AMS Heart Failure 2024 PDF

Heart Failure – Clinical Aspects Dr Daniel Obaid 21 November 2023  Lecture Plan 1)Clinical Presentation 2)Pathophysiology 3)Management  Definition “Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symp...

Heart Failure – Clinical Aspects Dr Daniel Obaid 21 November 2023  Lecture Plan 1)Clinical Presentation 2)Pathophysiology 3)Management  Definition “Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral oedema). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. 2021  Definition “Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral oedema). It is due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise.” ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. 2021  Clinical Presentation Symptoms Breathlessness Orthopnoea Paroxysmal nocturnal dyspnoea Reduced exercise tolerance Fatigue Ankle swelling  Clinical Presentation New York Heart Association Classification of Heart Failure Class II Class III Class IV Class I Slight limitation of Marked limitation of Unable to carry out any No limitation of physical activity physical activity. physical activity. physical activity. without discomfort. Comfortable at rest, Comfortable at rest, Ordinary physical Symptoms of heart but ordinary physical but less than ordinary activity does not cause failure are present even activity results in activity results undue undue breathlessness, at rest with increased undue breathlessness, breathlessness, fatigue, fatigue, or palpitations. discomfort on physical fatigue, or palpitations. or palpitations. activity.  Clinical Presentation Symptoms Signs Breathlessness Elevated jugular venous pressure Orthopnoea Pitting Oedema Paroxysmal nocturnal dyspnoea Reduced exercise tolerance Lung crepitations Fatigue Ankle swelling  Clinical Presentation Elevated jugular venous pressure Pitting Oedema  Clinical Presentation Normal breath sounds Clinical Presentation Lung crepitations  Pathophysiology 1)Identification of the aetiology of the underlying cardiac dysfunction is important as the pathology can determine subsequent treatment.  Pathophysiology 1)Identification of the aetiology of the underlying cardiac dysfunction is important as the pathology can determine subsequent treatment. 2) Most commonly, Heart Failure is due to myocardial dysfunction: However, pathology of the valves, pericardium, and endocardium, and abnormalities of heart rhythm and conduction can also cause or contribute.  Pathophysiology Coronary Valvular Hypertension heart disease artery disease Infective Drug-induced Infiltrative Storage disorders Endomyocardial disease Pericardial disease Cardiomyopathy Metabolic Neuromuscular disease Arrhythmia Congenital heart disease  Pathophysiology Frank-Starling Mechanism Normal heart Stroke Volume (ml) Left ventricular End Diastolic Pressure (Preload)  Pathophysiology Frank-Starling Mechanism Normal heart Stroke Volume (ml) Heart failure Left ventricular End Diastolic Pressure (Preload)  Pathophysiology Systole 1 Contraction 2 Ejection Diastole 3 Relaxation 4 Filling Most patients with HF have evidence of both systolic and diastolic dysfunction. Systolic = failure of the ventricle to eject blood Diastolic = failure of the ventricle to relax and fill with blood  Management Figure 1 The diagnostic algorithm for heart failure. BNP = B-type natriuretic peptide; ECG = electrocardiogram;... Eur Heart J, Volume 42, Issue 36, 21 September 2021,  Management Figure 1 The diagnostic algorithm for heart failure. BNP = B-type natriuretic peptide; ECG = electrocardiogram;... Eur Heart J, Volume 42, Issue 36, 21 September 2021,  Management NT-proBNP BNP: B-type natriuretic peptide ‘Brain natriuretic peptide’ Released by ventricles in response to wall tension “stretch” A ‘blood test for heart failure’ Selecting breathless patients for further investigation Guide to treatment  Management Figure 1 The diagnostic algorithm for heart failure. BNP = B-type natriuretic peptide; ECG = electrocardiogram;... Eur Heart J, Volume 42, Issue 36, 21 September 2021,  Management Echocardiography - Normal Echocardiography – Impaired systolic function  Management Figure 1 The diagnostic algorithm for heart failure. BNP = B-type natriuretic peptide; ECG = electrocardiogram;... HF with reduced ejection fraction (HFREF) HF with preserved ejection fraction (HFPEF) Eur Heart J, Volume 42, Issue 36, 21 September 2021,  Management Kaplan-Meier curve of survival for people with a new diagnosis of heart failure who were admitted to hospital or not admitted to hospital at time of diagnosis and for comparators matched by age, sex, and practice. Clare J Taylor et al. BMJ 2019;364:bmj.l223  Management Disease modifying Prognostic: Reduce mortality Treat underlying condition 50% Sudden Cardiac Death (e.g. hypertension, CAD, valve 50% Pump failure disease, alcohol) Symptomatic: Reduce morbidity Lifestyle and education -Improve QOL - Patient &family -Reduce hospitalisation  Management Neuro-hormonal paradigm  Management Neuro-hormonal paradigm Management  Management Enalapril Ramapril  Management Bisoprolol Carvedilol  Management Spironolactone Epleronone Management Valsartan Candesartan Treatment Sacubitril & Valsartan Management Empaglifozin Dapaglifozin European J of Heart Fail. 2021  Management Non pharmacological treatment Resynchronisation therapy/ Valve repair/replacement Coronary Artery Bypass Mechanical circulatory implantable defibrillator Surgery (CABG) / Support / Percutaneous Coronary Transplantation intervention (PCI) Management Management Management Muthiah Vaduganathan er al Lancet 2020 , Management Muthiah Vaduganathan er al Lancet 2020 ,  Learning Outcomes 1)Clinical Presentation Classification Diagnosis 2)Pathophysiology Elevated filling pressure and impaired contraction Neuro hormonal Paradigm 3)Treatment Symptomatic control, reduction in preload Treatments proven to improve prognosis in RCTs “the 4 pillars” My Survey