Congestive Heart Failure

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Congestive Heart Failure

• Madi Capoccia DO
• 5 Jun 2007
• Dewitt Army Hospital

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Objectives

• Definition and Epidemiology
• Pathophysiology
• Diagnosis and Classification
• Treatment of Systolic Dysfunction
• Medical Therapy
• Device Therapy

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What is CHF?

• Definition
• Abnormality of cardiac function that leads to the
  inability of the heart to pump blood to meet the
  bodys basic metabolic demands or when it can do
  so only with an elevated filling pressure

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Epidemiology

• Prevalence
• Affects nearly 5 million Americans currently,
  500,000 new cases diagnosed each year
• Cost
• Annual direct cost in 10 billion dollars
• Incidence increased with age
• Effects 1-2 of patient from 50-59-years-old and
  10 of patient over the age of 75
• Frequency
• It is the most common inpatient diagnosis in the
  US for patients over 65 years of age
• Visits to their family practitioner on average
  2-3 times per year
• Gender
• Men women in those between 40 and 75 years of
  age
• The sexes are equal over 75 years of age

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Pathophysiology of Heart Failure

• Hemodynamic Model
• Neurohumoral Adaptations
• double-edged swords
• Renin-Angiotensin-Aldosterone System
• Sympathetic Nervous System
• Antidiuretic Hormone
• Atrial and B-type Natriuretic Peptides
• Endothelin

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Help initially

• Vasoconstriction
• Redistributes blood to vital organs
• Restoration of Cardiac Output
• Increased myocardial contractility and heart rate
• Expansion of the extracellular fluid volume

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Neurohumoral-RAAS
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Hurt long-term
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Precipitating Causes

• Common
• CAD (70)
• Systemic Hypertension
• Idiopathic
• Less Common
• Diabetes Mellitus
• Valvular Disease

• Rare
• Anemia
• Connective Tissue Disease
• Viral Myocarditis
• Hemochromatosis
• HIV
• Hyper/Hypothyroidism
• Hypertrophic Cardiomyopathy
• Infiltrative Disease including amyloidosis and
  sarcoidosis
• Mediastinal radiation
• Peripartum cardiomyopathy
• Restrictive pericardial disease
• Tachyarrhythmias
• Toxins
• Trypanosomiasis (Chagas disease)

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Systolic vs. Diastolic

• Diastolic dysfunction
• EF normal or increased
• Hypertension
• Due to chronic replacement fibrosis
  ischemia-induced decrease in distensibility
• Systolic dysfunction
• EF
• Usually from coronary disease
• Due to ischemia-induced decrease in contractility
• Most common is a combination of both

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Subtypes of Systolic Heart Failure

• High output
• Severe anemia
• AV malformations
• hyperthyroidism
• Low cardiac output

• Right Heart Failure
• Peripheral edema
• Left Heart Failure
• Pulmonary congestion
• Biventricular Failure
• Systemic and pulmonary congestion

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Evaluation

• History risk factors for ischemic heart disease,
  family history
• Physical exam S3, JVD more specific signs of HF
  than rales, peripheral edema

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Exam

• Major Criteria
• Paroxysmal nocturnal dyspnea
• Neck Vein Distention
• Rales
• Cardiomegaly
• Pulmonary Edema
• S3 Gallop
• Hepatojugular Reflex

• Minor Criteria
• Ankle edema
• Nocturnal Cough
• Dyspnea on ordinary exertion
• Hepatomegaly
• Pleural Effusion
• Tachycardia 120bpm

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Confirming the Presence of Heart Failure

• CXR-cardiomegaly and pulmonary edema Kerleys B
  Lines
• Laboratory Values
• BNP
• Maybe inc by age, female gender, CRI, pulm
  disease, hyperthyroid, obesity, steroid use
• Electrocardiogram/ECHO
• Anterior Q waves, LBBB, LVH

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Negative Prognostic Factors

• Clinical
• Increased Age, Diabetes, Smoking
• Laboratory
• Hyponatremia, Elevated neurohormones
• Hemodynamic
• Reduced EF, Increased Pulm Cap Wedge Pressure
• Electrophysiological
• A-fib, A-flutter, Ventricular ectopy, V-tach

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Classification of Heart Failure ACC/AHA Stage vs
NYHA Class
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Principles of Treatment

• Systolic HF
• ? Preload
• ? Afterload
• ? Ionotropy
• ? Neurohumoral
• activity

• ACE-I, Beta-blockers, and aldosterone antagonist
  are the mainstay of treatment

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Treatment of Systolic Heart Failure

• ACE Inhibitors-
• Works to inhibit the over stimulation of the RAS
  that leads to myocardial hypertrophy and fibrosis
• Causes balanced vasodilation
• Decrease the rate of morbidity mortality in
  all pts with systolic heart failure
• -If treating acute HF, can start after BP
  tolerates and pulmonary edema is relieved

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ACE-I

• CONSENSUS-Enalapril 2.5-40mg (188 days) vs
  placebo
• Pts were already taking digoxin and diuretics
• 253 Patient with NYHA Class IV
• Dec mortality at
• 6 months -40
• 1 Year 27

• SOLVD-Enalapril 20mg/day (41 mo)
• 2569 Patients with and EF
• Earlier stages of HF even asymptomatic
• NYHA Class II-III
• All cause mortality dec by 16
• Morality rate from HF dec by 16

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Angiotensin-Receptor Blockers

• Comparable to ACE inhibitors
• Reduce all-cause mortality
• Suitable alternative for patient with adverse
  events (angioedema, cough, hyperkalemia) occur
  with ace-i

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ACE ARB

• CHARM-Added (Lancet 2003)
• 2548 NYHA II-IV LVEF
• CV death, hospital admission
• NNT25
• Second study found no benefit
• But 23 discontinued due to side effects
  (increased cr, hypotension, hyperkalemia)
• Currently Ace Arb is not recommended

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Beta-Blockers

• 34 reduction in all mortality with use of
  beta-blockers
• Decrease Cardiac Sympathetic Activity
• Use in stable, chronic disease (start as early as
  discharge-IMPACT-HF)
• Titrate slowly
• Contraindications-bradycardia, heart block or
  hemodynamic instability
• Mild asthma was not a contraindication
• Work irrespective of the etiology of the heart
  failure

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Beta-blocker therapy-which to pick?

• Three beta-blockers
• Bisoprolol (Zebeta) -Trial CIBIS-II
• Metoprolol (Toprol XL) Trial MERIT-HF
  (sustained release)
• Carvedilol (Coreg) Trial-COPERNICUS
• 6 RCTs with 9,000 pts already taking ACE-I
  showed a significant reduction in total mortality
  and sudden death (NNT 24, and 35 over 1-2 years)
  regardless of severity
• Carvedilol vs. Metoprolol (COMET 2003)
• 3029 pts carvedilol 25mg bid vs. metoprolol 50
  mg bid
• Patient with NYHA Classes II-IV
• Carvedilol greater reduction in mortality (NNT,
  18 over 5 years) and cardiovascular mortality
  (NNT, 16 over 5 years) than metoprolol but
  hypotension was greater in carvedilol (14 vs 11
  percent)

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Initial and Target Doses of beta-blockers for HF
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Aldosterone Antagonists

• Spironolactone (Aldactone RALES 1999)
• Pts 1,663 Class III/IV, ACE, Loop,Dig, EF
• Decreased all cause mortality of 30, NNT10
• Hyperkalemia, gynecomastia
• Eplerenone (Inspra EPHESUS 2003)
• Pts 6,642 asym LV dysfunction, DM, or after MI
• Dec CV mortality of 13, NNT43
• Newer more selective inhibitor fewer side
  effects
• More pts on beta-blockers

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Hydralazine (Apresoline) and isosorbide dinitrate
(Sorbitrate)

• Hydralazine
• Reduces systemic vascular resistance by
  preferentially dilating arterioles
• Isosorbide Dinitrate
• Preferential Venodilator-reduces ventricular
  filling pressure and treat pulmonary congestion
• Reduces mortality upto 28
• Poor tolerability-30 drop out of study
• flushing, headaches, gi upset, less frequently
  can cause positive ANA titers and lupus-like
  syndrome

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Hydralazine (Apresoline) and isosorbide dinitrate
(Sorbitrate)

• African-American Heart Failure Trial (A-HeFT)
• advanced HF and a fixed dose of isosorbide
  dinitrate and hydralazine
• Added to Standard B-blocker/Ace-I therapy
• Some survival improvement

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Digoxin

• May relieve symptoms, does not reduce mortality
• Pts taking digoxin are less likely to be
  hospitalized (25 reduction)
• More admissions for suspected digoxin toxicity

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Loop Diuretics

• Mainstay of symptomatic treatment
• Improve fluid retention
• Increase exercise tolerance
• No effects on morbidity or mortality

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Antiplatelet Therapy and Anticoagulation

• Increased risk of Thromboembolic events, 1.6-3.2
  per year
• Antiplatelet therapy (aspirin) in not useful in
  patient in sinus rhythm
• Coumadin for patient with atrial fibrillation or
  a previous thromboembolic event

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Nesiritide (Natrecor)

• Recombinant form of human BNP
• Causes venous and arterial vasodilation
• has been shown to improve dyspnea and global
  assessments at 3 hours after initiation in pts
  with Acute HF.
• Risks- deleterious effect on renal function and
  decreased 30 day survival

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Nonpharmacological Management

• Sodium Restriction to 2g/day
• Risk Factor Management
• Exercise
• Decreases mortality (NNT4)
• Decreases hospitalizations (NNT5)
• Multidisciplinary, Disease-Management Approach
• CHAMP Cardiovascular Hospital Atherosclerosis
  Management Program
• ASA, beta-blocker, Nitrates, ACE-I, Statin,
  Exercise, Smoking Cessation, Dietary counseling
  (use increased by 80)

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Device Therapy

• Implantable Cardioverter-Defibrillators (ICD)
• Cardiac Resynchronization Therapy (CRT)
• Left Ventricular Assist Devices (LVAD)

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ICD

• SCD-HeFT (sudden cardiac death)
• 2521 patients with depressed LV systolic function
  and Class II-III HF
• Randomized to standard therapy vs. standard
  therapy plus ICD vs. standard therapy plus
  amiodarone
• 23 reduction in mortality with ICD
• No difference in mortality with amiodarone
• Results did not vary based on etiology of LV
  dysfunction

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ICD

• Recommended in pts with EFmoderate symptoms of HF
• Survival with good functional capacity is
  anticipated for 1 year

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CRT

• COMPANION Trial
• 1520 patients most with Class III-IV HF, QRS
  duration 120 ms
• Randomized in 122 ratio to standard therapy vs
  standard therapy plus CRT vs standard therapy
  plus CRT with device that also defibrillated
• 34 reduction in death or any hospitalization
  with CRT
• 40 reduction when combined with ICD

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Left Ventricular Assist Devices (LVAD)

• REMATCH Trial-
• 1 yr survival 52 (LVAD) vs 24 (rx)
• 2 yr survival 23 vs 8
• End-Stage (Class IV)
• HF pts ineligible for transplant due to
• 65yo
• DM with EOD
• CRI

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Diastolic Dysfunction

• Acute Management is the SAME
• Chronic Management is CONTROVERSIAL
• Diuretics-dec fluid volume
• CCB-promote left ventricular relaxation
• ACE-I-promote regression of left ventricular
  hypertrophy
• Beta-blockers/antiarrhytmic agents-control heart
  rate or maintain atrial contraction

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• QUESTIONS?

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Recent Inservice Exam Questions

• 1. Which one of the following is considered a
  contraindication to the use of beta-blockers for
  congestive heart failure?
• A) Mild Asthma
• B) Symptomatic Heart Block
• C) New York Heart Association (NYHA) Class III
  heart failure
• D) NYHA Class I heart failure in a patient with a
  history of a previous myocardial infarction
• E) An ejection fraction

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• 1. Answer B
• According to several randomized, controlled
  trial, mortality rates are improved in patient
  with heart failure who receive beta blockers in
  addition to diuretics, ACE inhibitors, and
  occasionally, digoxin. Contraindications to beta
  blocker use include hemodynamic instability,
  heart block, bradycardia, and severe asthma.
  Beta-blockers may be tried in patients with mild
  asthma or COPD as long as them are monitored for
  potential exacerbations. B-blocker use has been
  shown to be effective in patient with NYHA Class
  II or III heart failure. There is no absolute
  threshold ejection fraction . B-blockers have
  also been shown to decrease mortality in patients
  with a previous history of myocardial infarction,
  regardless of their NYHA classification

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• 2. Which one of the following serologic tests
  would be the most helpful for detecting left
  ventricular dysfunction?
• A) B-type natriuetic peptide (BNP)
• B) Troponin-T
• C) C-reactive protein (CRP)
• D) D dimer
• E) Cardiac interleukin-2

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• 2. Answer A.
• ?NP is a 32-amino acid polypeptide secreted from
  the cardiac ventricles in response to ventricular
  volume expansion and pressure overload. The
  major source of BNP is the cardiac ventricles,
  and because of its minimal presence in storage
  granules, its release is directly proportional to
  ventricular dysfunction. It is a simple and
  rapid test that reliably predicts the prescence
  or absence of heart failure.

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• 3. Which one of the following is a risk factor
  for perioperative arrhythmias?
• A) Supraventricular Tachycardia
• B) Congestive Heart Failure
• C) Age 60
• D) Premature Atrial Contractions
• E) Past history of hyperthyroidism

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• 3. Answer B
• Significant predictors of intraoperative and
  perioperative ventricular arrhythmias include
  preoperative ventricular (not supraventricular)
  ectopy, CHF, and tobacco use. Age and history of
  hyperthyroidism are not significant predictors of
  perioperative ventricular arrhythmias.

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• 4. Which one of the following is preferred for
  chronic treatment of congestive heart failure due
  to left ventricular systolic dysfunction?
• A) Diuretics
• B) Digoxin
• C) Calcium Channel Blockers
• D) ACE inhibitors
• E) Hydralazine (Apresoline) plus isosorbide
  dinitrate (Isordil, Sorbitrate)

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• 4. Answer D
• ACE-I are the preferred drugs for CHF due to LV
  systolic dysfunction, because they are associated
  with the lowest mortality. The combination of
  hydralazine/isosorbide dinitrate is a reasonable
  alternative, and diuretics should be used
  cautiously. It is not known whether Digoxin
  affects mortality, although it can help with
  symptoms.

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• 5. A 72-year-old male with class III CHF due to
  systolic dysfunction asks if he can take
  ibuprofen for his aches and pains.

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• A) NSAIDs are a good choice for pain relief, as
  they decrease systemic vascular resistance
• B) NSAIDs are a good choice for pain relief, as
  they augment the effect of his diuretic
• C) High-dose aspirin (325mg/day) is preferable
  to other NSAIDs for patients talking ACE-I
• D) NSAIDs, including high-dose aspirin, should
  be avoided in CHF patient because they can cause
  fluid retention

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• 5. Answer D
• If possible, NSAIDs should be avoided in patients
  with heart failure. They cause sodium and water
  retention, as well as an increase in systemic
  vascular resistance which may lead to cardiac
  decompensation. NSAIDs may negate or decrease
  entirely the beneficial unloading effects of ACE
  inhibition.

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References

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