Heart Failure - Cardio Dr Hawary 2022 PDF

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1 EA RT FAILURE H DEFINITIONli -l·lrMHfflllild ?:!: ·urr·n1,,, P' ,s nnd/or S, ns lh:il result from a 20 2,1 ny: · \VII1 l. ·1·1ly O f f I lC vcntnc JU) M. , I 10n11 alit y t hat l tile c l (s) l o.. /\ {:UN/C,tl S..r',D nhn 1 )I [lbl V 1 I a. R.-1 1 21 nd/or f l}J\( TJJL- ou c of lhc following: r b Y UJ.I..sf il.1-,.ll'a aJ - nit cd - ocl... coi < bo. l ( Tl.. TR W-A-"-. Ii,Jr't'f hi< r nliogc111c Pulmonary or, ystcm,c congc tio 1 wil h. i c cv1clcnc,c O n 11. t nn d/ m or l.JC ill. F · I· I ·v c l N:1triun:t1' Pq dl t:.ETIOLOGY PULMONARY HTN (e.g. CC Pn) 't trEMI.... ,,. VaJvular disease: PS d, c 1 A S disease: PS vatvubr norla Congenital. ·eta ti on of--+--------------.'.... e.. Coc1, Prcssu re o, crload ·. I dis ·ns noc.nil,l -- - I()N / HYPERDYNAMIC CIRCULATION C ClRC HYPERDYNAl'v11 R [ Valvular disease: PR, TR AR, Valvular disease: I Congenita l disease: ASD ------ ·- 1 e: VS ------.....--..- Congenitnl diseas - me onrload L _ --- -- - ·.:. '!tire , Iatrogenic fluid overload Rena 1 1ai ,_ 1,;· l -·- ---- -. ·-. - Segmental affection ------c.., ntractility · d'ia I e f"'i Pcncar ,:on , Constrictive pericarditis ·c.!:;:. Relaxation (Filling) IICM, RCM OTHERS AJcohol, Cocaine] J. t fost common cause. ·:;HTN (esp. gp 2 & 3) IHJJ,. - - PRECIPITATI G CTORS 1 1 Tri ggers 11 - These factors: may change a state of Stable (Compensated) HF into Acute.Decompensated HF. - These factors: if not removed during treatment, HF will becom e Refractory. ' Infections: esp. infective endocarditis. rheumatic activity & chest infection. Iatrogenic:.C? rtico teroi_ds &.C Bs (Non-DHP) & I!Hf.D1scontmuat1on of ant1-faI1ur. (except Amlodipine & Felodipine}. 1 c trea tm ent. 0.Excessive salt.- intake & JV fluids. '-·' Anemia u1yrot c' ,., ox1·cos1· s & other causes of Acut e oronary Syndr hyperdynamic circulation. Y ome e.g. AMI). A Y brupt severe j in systemi c BP (l- C acute Coronary syndrome Arrhythmias (e ryperte. nsi. vc emergen _. g. AF·Q!. Bm2 Kg/week) Bloated feeling , Loss of appetite Weight loss (Cachexia in advanced HF) Palpitatio n , Syncope Tachycardia, Tachypnea Confusion, Depression , Dizziness Irregular pulse, Narrow pulse pressure Bendopnea Cold extremities, Oliguria Cardiac m urmur, Pulmonary crepitations Hepatomegaly, Ascites Pleural effusion Cheyne Stokes respiration PATIENT WITH SUS PECTED HF (non-acute onset) ! ASSESSMENT OF HF PROBABIUTY I, Cllnlcal history: History or CAD (Ml. reva.scululntlon) History of arterial hypertension Exposition to cardiotoxlc: druglradfnlon Use or diuretics Orthopnoea / paro,cysmal noc:tumi.l dyJpnoca l. Physical e:umlnatlon: Rales Bilateral ankle oedema Hc-a r1 murmur JuJ\llar venous dilatation Laterally dlsplaced/broadened apical beat 3. ECG: l Any abnormality 2: 1 present Assessment of Natriuretic ------=-=-===---' NATR JURETI C PEPTIDES ,------, HF unlikely; peptides consider other NT-proBNP 2 1 25 pg/ml I dlqnosls not routinely BNP 235 pg/ml No done in clinical practice /4 · Yes y ECH OCA RDI OGRAPHY l all available daa): I{ HE ,oofiancd ('based 00 sort app ropriate ueacment determine aedology and  iTREA I Mt:N 1 fac tor & an y Com orb idi ty. 1. Treatm ent of the cau se , pre cip itat in g 2. Treatm ent of the syn dro me of He art Fa ilure. 3. Tre atment of Refractory Hea rt Fai lure. Pulmonary oedema). 4. Tre atment of Ac ute He art Fai lure (Acute FAI LUR E trR EATM ENT O F TI-f E SYN D RO M E O F H EA RT "GENERAL PLAN " Decrea ·i11g cardiac load a) Rest: Physical & emotional. b) Reduction of preload: 0 Diet control, especially salt restriction. o Diure tics. o Vasodilators (Venous). c) Reduction of a fterload: o Vasodilators (Arterial). Decreasine Pathologic L V remodeling: - RAAS blockers (ACE-I U.£ ARB), B-blockers. Increasing mvocardial co11tractility: a) Digitalis: (For Chronic HF & Acute HF when associated e AF). b) Other inotropic agents: (For Acute HF). o Sympathomimetic amines: Dopamine, Dobutami11e. o Phosphodiestrase inhibitors: Amrinflll.C, MilrinilllC.., Enoximfl..!lf.. o Calcium sensitizer: Levosimendan. Resvnchronizi11g the ventricles: ''CRT" - In patients with HF who have the problem of "Intraventricular con du ction delay" or b un dle branch block. S.ymnto111atic treatment: a) For hypoxemia: oxygen administration. b) For cardiac dyspnea: aminophylline administration. Reducing Hospitalization. "RE CENT ME DICATIONS ' 1 ) Ivab radine (Funny chan nel inhi bitor) J SAN rate 1 Ven tricular fill ing. 2) Angiotensin Receptor - Nepri1ysin 1nh ibit or (AR NI) : A (Va lsartan) -+ J RA AS + Nepri lys in Inh ibi tor (Sa cub itril) t NP. 3) _lio dm m-GL uco se co - Transporter-1 - ln hib itors (SG LT2 - I): Dapagl iflozin JU Em pag lifl ozin are recom me nd ed to "', th e com b me Ho p1·t rizat1· on & cardio asc ula r dea th in. d ns. k o f HF. : symptoma tic pat ien ts e HFrEF, already on.Gu 1delme-,ll 1rec ted.Me d1c al Ih erapy - (GD--- M"-'L.&.. I), reg ardl ess of the presence ofT2D M. 9 -  12 PH YS ICAL RE S _ BEN EFIT B ed re t red uce s t he metabolic needs of U.c bod ---X &...... t he c,1. rc1J.ac load. _ POS JTION: Se m mttmg po 1 t 1on ,s prefe rred to dccrcnsc ' · ll ic, ven ous ret urn. _ COM PLJC ATI O S o f prolonged b ed rc._ t: DVT & PULMON A RY EMBOLI S M. Pneumon ia. Constipat ion & reten tion of u rine. 1usclc wasting & osteoporosis. Bed sores. Psychoneurosis. MOTIONAL REST SEDATION: may be ach ieved by: Diazepam 2 - 5 mg tds orally. IET CONTRO Salt re triction : L blood vol ume & thus J preload. FJ uid restri ction: only needed in severe cases of H F. Sma l l freq uent meals: to l the work o f the heart. Reduction ofbody weigh.I in obese patients. VASODILATO Action J. Reduct ion of J!Ilload by: vcno di latation. 2. Reduct ion of a ffcrload by: arteriolar di latat ion. Types I VASODJ LATOR ' SITE O F ACTION ' A DM INJST'RATION I Nitrates Venou 20 - 40 mg I 8h orally ' I Jydra lnzinc Arterial 50 mg / 6h orally - Na nitropru side ACE - I : Arterial & vcnou Arterial & venous 0.5 - lO µg / kg I min, JV infusion Short a tin T: Captopril 6.25 - 25 mg I 8h orally Long acting: Ramipri/ 1.25 - 2.5 mg I day oralJy ARB: Arterial & venous I Candesartan 1 Initially 4, target 32 mg / day orally / Importa nt points - Con traindications to ACE - I / A R B: I. Intolerance due to side effects : e.g. d1J' cough... (Only n'ith ACE - 1). 2. H YPER KA L EMIA: serum K > 5. 5 mEqlliter. 3. Hypotension: SBP < 90 mm Hg. 4. B i Jateral renal artery stenos is: forfear of causing renalfailure. 5. Caut ion i n renal failure with serum crcatinine > 3. 0 mg/dL & stop the drug ff: sernm creatinine rises by more than 30 % of the base-line level. - In case of contraindication to ACE - I / A RB, use an alternative good VD: - Combination of: HydraJazjne (Arteriolar dilator) & Nitrates (Veno dilator). H - IS DN == Hydralazine & IsoSorbide Di itrate (esp. Can desarta n). _ In ens\· of cont rn i ndica ti on to ACE - J CTntoJerance}, use an ARB 12  WJIU!?II U§J e n t of H F. i n th e t i.c,at m. Th ey are ',e ry u s e fu l t & w at c1 t h s : l blo od vo l ume & l prel o a d. lo s s, o f s " l Th e y p ro m o te h ia zi de _ Ty pe d.1 u re t·I CS. ·, ,tm [C:.S. , to l rcubsorpt i n o f Na, 1-120, K, C l O i l t II , {/J\·ta I -..: - · I A L> t i o n · : f_1Tua n1ti. o n.h lo r t lt tn. Z I. C 1 ,.. 2 5 _ 1 o mg / day. If ,c I i o ·,,1 z i d. 2. 5 - I O mg / day. B n dr ll utn t I 1 1 _ S ic k e ffe ct s : - I. 11r,w k a lc m in.. -· l lrL"' clt lo rc1 1ic a l k a l o s1s.. 1 /r[W natrc m ia. 4. //rpo m ngne se m i a. 5. Hy per Glyce mia. 6. J I) per Lipide mia. 7. H per Uricemia 8. H per Calccmia. Loop o f Henle - ifhiazide - Like diuretics - Acti o n : on th e distal tubules. - Prepa rations: I n dapamide: 2.5 - 5 mg / day. Metolazone: 2.5 - 10 mg / day. Chlorthalidone: 1 2.5 - 25 mg / day (not commonly used in HF a first-line diuretic in HJ - Side effects: Same as Thiazidcs. 2. Loop diuretic - Action : on the asce11ding limb ofloop o(He11le, to i reabsorption of: Na, H20, K, Cl. THEY ARE THE MOST POTENT DIURETICS IN HF - Preparations: Frusemide: 40 - 240 mg I day. Torsemi d e: 1 0 - 20 mg / day. Bumetanide : 1 -5 mg / day. ldosterone antagonist5 - Side Effects: (Spironolactone & cplercoe are used as add · on therapy Same as Thiazides (but with hypocalcemia). ACE - I (or ARB) in scvcrc H a. Potass ium spa ring diu reti cs (Take care of serum Kl - Action : on the distal tubu les to J reab sorp tion of: Na, & H,O ,......... BUT : The y have the adva ntage of reta inin g K (the y t the se c retio n of K). TH EY ARE WEAK DIU RE TIC S Used to potentiate the action of Thiazide or loop diuretics. Used to avoid the potassium losing effect of Thiazide or loop diuretics. - Prepar atio ns: Spi ron olac tone (Aid. antagonist == MRA): 25 - 50 mg 4. Other diuretics / day. Epl erenone (Ald. antagoni st = MRA ): 25 - 50 mg / day. a) Natriuretic peptides (Recombinant by infuSion) Triametrin e, Ame Jorid e. Natriuresis Aff. a VD. Eff. a VC - i GFR - Side effects: Peripheral VD b) Carbonic anhydrase inhibitors (Acetazolanude) Hyperkalem ia & Met abo lic acid osis. ! reabsorption of NaHCOi i n J>CT· Gyn e co m asti a (with Spirono l acto ne w th r o L-,__._Not common_Iy_used in HF. -- i p o l n g ed use). _____ _____  14 DIGITALI ''rt is no longer extensively u cd in the treat m ent or J-t r a l t ho ugh it i nn e ffec t i ve + vc i n otrop c'' !ACTIONS It i n cre ases the myocard ial co ntrnct i l i ty: Co mpetitiv e inh ibition o f sod ium-p otassi um ATPas e j i ntrnc el l u lar Na. Then, Na-Ca exchange occurs & this i ncrease s the intrace ll u lar a. H igh intrac l lular Ca pro mote t iding of act i n & myo sin. This I ad to increased force of myocardial con lrn c t i l ity...,._ It slo" s the heart ra te: - Vagal timulation. - D irect i nhibition of the SAN...,._ It i n c reases the excitability of the atria & ven tricles: - In digitalis toxici ty, arrhythmia may occur...,.. It i n h i b i ts the cond uction of the AVN: - ln digital i s toxicity, AV block may occur. - D igita l is can be used to protect the ventricle in atrial arrhythmias...,._ On the ECG: - Digital is effect: Sagging depression ofST segment, Flat or i11 verted I wave. - Dig i ta l is toxicity: D(fferent typ es of arrlzJ thmias. Q R S - ST morphology is described as: Sagging QJ_· "Salvador Dali's Moustache"... -: : _J ; INDICATIONS..,. SJ tolic H eart Fa i lure..._. Rap i d atrial arrhythmias : AF, Atrial flutter, SVT. CONTRAINDICATIONS.._. ABSOL UTE CONTRAINDICATIONS: - Digitals toxicity. - Ventr icular tachy cardia (Digitalis may change it to fatal VF)..._. REL ATIV E CON TRA IND ICATION S : "Better avoid ed" I ncom plete heart block. - Nod al rhyth m. r ypcrtroph ic card iomyopat hy (HC M). - I I yp kalc mia. 14  ·y 1 ) CL INI CA L PIC TU RE G a s t ro i n t es t i n a l _ A norex i a : u ua l ly t he first svmntom. _ Na uscn, Vi m i l i ng, A bdom i n a l pa i n. Ca rd iovas c u l a r "Di fferent types o f arr hyt h m ias & he art h l o c k ". - Prema ture beats: esp. occ urring i n bigemin i or ;.ig e 111 1 11 1.. ;. - Paroxysm al a t ri a l tachycard ia : with hea rt bloc k. - Paroxysmal ventricu lar tachycardia: m os t serious....,. Neu ro logical - M ENTAL disturbances, e.g. Psychosis. - PA I N : Headache & Neuralgias. - VI S ION: B l urring of v i sion & Coloured vis i on (yello w Qt green). 2) TR EATMENT 9't Stop digi tal is. 4a Correct hypokalemia, if present: - Stop drugs causing hypokalemia: e.g. loop diuretics. - Give potassium : Orally or IV 4a Digital is specific antibodies: esp. in life-threatening overdose. 4- TTT of the man i festat ions of digi talis toxicity: - For vom iting: Anti -emetic drngs, e.g. metoclopramide. - For anhythmias: 1. Anti -arrhythmic Drugs : especially Lidocaine & Epanutin. 2. Atropine: for heart block & bradycardia. 3. DC: Avoided because it may induce more serious arrhythmias. Al lowed ONLY in case of the fatal arrhythmia: VF. Why does a patient on digitalis develop DIGITALIS TOXICITY ?  16 * IJETA - BLOCKE RS _ TN DI CATl ON S o Chronk I U. o l\ lo