
E#ercise training in patients -ith HF
E#ercise training in patients -ith HF
decrease s!mtoms
decrease s!mtoms
imroves e&ercise tolerance

imroves e&ercise tolerance
%enefit additive to that attained Eith ACEI

%enefit additive to that attained Eith ACEI
no Eorsening of left ventricular function

no Eorsening of left ventricular function
E&ercise Training
E&ercise Training
Clinical (rials on e#ercise follo-ing .I
Clinical (rials on e#ercise follo-ing .I
EA.I
EA.I
(E#ercise and Anterior .I$
(E#ercise and Anterior .I$
E>&D
E>&D
(E#ercise in >& Dysfunction$
(E#ercise in >& Dysfunction$
!oth inter%entional groups sho-ed impro%ement in

!oth inter%entional groups sho-ed impro%ement in
functional capacity and decrease in symptoms
functional capacity and decrease in symptoms
E>&D also sho-ed an impro%ement in eFection

E>&D also sho-ed an impro%ement in eFection
fraction
fraction
Conclusion
Conclusion
Effects of "eart Failure Theraies
Imrove in survival
Imrove in survival
ACE inhi%itors
ACE inhi%itors
L'%loc?ing drugs *selective+

Increased mortalit!
Increased mortalit!
ositive inotroic agents

ositive inotroic agents
calcium channel %loc?ing drugs *M+

calcium channel %loc?ing drugs *M+
2eutral on survival
2eutral on survival
digitalis
digitalis
Conclusion
Conclusion
Prevention of ischemia
Prevention of ischemia

coronar! revasculariBation
coronar! revasculariBation
anticoagulant thera!
anticoagulant thera!
"emod!namic imrovement
"emod!namic imrovement
ACEI# digitalis# diuretics# h!dralaBine3ISD2

ACEI# digitalis# diuretics# h!dralaBine3ISD2
Prevention of sudden death

Prevention of sudden death
amiodarone and AICD

amiodarone and AICD
Evaluation and
Evaluation and
Management of Acute
Management of Acute
Decomensated "eart
Decomensated "eart
Failure
Failure
1232 HF'A Recommendations
1232 HF'A Recommendations
Acute "FCDiagnosis
Acute "FCDiagnosis
#ecommendation %2.% #ecommendation %2.%
The diagnosis of AD"F should %e %ased rimaril! on The diagnosis of AD"F should %e %ased rimaril! on
signs and s!mtoms. signs and s!mtoms. trength of )+idence trength of )+idence
> C > C
@hen the diagnosis is uncertain# determination of ;2P @hen the diagnosis is uncertain# determination of ;2P
or 2T'ro;2P concentration or 2T'ro;2P concentration is recommended is recommended in in
atients %eing evaluated for d!snea Eho have signs atients %eing evaluated for d!snea Eho have signs
and s!mtoms comati%le Eith "F. and s!mtoms comati%le Eith "F. trength of )+idence trength of )+idence
> A > A
The natriuretic etide concentration should not %e The natriuretic etide concentration should not %e
interreted in isolation# %ut in the conte&t of all interreted in isolation# %ut in the conte&t of all
availa%le clinical data %earing on the diagnosis of "F# availa%le clinical data %earing on the diagnosis of "F#
and Eith the ?noEledge of cardiac and non'cardiac and Eith the ?noEledge of cardiac and non'cardiac
factors that can raise or loEer natriuretic etide factors that can raise or loEer natriuretic etide
levels. levels.
3 of 5 3 of 5
Acute "FC"osital Admission
#ecommendation %2.2 #ecommendation %2.2
"osital admission
"osital admission
is recommended
is recommended
for atients
for atients
resenting Eith AD"F Ehen the clinical
resenting Eith AD"F Ehen the clinical
circumstances listed in Ta%le 7G.7.a are resent.
circumstances listed in Ta%le 7G.7.a are resent.
Patients resenting Eith AD"F

Patients resenting Eith AD"F
should
should
%e considered
%e considered
for hosital admission Ehen the
for hosital admission Ehen the
clinical circumstances listed in Ta%le 7G.7.% are
clinical circumstances listed in Ta%le 7G.7.% are
resent.
resent.

1 of 5 1 of 5
Ta%le 7G.7.*a+ Ta%le 7G.7.*a+ "ositaliBation "ositaliBation recommended recommended in the resence of: in the resence of:
Evidence of severel! decomensated "F# including: Evidence of severel! decomensated "F# including:
@orsening renal failure @orsening renal failure
Altered mentation Altered mentation
D!snea at rest D!snea at rest
T!icall! reflected %! resting tach!nea T!icall! reflected %! resting tach!nea
)ess commonl! reflected %! o&!gen saturation . P01 )ess commonl! reflected %! o&!gen saturation . P01
"emod!namicall! significant arrh!thmia "emod!namicall! significant arrh!thmia
Including neE onset of raid atrial fi%rillation Including neE onset of raid atrial fi%rillation
Acute coronar! s!ndromes Acute coronar! s!ndromes trength of )+idence > C trength of )+idence > C
5 of 5 5 of 5
Ta%le 7G.7.*%+ Ta%le 7G.7.*%+ "ositaliBation "ositaliBation should %e considered should %e considered in the resence of: in the resence of:
@orsened congestion @orsened congestion
Even Eithout d!snea Even Eithout d!snea
Signs and s!mtoms of ulmonar! or s!stemic congestion Signs and s!mtoms of ulmonar! or s!stemic congestion
Even in the a%sence of Eeight gain Even in the a%sence of Eeight gain
Ma-or electrol!te distur%ance Ma-or electrol!te distur%ance
Associated comor%id conditions Associated comor%id conditions
Pneumonia# ulmonar! em%olus# dia%etic ?etoacidosis# s!mtoms suggestive of Pneumonia# ulmonar! em%olus# dia%etic ?etoacidosis# s!mtoms suggestive of
TIA or stro?e TIA or stro?e
(eeated ICD firings (eeated ICD firings
Previousl! undiagnosed "F Eith signs and s!mtoms of s!stemic or Previousl! undiagnosed "F Eith signs and s!mtoms of s!stemic or
ulmonar! congestion ulmonar! congestion

3 of 1 3 of 1
Acute "FCTreatment ,oals
It is recommended
It is recommended
that atients admitted
that atients admitted
Eith AD"F %e treated to achieve the goals
Eith AD"F %e treated to achieve the goals
listed in Ta%le 7G.8.
listed in Ta%le 7G.8.

1 of 1 1 of 1
Ta%le 7G.8 Ta%le 7G.8 Treatment ,oals for Patients Admitted for AD"F Treatment ,oals for Patients Admitted for AD"F
Imrove s!mtoms# eseciall! congestion and loE outut s!mtoms Imrove s!mtoms# eseciall! congestion and loE outut s!mtoms
(estore normal o&!genation (estore normal o&!genation
OtimiBe volume status OtimiBe volume status
Identif! etiolog! Identif! etiolog!
Identif! and address reciitating factors Identif! and address reciitating factors
OtimiBe chronic oral thera! OtimiBe chronic oral thera!
MinimiBe side effects MinimiBe side effects
Identif! atients Eho might %enefit from revasculariBation or device Identif! atients Eho might %enefit from revasculariBation or device
thera! thera!
Identif! ris? of throm%oem%olism and need for anticoagulant thera! Identif! ris? of throm%oem%olism and need for anticoagulant thera!
Educate atients concerning medications and self assessment of "F Educate atients concerning medications and self assessment of "F
Consider and# Ehere ossi%le# initiate a disease management rogram Consider and# Ehere ossi%le# initiate a disease management rogram
Acute "FCPatient Monitoring
Acute "FCPatient Monitoring
Patients admitted Eith AD"F should %e

Patients admitted Eith AD"F should %e
carefull! monitored.
carefull! monitored.
It
It
is recommended
is recommended
that the items listed in
that the items listed in
Ta%le 7G./ %e assessed at the stated
Ta%le 7G./ %e assessed at the stated
freHuencies.
freHuencies.

Acute "FCTa%le 7G./. Patient Monitoring^
Acute "FCTa%le 7G./. Patient Monitoring^
FreHuenc! FreHuenc! 4alue 4alue Secifics Secifics
At least dail! At least dail! @eight @eight Determine after voiding in the morning Determine after voiding in the morning
Account for ossi%le increased food inta?e due to imroved Account for ossi%le increased food inta?e due to imroved
aetite aetite
At least dail! At least dail! Fluid inta?e Fluid inta?e
and outut and outut
More than More than
dail! dail!
4ital signs 4ital signs Orthostatic %lood ressure# if indicated Orthostatic %lood ressure# if indicated
O&!gen saturation dail! until sta%le O&!gen saturation dail! until sta%le
At least dail! At least dail! Signs Signs Edema# ascites# ulmonar! rales# heatomegal!# increased Edema# ascites# ulmonar! rales# heatomegal!# increased
-ugular venous ressure# heato-ugular reflu&# liver -ugular venous ressure# heato-ugular reflu&# liver
tenderness tenderness
At least dail! At least dail! S!mtoms S!mtoms Orthonea# aro&!smal nocturnal d!snea or cough# Orthonea# aro&!smal nocturnal d!snea or cough#
nocturnal cough# d!snea# fatigue# lightheadedness nocturnal cough# d!snea# fatigue# lightheadedness
At least dail! At least dail! Electrol!tes Electrol!tes Potassium# sodium Potassium# sodium
At least dail! At least dail! (enal function (enal function ;U2# serum creatinine ;U2# serum creatinine
Âll Âll (ecommended (ecommended# Strength of Evidence O C # Strength of Evidence O C
Acute "FCFluid Overload and Diuretics
Acute "FCFluid Overload and Diuretics
#ecommendation %2.A #ecommendation %2.A
It is recommended
It is recommended
that atients
that atients
admitted Eith AD"F and evidence of
admitted Eith AD"F and evidence of
fluid overload %e treated initiall! Eith
fluid overload %e treated initiall! Eith
loo diureticsCusuall! given
loo diureticsCusuall! given
intravenousl! rather than orall!.
intravenousl! rather than orall!.


Acute "FCDiuretic Dosing
Acute "FCDiuretic Dosing
#ecommendation %2.@ #ecommendation %2.@
It
It
is recommended
is recommended
that diuretics %e
that diuretics %e
administered:
administered:
at doses needed to roduce a rate of diuresis sufficient to at doses needed to roduce a rate of diuresis sufficient to
achieve achieve otimal volume status Eith relief of signs and otimal volume status Eith relief of signs and
s!mtoms of congestion s!mtoms of congestion
(edema, ele%ated U&P, dyspnea$ (edema, ele%ated U&P, dyspnea$
Eithout inducing an e&cessivel! raid reduction in: Eithout inducing an e&cessivel! raid reduction in:
intra%ascular %olume, -hich may result in symptomatic intra%ascular %olume, -hich may result in symptomatic
hypotension andMor -orsening renal function hypotension andMor -orsening renal function
or serum electrolytes, -hich may precipitate arrhythmias or or serum electrolytes, -hich may precipitate arrhythmias or
muscle cramps+ muscle cramps+
Acute "FCDiuretics D Assessment
Acute "FCDiuretics D Assessment
#ecommendation %2.B #ecommendation %2.B
Careful reeated assessment of signs and

Careful reeated assessment of signs and
s!mtoms of congestion and changes in
s!mtoms of congestion and changes in
%od! Eeight
%od! Eeight
is recommended
is recommended
# %ecause
# %ecause
clinical e&erience suggests it is difficult to
clinical e&erience suggests it is difficult to
determine that congestion has %een
determine that congestion has %een
adeHuatel! treated in man! atients.
adeHuatel! treated in man! atients.

Acute "FCDiuretics DMonitoring
Acute "FCDiuretics DMonitoring
#ecommendation %2.C #ecommendation %2.C
Monitoring of dail! Eeights# inta?e# and outut

Monitoring of dail! Eeights# inta?e# and outut
is recommended
is recommended
to assess clinical efficac! of
to assess clinical efficac! of
diuretic thera!.
diuretic thera!.
(outine use of a Fole! catheter

(outine use of a Fole! catheter
is not
is not
recommended
recommended
for monitoring volume status.
for monitoring volume status.
"oEever# lacement of a catheter

"oEever# lacement of a catheter
is recommended
is recommended

Ehen close monitoring of urine outut is needed or
Ehen close monitoring of urine outut is needed or
if a %ladder outlet o%struction is susected of
if a %ladder outlet o%struction is susected of
contri%uting to Eorsening renal function.
contri%uting to Eorsening renal function.
3 of 1 3 of 1
Acute "FCDiuretic Side Effects
#ecommendation %2.D (% of 2, #ecommendation %2.D (% of 2,
Careful o%servation for develoment of a variet! of Careful o%servation for develoment of a variet! of
side effects# including renal d!sfunction# electrol!te side effects# including renal d!sfunction# electrol!te
a%normalities# s!mtomatic h!otension# and gout a%normalities# s!mtomatic h!otension# and gout
is recommended is recommended in atients treated Eith in atients treated Eith
diuretics# eseciall! Ehen used at high doses and in diuretics# eseciall! Ehen used at high doses and in
com%ination. com%ination.
Patients should undergo routine la%orator! studies Patients should undergo routine la%orator! studies
and clinical e&amination as dictated %! their clinical and clinical e&amination as dictated %! their clinical
resonse. resonse.
1 of 1 1 of 1
#ecommendation %2.D (2 of 2, #ecommendation %2.D (2 of 2,
It is recommended
It is recommended
that serum otassium and
that serum otassium and
magnesium levels %e monitored at least dail!
magnesium levels %e monitored at least dail!
and maintained in the normal range. More
and maintained in the normal range. More
freHuent monitoring ma! %e necessar! Ehen
freHuent monitoring ma! %e necessar! Ehen
diuresis is raid.
diuresis is raid.

C C
Overl! raid diuresis ma! %e associated Eith

Overl! raid diuresis ma! %e associated Eith
severe muscle crams. If indicated# treatment
severe muscle crams. If indicated# treatment
Eith otassium relacement
Eith otassium relacement
should %e
should %e
considered
considered
.
.

Acute "FCDiuretics D (enal D!sfunction
Acute "FCDiuretics D (enal D!sfunction
#ecommendation %2.%1 #ecommendation %2.%1
Careful o%servation for the develoment of renal

Careful o%servation for the develoment of renal
d!sfunction
d!sfunction
is recommended
is recommended
in atients treated
in atients treated
Eith diuretics.
Eith diuretics.
Patients Eith moderate to severe renal d!sfunction

Patients Eith moderate to severe renal d!sfunction
and evidence of fluid retention should continue to
and evidence of fluid retention should continue to
%e treated Eith diuretics.
%e treated Eith diuretics.
In the resence of severe fluid overload# renal

In the resence of severe fluid overload# renal
d!sfunction ma! imrove Eith diuresis.
d!sfunction ma! imrove Eith diuresis.

Acute "FCDiuretic Alternatives
Acute "FCDiuretic Alternatives
#ecommendation %2.%% #ecommendation %2.%%
@hen congestion fails to imrove in resonse to diuretic @hen congestion fails to imrove in resonse to diuretic
thera!# the folloEing thera!# the folloEing otions otions should %e considered should %e considered: :
(e'evaluating resence3a%sence of congestion# (e'evaluating resence3a%sence of congestion#
(estricting sodium and fluid# (estricting sodium and fluid#
Increasing doses Increasing doses of loo diuretic# of loo diuretic#
Continuous infusion of a loo diuretic# Continuous infusion of a loo diuretic#
Or Or addition of a second t!e of diuretic orall! *metolaBone or addition of a second t!e of diuretic orall! *metolaBone or
sironolactone+ or intravenousl! *chlorothiaBide+. sironolactone+ or intravenousl! *chlorothiaBide+.
Another otion# ultrafiltration# Another otion# ultrafiltration# ma! %e considered ma! %e considered. .
Acute "FCSodium
Acute "FCSodium
A loE sodium diet *G g dail!+

A loE sodium diet *G g dail!+
is
is
recommended
recommended
for most hositaliBed
for most hositaliBed
atients.
atients.

C C
In atients Eith recurrent or refractor!

In atients Eith recurrent or refractor!
volume overload# stricter sodium restriction
volume overload# stricter sodium restriction
ma! %e considered
ma! %e considered
.
.

Acute "FCFluid (estriction
Acute "FCFluid (estriction
Fluid restriction *.G liters3da!+:

Fluid restriction *.G liters3da!+:
Is recommended Is recommended in atients Eith moderate h!onatremia in atients Eith moderate h!onatremia
*serum sodium . 780 mEH3)+ *serum sodium . 780 mEH3)+
Should %e considered Should %e considered to assist in treatment of fluid overload in to assist in treatment of fluid overload in
other atients. other atients. trength of )+idence > C trength of )+idence > C
In atients Eith severe *serum sodium . 7G6 mEH3)+

In atients Eith severe *serum sodium . 7G6 mEH3)+
or Eorsening h!onatremia# stricter fluid restriction
or Eorsening h!onatremia# stricter fluid restriction
ma! %e considered
ma! %e considered
.
.

Acute "F''O&!gen
Acute "F''O&!gen
(outine administration of sulemental

(outine administration of sulemental
o&!gen:
o&!gen:
Is recommended
Is recommended
in the resence of h!o&ia.
in the resence of h!o&ia.
Is not recommended
Is not recommended
in the a%sence of
in the a%sence of
h!o&ia.
h!o&ia.

"trength of Evidence : C "trength of Evidence : C
Acute "F''2I4
Acute "F''2I4
#ecommendation %2.%A #ecommendation %2.%A (()E in 21%1, (()E in 21%1,
Use of non'invasive ositive ressure

Use of non'invasive ositive ressure
ventilation
ventilation
ma! %e considered
ma! %e considered
for
for
severel! d!sneic atients Eith clinical
severel! d!sneic atients Eith clinical
evidence of ulmonar! edema.
evidence of ulmonar! edema.

"trength of Evidence : C "trength of Evidence : C
Acute "FC4T Proh!la&is
#ecommendation %2.%@ #ecommendation %2.%@ (()E in 21%1, (()E in 21%1, 7 of G 7 of G
4enous throm%oem%olism roh!la&is Eith loE

4enous throm%oem%olism roh!la&is Eith loE
dose unfractionated hearin# loE molecular Eeight
dose unfractionated hearin# loE molecular Eeight
hearin# or fondaarinu& to revent ro&imal
hearin# or fondaarinu& to revent ro&imal
dee venous throm%osis and ulmonar! em%olism
dee venous throm%osis and ulmonar! em%olism
is recommended
is recommended
for atients Eho are admitted to
for atients Eho are admitted to
the hosital Eith AD"F and Eho are not alread!
the hosital Eith AD"F and Eho are not alread!
anticoagulated and have no contraindication to
anticoagulated and have no contraindication to
anticoagulation.
anticoagulation.

Strengt# of E$idence % '
#ecommendation %2.%@ #ecommendation %2.%@ (()E in 21%1, (()E in 21%1, 2 2 of G of G
4enous throm%oem%olism roh!la&is Eith a

4enous throm%oem%olism roh!la&is Eith a
mechanical device *intermittent neumatic
mechanical device *intermittent neumatic
comression devices or graded comression
comression devices or graded comression
stoc?ings + to revent ro&imal dee venous
stoc?ings + to revent ro&imal dee venous
throm%osis and ulmonar! em%olism
throm%osis and ulmonar! em%olism
should
should
%e considered
%e considered
for atients Eho are admitted to the
for atients Eho are admitted to the
hosital Eith AD"F# Eho are not alread!
hosital Eith AD"F# Eho are not alread!
anticoagulated# and Eho have a
anticoagulated# and Eho have a
contraindication
contraindication
to anticoagulation.
to anticoagulation.
Acute "FCI4 4asodilators
#ecommendation %2.%B #ecommendation %2.%B
In the a%sence of s!mtomatic h!otension# intravenous In the a%sence of s!mtomatic h!otension# intravenous
nitrogl!cerin# nitrorusside or nesiritide nitrogl!cerin# nitrorusside or nesiritide ma! %e ma! %e
considered considered as an addition to diuretic thera! for raid as an addition to diuretic thera! for raid
imrovement of congestive s!mtoms in atients admitted imrovement of congestive s!mtoms in atients admitted
Eith AD"F. Eith AD"F.
FreHuent %lood ressure monitoring FreHuent %lood ressure monitoring is recommended is recommended Eith these Eith these
agents. agents. trength of )+idence > ? trength of )+idence > ?
These agents should %e decreased in dosage or discontinued if These agents should %e decreased in dosage or discontinued if
s!mtomatic h!otension or Eorsening renal function develos. s!mtomatic h!otension or Eorsening renal function develos.
(eintroduction in increasing doses (eintroduction in increasing doses ma! %e considered ma! %e considered once once
s!mtomatic h!otension is resolved. s!mtomatic h!otension is resolved. trength of )+idence > C trength of )+idence > C
#ecommendation %2.%C #ecommendation %2.%C
Intravenous vasodilators *intravenous

Intravenous vasodilators *intravenous
nitrogl!cerin or nitrorusside+ and
nitrogl!cerin or nitrorusside+ and
diuretics
diuretics
are recommended
are recommended
for raid
for raid
s!mtom relief in atients Eith acute
s!mtom relief in atients Eith acute
ulmonar! edema or severe h!ertension.
ulmonar! edema or severe h!ertension.


#ecommendation %2.%D #ecommendation %2.%D
Intravenous vasodilators
Intravenous vasodilators
ma! %e considered
ma! %e considered
in
in
atients Eith AD"F Eho have ersistent severe
atients Eith AD"F Eho have ersistent severe
"F desite aggressive treatment Eith diuretics
"F desite aggressive treatment Eith diuretics
and standard oral theraies.
and standard oral theraies.
2itrorusside 2itrorusside trength of )+idence > ? trength of )+idence > ?
2itrogl!cerine# nesiritide 2itrogl!cerine# nesiritide trength of )+idence > C trength of )+idence > C
3 of 5 3 of 5
Acute "FCI4 Inotroes
#ecommendation %2.21 (% of 0, #ecommendation %2.21 (% of 0,
Intravenous inotroes *milrinone or do%utamine+ Intravenous inotroes *milrinone or do%utamine+ ma! %e ma! %e
considered considered to relieve s!mtoms and imrove end'organ to relieve s!mtoms and imrove end'organ
function in atients Eith advanced "F characteriBed %!: function in atients Eith advanced "F characteriBed %!:
)4 dilation )4 dilation
(educed )4EF (educed )4EF
And And diminished eriheral erfusion or end'organ d!sfunction diminished eriheral erfusion or end'organ d!sfunction
*loE outut s!ndrome+ *loE outut s!ndrome+
Particularl! Particularl! if these atients: if these atients:
"ave marginal s!stolic %lood ressure *.P0 mm "g+# "ave marginal s!stolic %lood ressure *.P0 mm "g+#
"ave s!mtomatic h!otension desite adeHuate filling ressure# "ave s!mtomatic h!otension desite adeHuate filling ressure#
Or Or are unresonsive to# or intolerant of# intravenous vasodilators. are unresonsive to# or intolerant of# intravenous vasodilators.
1 of 5 1 of 5
#ecommendation %2.21 (2 of 0, #ecommendation %2.21 (2 of 0,
These agents These agents ma! %e considered ma! %e considered in similar atients Eith in similar atients Eith
evidence of fluid overload if the! resond oorl! to evidence of fluid overload if the! resond oorl! to
intravenous diuretics or manifest diminished or Eorsening intravenous diuretics or manifest diminished or Eorsening
renal function. renal function. trength of )+idence > C trength of )+idence > C
@hen ad-unctive thera! is needed in other atients Eith @hen ad-unctive thera! is needed in other atients Eith
AD"F# administration of vasodilators AD"F# administration of vasodilators should %e considered should %e considered
instead of intravenous inotroes *milrinone or do%utamine+. instead of intravenous inotroes *milrinone or do%utamine+.
Intravenous inotroes *milrinone or do%utamine+ are Intravenous inotroes *milrinone or do%utamine+ are not not
recommended recommended unless unless left heart filling ressures are ?noEn left heart filling ressures are ?noEn
to %e elevated or cardiac inde& is severel! imaired %ased on to %e elevated or cardiac inde& is severel! imaired %ased on
direct measurement or clear clinical signs. direct measurement or clear clinical signs.
5 of 5 5 of 5
#ecommendation %2.21 (0 of 0, #ecommendation %2.21 (0 of 0,
It is recommended
It is recommended
that administration of
that administration of
intravenous inotroes *milrinone or do%utamine+
intravenous inotroes *milrinone or do%utamine+
in the setting of AD"F
in the setting of AD"F
%e accomanied %!
%e accomanied %!
continuous or freHuent %lood ressure monitoring
continuous or freHuent %lood ressure monitoring
and continuous monitoring of cardiac rh!thm.
and continuous monitoring of cardiac rh!thm.
C C
If s!mtomatic h!otension or Eorsening

If s!mtomatic h!otension or Eorsening
tach!arrh!thmias develo during administration
tach!arrh!thmias develo during administration
of these agents# discontinuation or dose reduction
of these agents# discontinuation or dose reduction
.
. trength of )+idence > C trength of )+idence > C
Acute "FC"emod!namic Monitoring
#ecommendation %2.2% #ecommendation %2.2%
The routine use of invasive

The routine use of invasive
hemod!namic monitoring in atients
hemod!namic monitoring in atients
Eith AD"F is
Eith AD"F is
not recommended.
not recommended.

Invasive hemod!namic monitoring Invasive hemod!namic monitoring should %e considered should %e considered in a in a
atient: atient:
@ho is refractor! to initial thera! @ho is refractor! to initial thera!
@hose volume status and cardiac filling ressures are unclear @hose volume status and cardiac filling ressures are unclear
@ho has clinicall! significant h!otension *t!icall! S;P . J0 mm @ho has clinicall! significant h!otension *t!icall! S;P . J0 mm
"g+ or Eorsening renal function during thera! "g+ or Eorsening renal function during thera!
Or Or Eho is %eing considered for cardiac translant and needs Eho is %eing considered for cardiac translant and needs
assessment of degree and reversa%ilit! of ulmon. h!ertension assessment of degree and reversa%ilit! of ulmon. h!ertension
Or Or in Ehom documentation of an adeHuate hemod!namic resonse in Ehom documentation of an adeHuate hemod!namic resonse
to the inotroic agent is necessar! Ehen chronic outatient to the inotroic agent is necessar! Ehen chronic outatient
infusion is %eing considered infusion is %eing considered
Acute "FCEvaluation for Preciitating Factors
Acute "FCEvaluation for Preciitating Factors
It It is recommended is recommended that atients admitted Eith AD"F that atients admitted Eith AD"F
undergo evaluation for the folloEing reciitating factors: undergo evaluation for the folloEing reciitating factors:
Atrial fi%rillation or other arrh!thmias *e.g.# atrial flutter# Atrial fi%rillation or other arrh!thmias *e.g.# atrial flutter#
other S4T or 4T+ other S4T or 4T+
E&acer%ation of h!ertension E&acer%ation of h!ertension
M!ocardial ischemia3infarction M!ocardial ischemia3infarction
E&acer%ation of ulmonar! congestion E&acer%ation of ulmonar! congestion
Anemia# th!roid disease Anemia# th!roid disease
Significant drug interactions Significant drug interactions
Other less common factors Other less common factors

Acute "FCPatient Education
Acute "FCPatient Education
It
It
is recommended
is recommended
that ever! effort %e
that ever! effort %e
made to utiliBe the hosital sta! for
made to utiliBe the hosital sta! for
assessment and imrovement of atient
assessment and imrovement of atient
adherence via atient and famil!
adherence via atient and famil!
education and social suort services.
education and social suort services.

Acute "FCDischarge Criteria
Acute "FCDischarge Criteria
#ecommendation %2.2A #ecommendation %2.2A
It
It
is recommended
is recommended
that criteria in Ta%le
that criteria in Ta%le
7G.K %e met %efore a atient Eith "F is
7G.K %e met %efore a atient Eith "F is
discharged from the hosital.
discharged from the hosital.

Strength of Evidence O C Strength of Evidence O C
In atients Eith advanced "F or

In atients Eith advanced "F or
recurrent admissions for "F# additional
recurrent admissions for "F# additional
criteria listed in Ta%le 7G.K
criteria listed in Ta%le 7G.K
should %e
should %e
considered
considered
.
.

Strength of Strength of
Evidence O C Evidence O C
Acute "FCTa%le 7G.K. Discharge Criteria
Acute "FCTa%le 7G.K. Discharge Criteria
(ecommended for (ecommended for
all all "F atients "F atients
E&acer%ating factors addressed E&acer%ating factors addressed
2ear otimal volume status o%served 2ear otimal volume status o%served
Transition from intravenous to oral diuretic successfull! comleted Transition from intravenous to oral diuretic successfull! comleted
Patient and famil! education comleted# including clear discharge Patient and famil! education comleted# including clear discharge
instructions instructions
2ear otimal harmacologic thera! achieved# including ACEI and 2ear otimal harmacologic thera! achieved# including ACEI and
;; *for atients Eith reduced )4EF+ or intolerance documented ;; *for atients Eith reduced )4EF+ or intolerance documented
FolloE'u clinic visit scheduled# usuall! for K'70 da!s FolloE'u clinic visit scheduled# usuall! for K'70 da!s
Should %e Should %e
considered for considered for
atients Eith atients Eith
advanced "F or advanced "F or
recurrent recurrent
admissions for "F admissions for "F
Oral medication regimen sta%le for G/ hours Oral medication regimen sta%le for G/ hours
2o intravenous vasodilator or inotroic agent for G/ hours 2o intravenous vasodilator or inotroic agent for G/ hours
Am%ulation rior to discharge to assess functional caacit! after Am%ulation rior to discharge to assess functional caacit! after
thera! thera!
Plans for ost'discharge management *scale resent in home# visiting Plans for ost'discharge management *scale resent in home# visiting
nurse or telehone folloE u generall! no longer than 8 da!s after nurse or telehone folloE u generall! no longer than 8 da!s after
discharge+ (eferral discharge+ (eferral
for disease management# if availa%le for disease management# if availa%le
Acute "FCDischarge Planning
Acute "FCDischarge Planning
#ecommendation %2.2@ #ecommendation %2.2@
Discharge lanning Discharge lanning is recommended is recommended as art of the management of as art of the management of
atients Eith AD"F. Discharge lanning should address the folloEing atients Eith AD"F. Discharge lanning should address the folloEing
issues: issues:
Details regarding medication# dietar! sodium restriction and Details regarding medication# dietar! sodium restriction and
recommended activit! level recommended activit! level
FolloE'u %! hone or clinic visit earl! after discharge to reassess FolloE'u %! hone or clinic visit earl! after discharge to reassess
volume status volume status
Medication and dietar! comliance Medication and dietar! comliance
Alcohol moderation and smo?ing cessation Alcohol moderation and smo?ing cessation
Monitoring of %od! Eeight# electrol!tes and renal function Monitoring of %od! Eeight# electrol!tes and renal function
Consideration of referral for formal disease management Consideration of referral for formal disease management
"eart Failure and
"eart Failure and
4ADs
4ADs
;ridges for ;ro?en "earts
;ridges for ;ro?en "earts
Priya Gaiha .D .A
Priya Gaiha .D .A
.ay 16
.ay 16
th th
1232
1232
Dni%ersity of /entuc"y
Dni%ersity of /entuc"y
Grand Rounds
Grand Rounds
O%-ectives
O%-ectives
0hat is the pathophysiology of heart failure` 0hat is the pathophysiology of heart failure`
0hy is heart failure rele%ant` 0hy is heart failure rele%ant`
0hat is the history of mechanical circulatory support` 0hat is the history of mechanical circulatory support`
0hat are the %arious types of %entricular assist de%ices 0hat are the %arious types of %entricular assist de%ices
(&ADs$` (&ADs$`
Ho- and -hen are &ADs used` Ho- and -hen are &ADs used`
0hat is the ne#t generation of &ADs` 0hat is the ne#t generation of &ADs`
Etiologies of cardiac failure
Etiologies of cardiac failure
Coronar! arter! disease Coronar! arter! disease
Idioathic cardiom!oath! Idioathic cardiom!oath!
Periartum cardiom!oath! Periartum cardiom!oath!
Dilated cardiom!oath! Dilated cardiom!oath!
Ischemic cardiom!oath! Ischemic cardiom!oath!
Acute valvular disease Acute valvular disease
Arrh!thmia *suraventricular or ventricular+ Arrh!thmia *suraventricular or ventricular+
M!ocarditis M!ocarditis
Congenital heart disease Congenital heart disease
Drug induced Drug induced
Dia%etes mellitus Dia%etes mellitus
"!ertension "!ertension
Pathogenesis of "eart Failure
Pathogenesis of "eart Failure
/ann, '. Cir(%lation 1999;1!!;999=1!!#
2F"A classes
2F"A classes
Class Class Patient Symptoms Patient Symptoms
Class I (Mild) Class I (Mild) No limitation of physical activity. Ordinary physical No limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, or activity does not cause undue fatigue, palpitation, or
dyspnea (shortness of breath). dyspnea (shortness of breath).
Class II (Mild) Class II (Mild) Slight limitation of physical activity. Comfortable at Slight limitation of physical activity. Comfortable at
rest, but ordinary physical activity results in fatigue, rest, but ordinary physical activity results in fatigue,
palpitation, or dyspnea. palpitation, or dyspnea.
Class III Class III
(Moderate) (Moderate)
Marked limitation of physical activity. Comfortable Marked limitation of physical activity. Comfortable
at rest, but less than ordinary activity causes fatigue, at rest, but less than ordinary activity causes fatigue,
palpitation, or dyspnea. palpitation, or dyspnea.
Class IV (Severe) Class IV (Severe) Unable to carry out any physical activity without Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at discomfort. Symptoms of cardiac insufficiency at
rest. If any physical activity is undertaken, rest. If any physical activity is undertaken,
discomfort is increased. discomfort is increased.
www.americanheart.org
5ele4an(e
Otions for Advanced C"F
Otions for Advanced C"F
(ransplant (ZZZZZZ$
(ransplant (ZZZZZZ$
Assist De%ice (ZZZ$

Assist De%ice (ZZZ$
Die(Z$
Die(Z$
Preceded !y 6-31 months of medical therapy

Preceded !y 6-31 months of medical therapy
.ultiple hospital re-admissions

.ultiple hospital re-admissions
Hospice (ZZZ$
Hospice (ZZZ$
:ransplant
_ohn ,i%%on
_ohn ,i%%on
orn in 3N25 in Philadelphia orn in 3N25 in Philadelphia
Bth generation physician Bth generation physician
3N53, -atched a young -oman 3N53, -atched a young -oman

postop from cholecystectomy die postop from cholecystectomy die
from PE from PE
0or"ed for 12 years on dogs to 0or"ed for 12 years on dogs to

refine !ypass machine refine !ypass machine
Recei%ed financial and technical Recei%ed financial and technical

support from (homas 0atson of support from (homas 0atson of
I. I.
3NE5, first successful use of 3NE5, first successful use of

machine on patient during A'D machine on patient during A'D
repair repair
Christian ;arnard
Christian ;arnard



Short term Device otions
Short term Device otions
2rid&e to re(o4er)
2rid&e to de(ision
<A26
*C/C
:andem -eart
<mpella
A.io/ed 5!!!
Centrima&
Cir(%lation 11F 93;: 3#
Developed in late 1960s Developed in late 1960s
Counterpulsation is synchronized to the EKG or Counterpulsation is synchronized to the EKG or

arterial waveforms arterial waveforms
Increase coronary perfusion Increase coronary perfusion
Decrease left ventricular stroke work and Decrease left ventricular stroke work and
myocardial oxygen requirements myocardial oxygen requirements
Most widely used form of mechanical circulatory Most widely used form of mechanical circulatory
support support
Indications for its use include Indications for its use include
Failure to wean from cardiopulmonary bypass Failure to wean from cardiopulmonary bypass
Cardiogenic shock after MI Cardiogenic shock after MI
Refractory ventricular arrhythmias with Refractory ventricular arrhythmias with

ongoing ischemia ongoing ischemia
;ridge to %ridge: ECMO
;ridge to %ridge: ECMO
Immediately sta!ili;e circulation

Immediately sta!ili;e circulation
Impro%e end organ perfusion

Impro%e end organ perfusion
?%erall sur%i%al compara!le !et-een

?%erall sur%i%al compara!le !et-een
EC.? \ >&AD %ersus >&AD alone
EC.? \ >&AD %ersus >&AD alone
Clinical indicators of poor outcome

Clinical indicators of poor outcome
after EC.?, consider &AD
after EC.?, consider &AD
implantation carefully
implantation carefully
Ele%ated !lood lactate le%els

Ele%ated !lood lactate le%els
Ele%ated >F(s
Ele%ated >F(s
$agani et al. !nn Thorac Surg %&&&' (&)*+((-,-
Centrifugal ums
Centrifugal ums
Acute hemodynamic support Acute hemodynamic support
Continuous flo- Continuous flo-
E#tracorporeal E#tracorporeal
>&, R& or !i%entricular support >&, R& or !i%entricular support
0ide a%aila!ility 0ide a%aila!ility
Ease of use Ease of use
Relati%ely lo- cost Relati%ely lo- cost
>imited duration of support >imited duration of support
ridge to reco%ery ridge to reco%ery
ridge to decision ridge to decision

Hoy et al. Ann Thorac urg !"""# $"%&!'()*+
Tandem hearts
Tandem hearts
Acute hemodynamic support

Acute hemodynamic support
Centrifugal pump
Centrifugal pump
Percutaneous placement
Percutaneous placement
>& support %ia transseptal cannula

>& support %ia transseptal cannula
Dsed in high ris" cardiac

Dsed in high ris" cardiac
catheteri;ation procedures
catheteri;ation procedures
Ris" of %ascular inFuries due to

Ris" of %ascular inFuries due to
cannula si;e
cannula si;e
A%iomed 6000
A%iomed 6000
E#tracorporeal
E#tracorporeal
Pneumatic pulsatile pumps

Pneumatic pulsatile pumps
Dni- or !i%entricular support

Dni- or !i%entricular support
ridge to transplant
ridge to transplant
Easy to insert and operate so

Easy to insert and operate so
used in community hospitals
used in community hospitals
Flo-s 6>Mmin
Flo-s 6>Mmin
Circulation+ 122E)331,B54-BB4+
)ong term Device otions
)ong term Device otions
2rid&e to transplant
-eartmate <<
Jar4i, F!!!
CardioHest :A-
-eartmate VV*
Cir(%lation 11F 93;: 3#
:horate(
Thoratec
Thoratec
Pneumatic pump
Pneumatic pump
>&AD, R&AD or
>&AD, R&AD or
!i%entricular support
!i%entricular support
Dura!le
Dura!le
Can !e used in smaller

Can !e used in smaller
patients
patients
Flo-s I>Mmin
Flo-s I>Mmin
ridge to reco%ery
ridge to reco%ery
ridge to transplant
ridge to transplant
"eartmate =4E
"eartmate =4E
Pneumatic or %ented electric Pneumatic or %ented electric

plates plates
(e#tured internal surfaces (e#tured internal surfaces
?nly left-sided support ?nly left-sided support
Flo-s 32>Mmin Flo-s 32>Mmin
ridge to transplant ridge to transplant
First de%ice to !e appro%ed for First de%ice to !e appro%ed for

destination therapy destination therapy
7eed 'AT3+E 7eed 'AT3+E
>imited dura!ility, half life 34 >imited dura!ility, half life 34

months months
Infection ris" -ith percutaneous Infection ris" -ith percutaneous

dri%e line dri%e line
"eartmate II
"eartmate II
A#ial flo-
A#ial flo-
>& support
>& support
Flo-s 32>Mmin
Flo-s 32>Mmin
>ong term dura!ility

>ong term dura!ility
ridge to transplant
ridge to transplant
Appro%ed Uanuary 1232 for

Appro%ed Uanuary 1232 for
destination therapy
destination therapy
?%er B222 de%ices

?%er B222 de%ices
implanted to date
implanted to date
Imlantation of device
Imlantation of device
N Engl J Med 2007;357:885- N Engl J Med 2007;357:885-
96 96
Imlantation
Imlantation
Device comlications
Device comlications
Early
Early
leeding leeding
Right sided heart failure Right sided heart failure
Progressi%e multiorgan system failure Progressi%e multiorgan system failure
>ate
>ate
Infection Infection
7osocomial 7osocomial
De%ice related De%ice related
(hrom!oem!olism (hrom!oem!olism
Failure of de%ice Failure of de%ice

Cellular %enefits of 4ADs
Cellular %enefits of 4ADs
7ormali;ation of fi!er orientation

7ormali;ation of fi!er orientation
Regression of myocyte hypertrophy

Regression of myocyte hypertrophy
Reduction in contraction !and necrosis

Reduction in contraction !and necrosis
Re%erse %entricular dilation

Re%erse %entricular dilation
Impro%ement in EDP&R Impro%ement in EDP&R
Impro%ed efficiency of myocardial mitochondria

Impro%ed efficiency of myocardial mitochondria
Reduction in a!normalities along neurohormonal and

Reduction in a!normalities along neurohormonal and
cyto"ine path-ays
cyto"ine path-ays
Circulation. 7PPJSPJ:G89K'G89P.
Indicators of oor clinical
outcome
outcome
Ad%anced age
Ad%anced age
Independent predictor of poor sur%i%al Independent predictor of poor sur%i%al
Independent predictor of poor !ridge to transplant Independent predictor of poor !ridge to transplant
5IC post 52-day >&AD mortality 5IC post 52-day >&AD mortality
Age limit` T6E yo contraindication to transplant Age limit` T6E yo contraindication to transplant
Female
Female
Independent predictor of poor sur%i%al Independent predictor of poor sur%i%al
Independent predictor of poor !ridge to transplant Independent predictor of poor !ridge to transplant
Higher mortality Higher mortality
>onger -aiting time to transplant due to si;e criteria >onger -aiting time to transplant due to si;e criteria
Increased operati%e mortality Increased operati%e mortality
'maller 'A 'maller 'A
Impaired -ound healing Impaired -ound healing

JC:1 F!!5:13!;5: 13!F=1311
outcome
outcome
Dia!etes mellitus Dia!etes mellitus
B-fold increased ris" of early death B-fold increased ris" of early death
Associated -ith end organ failure Associated -ith end organ failure
Renal failure Renal failure
Increased allograft %asculopathy after transplant Increased allograft %asculopathy after transplant
(ype I D. is contraindication to transplant (ype I D. is contraindication to transplant
>o- preoperati%e serum al!umin >o- preoperati%e serum al!umin
'urrogate measure of nutritional status 'urrogate measure of nutritional status
Increased infections and impaired -ound healing Increased infections and impaired -ound healing
For e%ery 3 mgMd> increase in al!umin, had 3N+1 times increased For e%ery 3 mgMd> increase in al!umin, had 3N+1 times increased
li"elihood for !ridge to transplant li"elihood for !ridge to transplant
JC:1 F!!5:13!;5: 13!F=1311
M!ocardial recover!
M!ocardial recover!
Certain proportion of
Certain proportion of
idiopathic dilated
idiopathic dilated
cardiomyopathy patients
cardiomyopathy patients
ha%e potential for complete
ha%e potential for complete
cardiac reco%ery, 3E-12C
cardiac reco%ery, 3E-12C
Lounger age Lounger age
'horter history of heart failure 'horter history of heart failure
Faster and more complete Faster and more complete

restoration of pump function restoration of pump function
Diminished fi!rosis seen in Diminished fi!rosis seen in

myocyte !iopsies myocyte !iopsies
Ann Thorac urg !""&# $&%&"()&+
Congestive "eart
Congestive "eart
Failure
Failure
Uarrod Eddy, PGL1
Uarrod Eddy, PGL1
Internal .edicine
Internal .edicine
'u!-I >ecture 'eries
'u!-I >ecture 'eries
Congestive "eart Failure
Congestive "eart Failure
Clinical presentation of disease

Clinical presentation of disease
7?( a diagnosis in and of itself

7?( a diagnosis in and of itself
Differential includes
Differential includes
Dnderlying cardio%ascular disease

Dnderlying cardio%ascular disease
Precipitating factors
Precipitating factors
Predisosing Cardiac Diseases
Predisosing Cardiac Diseases
.yocardial infarction
.yocardial infarction
Chronic ischemia
Chronic ischemia
Cardiomyopathy
Cardiomyopathy
Arrhythmias
Arrhythmias
Diastolic dysfunction
Diastolic dysfunction
&al%ular diseases
&al%ular diseases
Aortic 'tenosis Aortic 'tenosis
.itral 'tenosis .itral 'tenosis
.itral Regurgitation .itral Regurgitation

Cardiac Ph!siolog!
Cardiac Ph!siolog!
*remem%er thisM+
*remem%er thisM+
C? [ '& # HR
C? [ '& # HR
HR, parasympathetic and sympathetic tone

HR, parasympathetic and sympathetic tone
'&, preload, afterload, contractility

'&, preload, afterload, contractility
Preload
Preload
Def,
Def,
4assive stretch of muscle prior to contraction
4assive stretch of muscle prior to contraction
.easurement, '-an-Gan;
.easurement, '-an-Gan;
>&EDP >&EDP
Really a function of >&ED&

Really a function of >&ED&
Affected !y
Affected !y
compliance
compliance
>o- compliance [ higher >&EDP d lo-er >&ED& >o- compliance [ higher >&EDP d lo-er >&ED&
False high estimate of preload False high estimate of preload
Fran"-'tarling right`
Fran"-'tarling right`
Afterload
Afterload
Def,
Def,
Force opposing9stretching muscle
Force opposing9stretching muscle
after
after

contraction begins
contraction begins
.easurement, '&R
.easurement, '&R
Really a function of,

Really a function of,
'&R
'&R
Cham!er radius (dilated cardiomyopathies$

Cham!er radius (dilated cardiomyopathies$
0all thic"ness (hypertrophy$

0all thic"ness (hypertrophy$
Contractilit!
Contractilit!
Def,
Def,
8ormal ability of the muscle to contract
8ormal ability of the muscle to contract
at a given force for a given stretch1
at a given force for a given stretch1
independent
independent
of preload or afterload forces
of preload or afterload forces
In other -ords,
In other -ords,
Ho- healthy is your heart muscle`

Ho- healthy is your heart muscle`
Ischemia, Hypertrophy (`$, .uscle loss

Ischemia, Hypertrophy (`$, .uscle loss
Classif!ing "eart Failure
Classif!ing "eart Failure
Anatomically
Anatomically
>eft %ersus Right

>eft %ersus Right
Physiologically
Physiologically
'ystolic %ersus Diastolic

'ystolic %ersus Diastolic
Functionally
Functionally
Ho- symptomatic is your patient`

Ho- symptomatic is your patient`
)eft versus (ight Failure
)eft versus (ight Failure
)eft "eart Failure
)eft "eart Failure
- Dyspnea
- Dyspnea
- Dec+ e#ercise tolerance
- Cough
- Cough
- ?rthopnea
- ?rthopnea
- Pin", frothy sputum
- Pin", frothy sputum
(ight "eart Failure
(ight "eart Failure
- Edema
- Edema
- HUR M U&D
- HUR M U&D
- Hepatomegaly
- Hepatomegaly
- Ascites
- Ascites
S!stolic versus Diastolic
S!stolic versus Diastolic
'ystolic
'ystolic
K ^canPt pump_
K ^canPt pump_
Aortic 'tenosis Aortic 'tenosis
H(7 H(7
Aortic Insufficiency Aortic Insufficiency
.itral Regurgitation .itral Regurgitation
.uscle >oss .uscle >oss
Ischemia Ischemia
Fi!rosis Fi!rosis
Infiltration Infiltration
Diastolic
Diastolic
- ^canPt fill_
- ^canPt fill_
.itral 'tenosis .itral 'tenosis
(amponade (amponade
Hypertrophy Hypertrophy
Infiltration Infiltration
Fi!rosis Fi!rosis
Clinical Data
Clinical Data
CHR
CHR
/erleyPs lines , A and

/erleyPs lines , A and
Pulmonary Edema
Pulmonary Edema
Cephali;ation
Cephali;ation
Pleural Effusions (!ilateral$

Pleural Effusions (!ilateral$
E/G
E/G
>eft atrial enlargement

>eft atrial enlargement
Arrhythmias
Arrhythmias
Hypertrophy (left or right$

Hypertrophy (left or right$
Cardiomyopathy
Pulmonary Edema
Clinical Data
Clinical Data
4)A#$ '*(!FFF
4)A#$ '*(!FFF
'ystolic .urmurs
'ystolic .urmurs
.itral Regurg
.itral Regurg
Aortic 'tenosis
Aortic 'tenosis
Diastolic .urmurs
Diastolic .urmurs
.itral 'tenosis
.itral 'tenosis
Aortic Insufficiency
Aortic Insufficiency
S8
S8
, Rapid filling of a diseased %entricle
, Rapid filling of a diseased %entricle
Clinical Data
Clinical Data
>a!oratory Data
>a!oratory Data
Chemistry
Chemistry
Renal Function, e 0ary Renal Function, e 0ary
7P
7P
Dsed in ER departments the -orld o%er Dsed in ER departments the -orld o%er
Good negati%e correlation Good negati%e correlation
7eed !aseline for positi%ity 7eed !aseline for positi%ity
Pulmonary %ersus cardiac dyspnea Pulmonary %ersus cardiac dyspnea

Treatment of C"F
Treatment of C"F
(reat Precipitating Factor(s$OOOO

(reat Precipitating Factor(s$OOOO
AdFust Heart Rate

AdFust Heart Rate
Decrease Preload
Decrease Preload
Decrease Afterload
Decrease Afterload
Increase Contractility
Increase Contractility
Increase ?#ygenation
Increase ?#ygenation
Treatment of C"F
Treatment of C"F
?#ygen K nasal, iPAP, intu!ation

?#ygen K nasal, iPAP, intu!ation
.orphine
.orphine
Preload Reduction
Preload Reduction
>oop diuretics
>oop diuretics
7itrates
7itrates
ACEi M AR
ACEi M AR
.orphine
.orphine
"eart
"eart
Failure
Failure
Amanda Ryan, D+?+
Amanda Ryan, D+?+
Cardiology Fello-
Cardiology Fello-
Fe!ruary 3Bth, 1224
Fe!ruary 3Bth, 1224
+earning &(1ectives
+ollo3in& this presentation, the

parti(ipant sho%ld .e a.le to:
1. 5e(o&nize the ma&nit%de of heart fail%re epidemi( and its p%.li(

health impli(ations
F. 'istin&%ish the different (lassifi(ations and sta&es of heart fail%re
3. 5e4ie3 %nderl)in& pathoph)siolo&) of heart fail%re
. 'is(%ss si&ns and s)mptoms of heart fail%re e0a(er.ation
5. <dentif) (%rrent pra(ti(e &%idelines for treatment of a(%te

de(ompensated heart fail%re
@hat is "eart Failure
@hat is "eart Failure
Heart failure occurs -hen the heart cannot

Heart failure occurs -hen the heart cannot
pump enough !lood fast enough to meet the
pump enough !lood fast enough to meet the
meta!olic needs of the !ody+
meta!olic needs of the !ody+
7o longer use the term ^congesti%e_ !ecause

7o longer use the term ^congesti%e_ !ecause
all heart failure does not result in clinically
all heart failure does not result in clinically
apparent %olume o%erload
apparent %olume o%erload
It is an Eidemic
It is an Eidemic
Estimated that o%er E million Americans ha%e heart

Estimated that o%er E million Americans ha%e heart
failure
failure
Estimated E22,222 ne- cases per year

Estimated E22,222 ne- cases per year
0ithin E years, half of those diagnosed -ill !e dead

0ithin E years, half of those diagnosed -ill !e dead
?%er 3 million hospitali;ations per year -ith HF as

?%er 3 million hospitali;ations per year -ith HF as
primary diagnosis
primary diagnosis
.ost common reason for hospitali;ation in those T6E

.ost common reason for hospitali;ation in those T6E
years old
years old
4EC of HF cases are in adults 6E and older

4EC of HF cases are in adults 6E and older
Heart failure is B
Heart failure is B
th th
in a list of Vuality of care initiati%es in
in a list of Vuality of care initiati%es in
%ulnera!le older adults
%ulnera!le older adults
Costs of $eart 0ailure
<t is the leadin& (a%se of hospitalization in patients older than 65 )ears

of a&e and is a primar) hospital dis(har&e dia&nosis in 1.1 million
people of all a&es ea(h )ear.
<t is one medi(al (ondition for 3hi(h mortalit) (ontin%es to in(rease.

+rom 199 to F!!, the o4erall death rate de(lined F.!A in the Qnited
1tates, .%t deaths from -+ in(reased F#A in the same time period.
A((ordin& to the National -eart, L%n&, and 2lood <nstit%te, the

estimated dire(t and indire(t (osts asso(iated 3ith -+ (are in the Q1 is
W33.F .illion )earl).
:he ma@orit) of the (osts " appro0imatel) t3o=thirds " are attri.%ta.le to
the mana&ement of episodes of a(%te -+ de(ompensation 9i.e.,
hospitalization;.
Different @a!s to Define "F
2ilated 5congestive6 cardiomyopathy 2ilated 5congestive6 cardiomyopathy is a group of heart is a group of heart
muscle disorders in -hich the %entricles enlarge !ut are not muscle disorders in -hich the %entricles enlarge !ut are not
a!le to pump enough !lood for the !ody*s needs, resulting in a!le to pump enough !lood for the !ody*s needs, resulting in
heart failure+ (E#ample - CAD, myocarditis, Et?H, HI&$ heart failure+ (E#ample - CAD, myocarditis, Et?H, HI&$
Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy includes a group of heart includes a group of heart
disorders in -hich the -alls of the %entricles thic"en disorders in -hich the -alls of the %entricles thic"en
(hypertrophy$ and !ecome stiff, e%en though the -or"load of (hypertrophy$ and !ecome stiff, e%en though the -or"load of
the heart is not increased+ (E#ample K congenital H?C., or the heart is not increased+ (E#ample K congenital H?C., or
acVuired$ acVuired$
.estrictive 5infiltrative6 cardiomyopathy .estrictive 5infiltrative6 cardiomyopathy includes a group of includes a group of
heart disorders in -hich the -alls of the %entricles !ecome heart disorders in -hich the -alls of the %entricles !ecome
stiff, !ut not necessarily thic"ened, and resist normal filling stiff, !ut not necessarily thic"ened, and resist normal filling
-ith !lood !et-een heart!eats+ (E#ample K radiation, -ith !lood !et-een heart!eats+ (E#ample K radiation,
amyloidosis$ amyloidosis$
Diastolic 4ersus S!stolic "eart Failure

Diastolic 4ersus S!stolic "eart Failure
A+ 'ystolic cardiac (heart$ dysfunction (or systolic
A+ 'ystolic cardiac (heart$ dysfunction (or systolic
heart failure$ occurs -hen the heart muscle doesn*t
heart failure$ occurs -hen the heart muscle doesn*t
contract -ith enough force, so there is not enough
contract -ith enough force, so there is not enough
o#ygen-rich !lood to !e pumped throughout the
o#ygen-rich !lood to !e pumped throughout the
!ody+
!ody+
+ Diastolic cardiac dysfunction (or diastolic heart
+ Diastolic cardiac dysfunction (or diastolic heart
failure$ occurs -hen the heart contracts normally,
failure$ occurs -hen the heart contracts normally,
!ut the %entricle doesn*t rela# properly so less !lood
!ut the %entricle doesn*t rela# properly so less !lood
can enter the heart+
can enter the heart+
Clinically, patients are classified as ha%ing HF

Clinically, patients are classified as ha%ing HF
of
of
ischemic
ischemic
or
or
nonischemic
nonischemic
etiology !ased on
etiology !ased on
a history of myocardial infarction (.I$ or
a history of myocardial infarction (.I$ or
!ased on o!Fecti%e e%idence of coronary artery
!ased on o!Fecti%e e%idence of coronary artery
disease (CAD$ such as angiography or
disease (CAD$ such as angiography or
functional testing+
functional testing+
Controversial .efinitions
Staging of "eart Failure
Staging of "eart Failure
Ne' ?ork $eart *ssociation
Class <: No o.4io%s s)mptoms, no limitations on patient

ph)si(al a(ti4it) 935 per(ent;.
Class <<: 1ome s)mptoms d%rin& or after normal a(ti4it),

mild ph)si(al a(ti4it) limitations 935 per(ent;.
Class <<<: 1)mptoms 3ith mild e0ertion, moderate to

si&nifi(ant ph)si(al a(ti4it) limitations 9F5 per(ent;.
Class <V: 1i&nifi(ant s)mptoms at rest, se4ere to total

ph)si(al a(ti4it) limitations 95 per(ent;.
Causes of "eart Failure
Causes of "eart Failure

Pro!lems -ith the heart muscle itself e"no-n as

Pro!lems -ith the heart muscle itself e"no-n as
cardiomyopathy (myocarditis, etc$f
cardiomyopathy (myocarditis, etc$f
Hypertension
Hypertension
Pro!lems -ith any of the heart %al%es

Pro!lems -ith any of the heart %al%es
A!normal heart rhythms (also called arrhythmias$

A!normal heart rhythms (also called arrhythmias$
(o#ic su!stances (Et?H, cocaine$

(o#ic su!stances (Et?H, cocaine$
Congenital heart disease

Congenital heart disease
Dia!etes
Dia!etes
(hyroid pro!lems
(hyroid pro!lems
HI&
HI&
.iastolic $0
'iastoli( heart fail%re is defined as a (ondition (a%sed .) in(reased resistan(e

to the fillin& of one or .oth 4entri(les; this leads to s)mptoms of (on&estion from
the inappropriate %p3ard shift of the diastoli( press%re=4ol%me relation.
!A of patients
<n(reasin& in(iden(e 3ith a&e
/ore (ommon in 3omen
-:N and (ardia( is(hemia are most (ommon (a%ses
Common pre(ipitatin& fa(tors in(l%de 4ol%me o4erload; ta(h)(ardia; e0er(ise;

h)pertension; is(hemia; s)stemi( stressors 9e.&., anemia, fe4er, infe(tion,
th)roto0i(osis;; arrh)thmia 9e.&., atrial fi.rillation, atrio4entri(%lar nodal .lo(,;;
in(reased salt inta,e; and %se of nonsteroidal anti=inflammator) dr%&s.
More A%out Diastolic
More A%out Diastolic
D!sfunction
D!sfunction
Alterations involve relaxation and/or

Alterations involve relaxation and/or
filling and/or distensibility.
filling and/or distensibility.
Arterial hypertension associated to

Arterial hypertension associated to
LV concentric remodelling is the main
LV concentric remodelling is the main
determinant of DD but several other
determinant of DD but several other
cardiac diseases, including
cardiac diseases, including
myocardial ischemia, and extra-
myocardial ischemia, and extra-
cardiac pathologies also possible.
cardiac pathologies also possible.
Stages of Diastole
Stages of Diastole
. . Isovolumetric relaxation Isovolumetric relaxation, , period occurring bet!een the period occurring bet!een the
end of LV systolic e"ection #$ aortic valve closure% and the end of LV systolic e"ection #$ aortic valve closure% and the
opening of the mitral valve, !hen LV pressure &eeps going its opening of the mitral valve, !hen LV pressure &eeps going its
rapid fall !hile LV volume remains constant. rapid fall !hile LV volume remains constant.
'. '. LV rapid filling LV rapid filling, !hich begins !hen LV pressure falls belo! , !hich begins !hen LV pressure falls belo!
left atrial pressure and the mitral valve opens. During this left atrial pressure and the mitral valve opens. During this
period the blood has an acceleration !hich achieves a maximal period the blood has an acceleration !hich achieves a maximal
velocity, direct related to the magnitude of atrio-ventricular velocity, direct related to the magnitude of atrio-ventricular
pressure, and stops !hen this gradient ends. pressure, and stops !hen this gradient ends.
(. (. diastasis diastasis, !hen left atrial and LV pressures are almost , !hen left atrial and LV pressures are almost
e)ual and LV filling is essentially maintained by the flo! e)ual and LV filling is essentially maintained by the flo!
coming from pulmonary veins * !ith left atrium representing a coming from pulmonary veins * !ith left atrium representing a
passive conduit * !ith an amount depending of LV pressure, passive conduit * !ith an amount depending of LV pressure,
function of LV +compliance+. function of LV +compliance+.
,. ,. atrial systole atrial systole, , !hich corresponds to left atrial contraction !hich corresponds to left atrial contraction
and ends at the mitral valve closure. -his period is mainly and ends at the mitral valve closure. -his period is mainly
influenced by LV compliance, but depends also by the influenced by LV compliance, but depends also by the
pericardial resistance, by the atrial force and by the atrio- pericardial resistance, by the atrial force and by the atrio-
ventricular synchronicity #$ ./0 12 interval%. ventricular synchronicity #$ ./0 12 interval%.
Patient .ifferences
-+ is a hemod)nami( disorder .%t there is a

poor relationship .et3een meas%res of
(ardia( performan(e and patient s)mptoms
+or e0ample, pts 3ith 4er) lo3 *+ ma) .e

as)mptomati( 3hile someone 3ith preser4ed
*+ ma) .e se4erel) disa.led 3ith s)mptoms
Body Compensatory
,echanisms
*pinephrine and norepinephrine release 3hi(h in(reases heart rate and

(ontra(tilit) 3hi(h in(reased m)o(ardial 3or, load
'e(rease salt and 3ater e0(retion from ,idne)s 3hi(h helps maintain
26 .) in(reasin& .lood 4ol%me, this leads to stret(hin& of heartIs
(ham.ers 3hi(h (an impair a.ilit) to (ontra(t
-)pertroph) and thi(,enin& of heart m%s(le 3hi(h initiall) in(reases

(ontra(tilit) .%t o4er time leads to stiff (ham.ers and (an impair
(ontra(tilit)
-+ patients ha4e hi&her le4els of epinephrine, norepinephrine,

aldosterone, an&iotensin <<, endothelin, inflammator) ()to,ines, and
4asopressin 3hi(h (ontri.%te to heart remodelin&, pro&ression of -+,
and hi&her le4els are asso(iated 3ith in(reased mortalit)
Potential (easons
Potential (easons
Alternation in %entricular distensi!ility

Alternation in %entricular distensi!ility
&al%ular regurgitation
&al%ular regurgitation
Pericardial restraint
Pericardial restraint
Cardiac rhythm
Cardiac rhythm
Conduction a!normalities
Conduction a!normalities
R& function
R& function
Also se%eral non-cardiac factors including peripheral

Also se%eral non-cardiac factors including peripheral
%ascular f#n, refle# autonomic acti%ity, renal sodium
%ascular f#n, refle# autonomic acti%ity, renal sodium
handling, etc+
handling, etc+

"F (is? Factors ' "istor!
"F (is? Factors ' "istor!
'mo"ing
'mo"ing
Et?H use
Et?H use
D.
D.
H(7
H(7
Dyslipidemia
Dyslipidemia
(hyroid disorder
(hyroid disorder
Chemotherapy
Chemotherapy
Radiation
Radiation
Cardioto#ic drugs
Cardioto#ic drugs
Fam H# of sudden
Fam H# of sudden
death, CAD, conduction
death, CAD, conduction
pro!lems, HC.
pro!lems, HC.
HI& status
HI& status
Cardiovascular Medical "&
Cardiovascular Medical "&
H# of heart failure
H# of heart failure
Angina
Angina
.I
.I
CAG
CAG
PCI
PCI
Pacema"erMICD
Pacema"erMICD
Em!olic e%ents
Em!olic e%ents
arrhythmias
arrhythmias
C&A
C&A
P&D
P&D
Rheumatic D#
Rheumatic D#
?ther %al%ular h#
?ther %al%ular h#
Congenital
Congenital
Signs and S!mtoms of "F
Signs and S!mtoms of "F
Dyspnea
Dyspnea
P7D
P7D
?rthopnea
?rthopnea
Cough
Cough
E#ercise intolerance
E#ercise intolerance
Edema
Edema
Fatigue
Fatigue
7ausea
7ausea
A!dominal Fullness
A!dominal Fullness
Rales
Rales
'5
'5
Pulmonary edema
Pulmonary edema
U&D
U&D
(achycardia
(achycardia
Cardiomegaly
Cardiomegaly
HepatoFugular refle#
HepatoFugular refle#
Peripheral Edema
Peripheral Edema
Hepatomegaly
Hepatomegaly
"F Diagnosis and Assessment
"F Diagnosis and Assessment
Remains primarily a clinical diagnosis !ut

Remains primarily a clinical diagnosis !ut
additional information %ia other diagnostics
additional information %ia other diagnostics
can !e !eneficial
can !e !eneficial
E%aluation depends on if this is first

E%aluation depends on if this is first
presentation, change in clinical symptoms,
presentation, change in clinical symptoms,
certainty of diagnosis, etc
certainty of diagnosis, etc

N&,*+
*symptomatic
+" .ysfunction
Compensated
C$0
.ecompensated
C$0
No symptoms
Normal e/ercise
Normal +" f/n
No symptoms
Normal e/ercise
*(normal +" f/n
No symptoms
E/ercise
*(normal +" f/n
%ymptoms
E/ercise
*(normal +" f/n
efractory
C$0
%ymptoms not controlled
'ith treatment
Chronic Congestive "eart Failure
Chronic Congestive "eart Failure
Evolution of Clinical Stages
Evolution of Clinical Stages
4entricular (emodeling in C"F
4entricular (emodeling in C"F
Jess%p, N*J/ F!!3
S!mtoms of "F
S!mtoms of "F

F
F
atigue
atigue
A
A
cti%ity decrease
cti%ity decrease
C
C
ough (especially supine$
ough (especially supine$
E
E
dema
dema
S
S
hortness of !reath
hortness of !reath
2IE0
2IE0
Aroach to the Patient
Aroach to the Patient
@ith "eart Failure
@ith "eart Failure
!
!
iagnose
iagnose
Etiology Etiology
'e%erity (>& 'e%erity (>&

dysfunction$ dysfunction$
I
I
nitiate
nitiate
DiureticMACE inhi!itor DiureticMACE inhi!itor

-!loc"er -!loc"er
'pirololactone 'pirololactone
Digo#in Digo#in
)
)
ducate
ducate
Diet Diet
E#ercise E#ercise
>ifestyle >ifestyle
C& Ris" C& Ris"
$
$
itrate
itrate
?ptimi;e ACE inhi!itor ?ptimi;e ACE inhi!itor
?ptimi;e ?ptimi;e
-!loc"er -!loc"er
(herapy of CHF
(herapy of CHF

Clinical Approach to CHF,
Clinical Approach to CHF,
-
Consider etiology
Consider etiology
-
Identify triggers
Identify triggers
-
E#clude ischaemia
E#clude ischaemia
-
General measures
General measures
-
'ymptomatic therapy
'ymptomatic therapy
-
Prognostic therapy
Prognostic therapy

'ee Guide for HF .anagement Chec"-list
'ee Guide for HF .anagement Chec"-list
'ymptoms @ 'igns of HF,
'ymptoms @ 'igns of HF,
8
Fatigue (lo- cardiac out-put$
Fatigue (lo- cardiac out-put$
8
'?
'?
U&P
U&P
8
Rales
Rales
8
'5
'5
8
Edema
Edema
8
Radiologic congestion
Radiologic congestion
8
Cardiomegaly
Cardiomegaly
?!tain CHR to rMo non-cardiac causes e+g+ interstitial lung ?!tain CHR to rMo non-cardiac causes e+g+ interstitial lung
disease @ PPH disease @ PPH
;2P in the Diagnosis of "F
(he role of natriuretic peptides (he role of natriuretic peptides
A7P-atrial natriuretic peptide A7P-atrial natriuretic peptide
Produced in atria in response to -all stress Produced in atria in response to -all stress
7P-!rain natriuretic peptides 7P-!rain natriuretic peptides
Produced in %entricles in response to %olume and pressure o%erload Produced in %entricles in response to %olume and pressure o%erload
C7P-central ner%ous system and endothelium C7P-central ner%ous system and endothelium
Produced in response to endothelial stress Produced in response to endothelial stress
Produced as prohormones and clea%ed to acti%e molecule Produced as prohormones and clea%ed to acti%e molecule
(A7PM7P$and inacti%e 7( forms (A7PM7P$and inacti%e 7( forms
A7PM7P ele%ated in
A7PM7P ele%ated in
'ystemic and pulmonary hypertension 'ystemic and pulmonary hypertension
Hypertrophic and restricti%e cardiomyopathy Hypertrophic and restricti%e cardiomyopathy
Pulmonary em!olism Pulmonary em!olism
C?PD C?PD
Cor pulmonale Cor pulmonale
A.I Cirrhosis A.I Cirrhosis
Renal Failure Renal Failure

Higher le%els of 7P correlate -ith
Higher le%els of 7P correlate -ith
higher PC0 pressures

higher PC0 pressures
in compensated and decompensated patients in compensated and decompensated patients
larger >& %olumes

larger >& %olumes
lo-er eFection fractions

lo-er eFection fractions
in symptomatic HF patients in symptomatic HF patients
7P study
7P study 5Circ #$$#&*$%( ;*%!;##6 5Circ #$$#&*$%( ;*%!;##6
7P sensiti%ity N2C and specificity I5C for HF 7P sensiti%ity N2C and specificity I5C for HF
;2P Diagnostic Cut Points for C"F
;2P Diagnostic Cut Points for C"F
GACC 211%80B(2,:0BD-CA.
GACC 211%80B(2,:0BD-CA.

7P T B22 pgM> K acute CHF present
7P T B22 pgM> K acute CHF present
7P 322 pgM> K B22 pgM>
7P 322 pgM> K B22 pgM>
8
Diagnostic of CHF -ith
Diagnostic of CHF -ith
'ensiti%ity N2C 'ensiti%ity N2C
'pecificity I6C 'pecificity I6C
Predicti%e accuracy 45C Predicti%e accuracy 45C
RM? pulmonary em!olism, >& dysfunction -ithout acute RM? pulmonary em!olism, >& dysfunction -ithout acute
CHF or cor pulmonale CHF or cor pulmonale
7P A 322 pgM> K N4C negati%e predicti%e accuracy
7P A 322 pgM> K N4C negati%e predicti%e accuracy
Identify triggers
Identify triggers

Acute'sudden onset
Acute'sudden onset
Ischaemia
Ischaemia
Arrhythmia
Arrhythmia
Infection
Infection
Pulmonary em!olism
Pulmonary em!olism
Acute %al%ular
Acute %al%ular
pathology
pathology
Chronic'gradual onset
Chronic'gradual onset

Anemia
Anemia
(hyroto#icosis
(hyroto#icosis
7on-compliance
7on-compliance
Diet
Diet
R# e+g+ 7'AIDPs
R# e+g+ 7'AIDPs
2on'Invasive Evaluation of the "eart Failure
2on'Invasive Evaluation of the "eart Failure
Patient'Imlications of )4 E-ection Fraction
Patient'Imlications of )4 E-ection Fraction
(o "no- -here you are

(o "no- -here you are
going you must "no-
going you must "no-
-here you are coming
-here you are coming
from
from
E%aluate >& function

E%aluate >& function
clinical clinical
echo echo
gated study gated study

EFection fraction
EFection fraction
(o!tain echo or >& gated study$
(o!tain echo or >& gated study$
8
>&EF
>&EF
B2C [ systolic dysfunction

B2C [ systolic dysfunction
8
>&EF B2-EEC [ mi#ed systolic and diastolic
>&EF B2-EEC [ mi#ed systolic and diastolic
dysfunction
dysfunction
8
>&EF
>&EF
EEC [ diastolic dysfunction

EEC [ diastolic dysfunction
identify triggers
identify triggers

treat underlying disorder

treat underlying disorder
(HP(MischaemiaMpericardial
(HP(MischaemiaMpericardial
constrictionMrestricti%e C.Minfiltrati%e
constrictionMrestricti%e C.Minfiltrati%e
disorders$
disorders$
Echocardiograhic Evaluation
Echocardiograhic Evaluation
of C"F
of C"F
>& function (EF$,cham!er >& function (EF$,cham!er

si;e,-all motion si;e,-all motion
'egmental dysfunction- 'egmental dysfunction-

coronary disease coronary disease
.'-se%erity, %al%e area .'-se%erity, %al%e area
A'- %al%e gradient, %al%e A'- %al%e gradient, %al%e

area area
ARM.R se%erity ARM.R se%erity
(R- R& systolic pressure [ (R- R& systolic pressure [

PA pressure PA pressure
R& function R& function
RM? IH'', HC. RM? IH'', HC.
RM? Pericardial Disease RM? Pericardial Disease
RM? rare causes e+g+ RM? rare causes e+g+

my#oma, infiltrati%e my#oma, infiltrati%e
disorders- restricti%e disorders- restricti%e
cardiomyopathy cardiomyopathy
Diastolic function Diastolic function
Hyperdynamic states Hyperdynamic states

52-E2C of elderly HF patients ha%e reser%ed

52-E2C of elderly HF patients ha%e reser%ed
>& systolic function
>& systolic function
Diastolic dysfunction may induce dyspnea on

Diastolic dysfunction may induce dyspnea on
e#ertion
e#ertion
Fran" congestion usually has identifia!le

Fran" congestion usually has identifia!le
precipitant
precipitant
Clinical Imlications of )4
Clinical Imlications of )4
D!sfunction in "eart Failure
D!sfunction in "eart Failure
Calculated EF !y echo Calculated EF !y echo

unrelia!le in remodeled unrelia!le in remodeled
>& >&
&isual estimate of EF &isual estimate of EF

semi-Vuantitati%e semi-Vuantitati%e
(CC7 >& function scale$ (CC7 >& function scale$
Grade I >& EF Grade I >& EF g gE2C E2C
Grade 1 >&EF 5E-BNC Grade 1 >&EF 5E-BNC
Grade 5 >&EF 12-5BC Grade 5 >&EF 12-5BC
Grade B >&EFA 12C Grade B >&EFA 12C

)4EF Entr! Criteria in ACE )4EF Entr! Criteria in ACE
inhi%itor and inhi%itor and

'%loc?er Trials '%loc?er Trials
'?>&D treatment an '?>&D treatment an

pre%ention pre%ention 5EC 5EC
'A&E (post .I$ 'A&E (post .I$ B2C B2C
D+'+ Car%edilol HF (rials D+'+ Car%edilol HF (rials

Program >&EF Program >&EF 5EC 5EC
.erit-HF >&EF .erit-HF >&EF B2C B2C
CII' II >&EF CII' II >&EF B2C B2C

Consider etiology
Consider etiology
8
Ischemic- Cardiomyopathy (C.$
Ischemic- Cardiomyopathy (C.$
8
HP(-C.
HP(-C.
8
&al%ular HD-C. (A'MARM.R$
&al%ular HD-C. (A'MARM.R$
8
.eta!olic,
.eta!olic,
M
M
thyroidMhemochromatosisM
thyroidMhemochromatosisM
pheochromocytoma
pheochromocytoma
8
(o#ins,
(o#ins,
AnthracyclinesMEtohMcocaineMamphetamines
AnthracyclinesMEtohMcocaineMamphetamines
8
&iral C.
&iral C.
8
Idiopathic Dilated C.
Idiopathic Dilated C.
8
?ther,
?ther,
(reatment
(reatment
General .easures
General .easures
General measures,
General measures,
8
Correct triggers and
Correct triggers and
precipitants of acute and
precipitants of acute and
chronic HF
chronic HF
8
>o- sodium diet
>o- sodium diet
8
Fluid restriction
Fluid restriction
8
Regular e#erciseM
Regular e#erciseM
8
Acti%ity HR R#
Acti%ity HR R#
8
(reat ischemia
(reat ischemia
8
Control hypertension
Control hypertension
8
DMC 'mo"ing
DMC 'mo"ing
8
(reat lipid
(reat lipid
a!normalities
a!normalities
8
(reat and control
(reat and control
dia!etes
dia!etes
8
Identify @ R#
Identify @ R#
depression
depression
'ia&nosti( :ests:
CV5>*CN>2N6
*(ho>5NA>/5<:
*tiolo&)>1e4erit)
*dditional Tests
%pecific T/
$Cath
$CA2N
$Val4e 10
'iastoli( -+:
50 (a%se5eferral
1)stoli( -+:
/edi(al10>'e4i(e
<s it -eart +ail%reX
1)mptoms T 1i&ns
Life 1t)le D
6atient *d%(ation
-+ Clini(s +>Q
"F Management Algorithm
"F Management Algorithm
<E"
<E"
Primar! Targets of Treatments
Primar! Targets of Treatments
in C"F
in C"F
Jess%p, N*J/ F!!3
Assess >& Function (echo, gated R7A$
8EF A B2C-systolic dysfunction
8EF B2-EEC-systolicMdiastolic dysfunction
8EF TEEC-diastolic dysfunction
Assess &olume 'tatus
'igns and 'ymptoms of
Fluid Retention
7o 'igns and 'ymptoms
of Fluid Retention
>oop Diuretic
\M- (hia;ide
(titrate to eu%olemic state$
ACE inhi!itorMAR if ACE intolerant
Com!ination R# if HF, hospitali;ation or -!loc"er intolerant
'pironolactone
(7LHA Class III-I& CHFMEFA5ECMCrA122M/AE$
Add Digo#in for
symptom control
'ymptoms Prognosis @ 'ymptoms
-!loc"er (7LHA II-I&$
"eart Failure Theraeutic ,oal
.ild-.oderate Heart Failure

.ild-.oderate Heart Failure
Primary goal [ Reduce mortality

Primary goal [ Reduce mortality
-!loc"ers \ ACE inhi!itors

-!loc"ers \ ACE inhi!itors
Pre%ent progression to symptoms

Pre%ent progression to symptoms
Pre%ent progressi%e >& dysfunction

Pre%ent progressi%e >& dysfunction
.oderate-'e%ere Heart Failure

.oderate-'e%ere Heart Failure
Primary goal [ Reduce symptoms

Primary goal [ Reduce symptoms
Impro%e Vuality of life (W?>$

Impro%e Vuality of life (W?>$
Reduce hospitali;ations
Reduce hospitali;ations
Pre%ent sudden death

Pre%ent sudden death
Inotropes, mitral repair, &AD, (# Inotropes, mitral repair, &AD, (#
,eneral (& Strategies in "F
,eneral (& Strategies in "F
Angiotensin Con%erting En;yme Inhi!itors Angiotensin Con%erting En;yme Inhi!itors
Car%edilolM Car%edilolM
-loc"ers -loc"ers
Diuretics ('pironolactone$ Diuretics ('pironolactone$
Digo#in Digo#in
7o Added 'alt 7o Added 'alt 1 gm 7a 1 gm 7a
Acti%ity as (olerated Acti%ity as (olerated Customi;ed E# (raining Customi;ed E# (raining
(ailored R# (ailored R#
Correct Cause( Correct Cause(
Arrhythmias Arrhythmias
Ischemia Ischemia
4ressure =oad 4ressure =oad
Asymptomatic Asymptomatic Mild9Mod Mild9Mod "evere "evere .efractory .efractory
Modified from 3arner!"tevenson1 ACC HF "ummit Modified from 3arner!"tevenson1 ACC HF "ummit
Severit! of "eart Failure
Severit! of "eart Failure
Modes of Death
Modes of Death
/*5<:=-+ 1t%d) Nro%p. ,ANCE+
1999;353:F!!1=!M.
D=G D=G
=CG =CG
BCG BCG
C$0 C$0
&ther &ther
%udden %udden
.eath .eath
n G 1!3 n G 1!3
N?$* -- N?$* --
=BG =BG
DFG DFG
FMG FMG
C$0 C$0
&ther &ther
%udden %udden
.eath .eath
n G 1!3 n G 1!3
N?$* --- N?$* ---
FBG FBG
DDG DDG
EEG EEG
C$0 C$0
&ther &ther
%udden %udden
.eath .eath
n G FM n G FM
N?$* -" N?$* -"
Theraies Provided %! Toda!$s
Theraies Provided %! Toda!$s
Dual'Cham%er ICDs
Dual'Cham%er ICDs
Atrium @
Atrium @
&entricle
&entricle
4
radycardia sensing radycardia sensing
4
radycardia pacing radycardia pacing
Atrium
4
AT3AF tach!arrh!thmia
detection
4
Antitach!cardia acing
4
Cardioversion
4entricle
4
4T3 4F detection
4
Antitach!cardia acing
4
Cardioversion
4
Defi%rillation
Thera! *C(T+
Thera! *C(T+
Atrial-!i%entricular
Atrial-!i%entricular
stimulation
stimulation
Electrical
Electrical
synchroni;ation
synchroni;ation

narro-er WR'
narro-er WR'
.echanical
.echanical
synchroni;ation
synchroni;ation

re%erse remodeling
re%erse remodeling
%tages of $eart 0ailure
At Ris! for (eart Failure)
%T*GE * $igh risk for developing $0
%T*GE B *symptomatic +" dysfunction
(eart Failure)
%T*GE C Past or current symptoms of $0
%T*GE . End4stage $0
Acute heart failure
Acute heart failure
A"F: A"F:
(he rapid onset of symptoms and signs secondary to (he rapid onset of symptoms and signs secondary to
a!normal cardiac function+ a!normal cardiac function+
(reduced C?, tissue hypoperfusion \ congestion, increase in PC0P$ (reduced C?, tissue hypoperfusion \ congestion, increase in PC0P$
7. 7. 0ith or -ithout pre%ious cardiac disease+ 0ith or -ithout pre%ious cardiac disease+
G. G. (he cardiac dysfunction can !e related, (he cardiac dysfunction can !e related,
a$ to systolic or diastolic dysfunction a$ to systolic or diastolic dysfunction
!$ to a!normalities in cardiac rhythm !$ to a!normalities in cardiac rhythm
c$ to preload and afterload mismatch c$ to preload and afterload mismatch
8. 8. ?ften life threatening and reVuires urgent treatment+ ?ften life threatening and reVuires urgent treatment+
The Tas? Force on Acute "eart Failure of the Euroean Societ! of Cardiolog! The Tas? Force on Acute "eart Failure of the Euroean Societ! of Cardiolog!
70&8*. 0*-+9E: (+o' Cardiac &utput)#
.ecreased perfusion of the (rain (confusion)6
kidneys (impaired renal function),
skin (cyanosis) etc6
7
7B*C28*.
0*-+9E:
#
-ncreased
pulmonary
venous pressure,
pulmonary edema
Acute heart failure
Acute heart failure
Epidemiology
Epidemiology
Increase of pts -ith CHF (aging of population \ impro%ed

Increase of pts -ith CHF (aging of population \ impro%ed
sur%i%al$ [ increase in the num!er of hospitalisations for
sur%i%al$ [ increase in the num!er of hospitalisations for
the decompensated heart failure +
the decompensated heart failure +
Poor prognosis,
Poor prognosis,
AMI Q S"F
AMI Q S"F
:
:
52C annual mortality
52C annual mortality

APO:
APO:
B2C annual
B2C annual
mortality
mortality

31C in-hospital mortality
31C in-hospital mortality
3+ 3+ CAD, CAD, 62-I2C (particularly in elderly population$ 62-I2C (particularly in elderly population$
1+ 1+ Dilated cardiomyopathy, arrhythmia, congenital or &HD or Dilated cardiomyopathy, arrhythmia, congenital or &HD or
myocarditis, myocarditis, in youmger su!Fects+ in youmger su!Fects+
Acute Heart Failure , Classification
Acute Heart Failure , Classification
+
Acute de no%o (ne- onset of AHF in a patient
Acute de no%o (ne- onset of AHF in a patient
-ithout pre%iously "no-n cardiac dysfunction$+
-ithout pre%iously "no-n cardiac dysfunction$+
or
or
+
Acute decompensation of chronic heart failure+
Acute decompensation of chronic heart failure+
Can resent itself as:
Can resent itself as:
*PHARMACOLOGICAL !RA!"GI" #
3e! drugs.
1harmacogenetics.
4etabolic modulation.
5mmunomodulation.

*$onp%armacological trategies#
4yocardial repair and regeneration by6
7tem cell89 progenetorcells
-issue engineering
*Gene t%erapy&

*'"VIC" !H"RAP(#
/2-
3.: VAD
*I$!"RV"$!IO$&

New drugs
NEW ENOTROPICS.
AQUARETICS &NATRIURETICS.
ENDOTHELIN ANTAGONISTS.
NEW B-BLOCKERS.
BROMOCRIBTIN.
Adatation in "F'
Adatation in "F'
S!mathetic nervous
S!mathetic nervous
s!stem is activated
s!stem is activated
-eart rate
+or(e of (ontra(tion
'ilatation of (oronar)
arteries
6erif. 4as(%lar resistan(e
5edistri.%tion 9renal .lood
s%ppl);
'ire(t ()toto0i( effe(t
Apoptosis
A(ti4ation of the 5AA1
Adatation'
Adatation'
Activation of the (AAS
Activation of the (AAS
2lood press%re
6erf%sion of the
@%0ta&lom. appar8t%s
1A a(ti4ation
1odi%m and 3ater retention
Vaso(onstri(tion
Aldosterone
A'- 94asopressin;
/)o(ardial h)pertroph)
/)o(ardial fi.rosis
*ndothel d)sf%n(tion
Coa&%lation
renin

Prof Univ DR Ion C.Tintoiu FESC Centrul de Cardiologie Al Armatei Universitatea Titu Maiorescu

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Prof Univ DR Ion C.Tintoiu FESC Centrul de Cardiologie Al Armatei Universitatea Titu Maiorescu

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Prof Univ Dr Ion C.

Diagnosing and classifying heart failure

Approach to management of CHF

i%entricular (i&$ pacers i%entricular (i&$ pacers

Intracardiac defi!rillators (ICDs$ Intracardiac defi!rillators (ICDs$

'urgery and Inter%entional (reatment 'urgery and Inter%entional (reatment

"eart failure is a clinical s!ndrome usuall! due to

The most common causes of heart failure are

Other causes are

The heart$s ina%ilit! to um enough %lood

It is a common end point for many

CAD CAD 671 671

Idioathic Idioathic 781 781

Undetermined Undetermined 701 701

4alve 4alve 701 701

"!ertension "!ertension 9./1 9./1

Atrial Fi%rillation Atrial Fi%rillation 81 81

From hemodynamic stand point HF can be

Changes in contractile proteins

Program cell death (

Increase amount of fibrous tissue

'i;e and shape of heart

E%idence of pulmonary %enous congestion (dilated

E-ection Fraction *EF+ is the ercentage of %lood

Diastolic d!sfunction Diastolic d!sfunction

EF normal or increased EF normal or increased

Due to chronic replacement fi!rosis @ Due to chronic replacement fi!rosis @

S!stolic d!sfunction S!stolic d!sfunction

Dsually from coronary disease Dsually from coronary disease

Due to ischemia-induced decrease in Due to ischemia-induced decrease in

.ost common is a com!ination of !oth .ost common is a com!ination of !oth

sudden onset -ith associated signs and symptoms

secondary to slo- structural changes occurring in

sudden e#acer!ation or onset of symptoms in

?ften precipitated !y a myocardial infarction+

'e%ere !reathlessness 'e%ere !reathlessness

Frothy pin" sputum Frothy pin" sputum

Cold clammy s"in Cold clammy s"in

>o- !lood pressure >o- !lood pressure

>ung crepitations >ung crepitations

Raised Fugular %enous pressure Raised Fugular %enous pressure

(hird heart sound (hird heart sound

S!mtoms include: S!mtoms include:

Dne#plained cough Dne#plained cough

Pulmonary crac"les Pulmonary crac"les

>o- o#ygen saturation >o- o#ygen saturation

(hird heart sound (hird heart sound

Reduced urine output Reduced urine output

Altered digestion Altered digestion

Di;;iness and light- Di;;iness and light-

Restlessness and an#iety Restlessness and an#iety

Fatigue and -ea"ness Fatigue and -ea"ness

>o-er e#tremity edema >o-er e#tremity edema

>i%er enlargement >i%er enlargement

A!dominal pain A!dominal pain

0eight gain 0eight gain

only in case of fluid retention

add ACEi or ARO

Hyonatraemia, hypo"alemia, %olume

starting dose, target dose

Hyperla"aemia, renal dysfunction

reduce >&EDP, ? reduce >&EDP, ?

Unsta%le Angina UA+ Unsta%le Angina UA+

Transmural M!ocardial Infarction AMI+ Transmural M!ocardial Infarction AMI+