Case of Heart Failure

Date:

Sunday, December 9, 2018

Case of Heart Failure

Prof. Dr. Soliman Ghareeb ,MD.

Professor of Cardiovascular Medicine Cairo University

Management of DHF

. Reduce symptoms

. Control hypertension

. Prevent myocardial ischemia

. Diuretics – provide the most symptoms relief if fluid retentionn is a future

. ACE inhibitors and β Blockers – complement diuretics well

. Central sympatholytics – hypertensive episodes

. Nitrates – preventing ischemia

. Trimetazidine – as a metabolic support

Did they apply the guidelines recommendation?

2013 ACCF/AHA Guideline for the Management of Heart Failure

. Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation

. Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation

. American College of Cardiology Foundation and American Heart Association, Inc.

Classification	Ejection Fraction	Description
I. Heart Failure with Reduced Ejection Fraction (HFrEF)	≤40%	Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date.
II. Heart Failure with Preserved Ejection Fraction (HFpEF)	≥50%	The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF.
a. HFpEF, Borderline	41% to 49%	These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF.
b. HFpEF, Improved	>40%	It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients

Initial and Serial Evaluation of the HF Patient Clinical Evaluation

Definition of Heart Failure

Initial and Serial Evaluation of the HF Patient

History and Physical Examination

A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors

that might cause or accelerate the development or progression of HF.

Initial and Serial Evaluation of the HF Patient

Diagnostic Tests

Initial laboratory evaluation of patients presenting with HF should include

1- complete blood count,

2- urinalysis,

3- serum electrolytes

4- blood urea nitrogen, serum creatinine,

5- glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone.

Serial monitoring, when indicated, should include

serum electrolytes and renal function.

. A12-lead ecg should be performed initially patients presenting with HF.

diagnostic tests for rheumatologic diseases amyloidosis,

Classification of Heart Failure

ACCF/AHA Stages of HF	NYHA Functional Classification
At high risk for HF but without structural heart disease or symptoms of HF.	None
Structural heart disease but without signs or symptoms of HF.	I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
Structural heart disease with prior or current symptoms of HF.	I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
	II	Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
	III	Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
Refractory HF requiring specialized interventions.	IV	Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

Initial and Serial Evaluation of the HF Patient

History and Physical Examination

A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors

that might cause or accelerate the development or progression of HF.

Initial and Serial Evaluation of the HF Patient

Diagnostic Tests

Initial laboratory evaluation of patients presenting with HF should include

1- complete blood count,

2- urinalysis,

3- serum electrolytes

4- blood urea nitrogen, serum creatinine,

5- glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone.

Serial monitoring, when indicated, should include

serum electrolytes and renal function.

. A12-lead ecg should be performed initially patients presenting with HF.

diagnostic tests for rheumatologic diseases amyloidosis

or pheochromocytomq are reasonable in patients presenting whith hf in whom there is a clinical suspicion of these diseases.

Biomarkers

Ambulatory/Outpatient

measurement of BNP or NT-probnp is useful for establishing diagnosis and prognosis or disease serverity in chronic HF.

. BNP

- 001<high negative predictive value

- 004> consistent with HF

- A.fib, chronic HF, pulmonary HTN, renal

failure " higher at baseline, so use higher cut-off for dx of acute diastolic heart failure

- Lower in obese people at baseline, so use lower cut-off for dx of acute diastolic heart failure

biomarkers of myocardial injury my be considered for additive risk stratification in patients with chronic HF.

Farmacological Treatment

Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity.

Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF.

Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT.

Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF.

The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF.

New treatment

Spironolactone

ConditionⅠⅠ

. Patient retuned back to his daily activities and continue on medical treatment including

- Ramipril 10 mg/day

- hydrochlorothiazide 12.5 mg/day

. being asymptomatic Patient after two years became

- non-compliant to treatment and life style

modification and he began to suffer from

. decrease his effort tolerance

. SOB on mild effort

. mild LL edema

. He sought medical advice

. Clinical examination revealed

- patient dyspnic at rest

- pulse 108/min , regular ,equal on UL &LL

- BP 158/116 mmHg

- LL oedema

- neck vein congested 12 cm

- cardiac apex in the 6th space out MCL

- S3 gallop

Physical Exam-Jugular Venous Distention

Technique for Measuring Jugular Venous Pressure

Patient reclining with head elevated 45°.

Measure elevation of neck veins above

the sternal angle (Lewis Method).

Add 5 cm to measurement since right

atrium is 5 cm below the sternal angle.

Normal CVP <= 8 cm H2O

. The patient was admitted to the hospital where he received The following medication :

Ramipril 10 mg/day.

furosemide 40 mg /day

digoxin .25 mg once /day

isosorbide dinitrate 10 mg/day

multivitamins once/day ???

The following investigations were ordered

. New ECG

. X-ray chest

. echocardiography

. Blood urea and creatinine

. Echocardiography was done and it showed

EDD 6.5 cm

ESD 5.1 cm

IVS 1.2 cm

PW 1.3 cm

LA 4.6 cm

EF 34 %

. blood urea 38 mg/dl normal

. Creatinine 1.4 mg/dl normal

Questions

What Type of heart failure this patient did suffer ?

What is wrong in the management ?

Systolic Heart FailureHFrEF

Characteristics of Systolic Heart Failure (HFrEF)

. Since the ventricle is inadequately emptied, ventricular end-diastolic pressure and volumes increase affecting the atrium.

. On the left side of the heart, the increased pressure is transmitted to the pulmonary vasculature extravasation of fluid into the lung parenchyma extravasation of fluid into the lung parenchyma pulmonary edema.

. On the right side of the heart, the increased pressure is transmitted to the systemic venous circulation and systemic capillary beds extravassation of fluid into the tissues of target organs and extremities dependent peripheral edema.

Ejection fraction drops below 40%.

. More readily recognized.

. Described as failure of the pump function of the heart.

Characterized by a decreased ejection fraction (less than 45%).

. The strength of ventricular contraction is attenuated and inadequate for creating an adequate stroke volume resulting in inadequate cardiac output.

. Caused by dysfunction or destruction of cardiac myocytes or their molecular components.

. Most common mechanism of damage is ischemia causing infarction and scar formation dead myocytes are replaced by scar tissue decreased function of myocardium causing wall motion abnormality.

Etiologies of Systolic Heart Failure

. Coronary Artery Disease (65%)

. Non compliant hypertensive patients

. Idiopathic dilated cardiomyopathy

. Alcohol/toxin-induced cardiomyopathy

. Infectious/inflammatory process

. Familial dilated cardiomyopathy

. Postpartum cardiomyopathy

. Stress induced cardiomyopathy

. Endocrine/nutritional causes . Tachycardia mediated cardiomyopathy

Final Clinical Pearls

. Heart failure is either Diastolic or Systolic Heart Failure.(HFpEF & HFrEF )