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Congestive Heart Failure

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Congestive Heart Failure Dr Ian Coombes Adopted from Duncan McRobbie Principal Clinical Pharmacist (with permission) * Circulating Ang (1-7) levels shown to increase ... – PowerPoint PPT presentation

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Title: Congestive Heart Failure


1
Congestive Heart Failure
  • Dr Ian Coombes
  • Adopted from Duncan McRobbie
  • Principal Clinical Pharmacist (with permission)

2
Signs and Symptoms
NYHA Classification
  • fatigue
  • exertional dyspnoea
  • orthopnoea
  • PND
  • cardiomegaly
  • pitting oedema
  • crackles
  • raised JVP
  • NYHA I - no limitation of physical activity
  • NYHA II- slight limitation
  • NYHA III - marked limitation
  • NYHA IV - inability to carry out physical
    activity

3
Causes
  • acute MI
  • hypertension
  • toxins (alcohol, cytotoxics)
  • viruses/bacteria
  • valve disease
  • cardiomyopathies

4
Prevalence
  • 1-2 population
  • 3-5 of those gt65 years of age
  • 10 of those gt80 years
  • 50 patients die within 2 years of diagnosis
  • 65 of patients with severe CHF die within 1 yr

5
Survival After Initial Diagnosis of HF
100
50
0
3 months
18 months
6
Hospitalisations
  • 74,500 hospital admissions in 2000/2001
  • Length of stay gt 13 days (3x average LOS)
  • 1,000,000 in-patient days
  • Admission rates projected to increase by gt50
    over the next 25 years
  • Readmission rates as high as 50 over 3 months

7
Readmission - causes
Over 50 preventable
Erhardt and Cline 1998 (Lancet)
8
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9
Signs and Symptoms
10
Classifying Heart Failure the New York Heart
Association method
  • NYHA I
  • No symptoms with ordinary physical activity
    (walking and climbing
  • stairs)
  • NYHA II (mild)
  • Slight limitation of activity with dyspnoea on
    moderate to severe activity (climbing
  • stairs or walking uphill)
  • NYHA III (moderate)
  • Marked limitation of activity. Less than ordinary
    activity causes dyspnoea
  • (restricting walking distance and limiting
    climbing to one flight of stairs)
  • NYHA IV (severe)
  • Severe disability, dyspnoea at rest (unable to
    carry out physical activity without
  • discomfort)

11
Rules of HF
Remember
symptoms haemodynamics symptoms
survival
Remember COSVxHR BPTPRxCO
Remember Starlings Law preload force of
contraction Lapaces Law large heart
inefficient
12
Neurohormonal model of Heart Failure
Sympathetic Response
afterload
cardiac workload
arterio- constriction
nor- epinephrine
cardiac output
aortic blood flow
SNS
Remember CO SV x HR
13
Neurohormonal model of Heart Failure
renin-angiotensin-aldosterone
preload
afterload
cardiac workload
Na and H2O retention
arterio- constriction
Remember Starlings Law
aldosterone
cardiac output
remodelling
Renal blood flow
veno- constriction
RAS
angiotensin
14
Treatment of Heart Failure
Remember Survival drug treatment
preload
afterload
hydralazine
cardiac workload
diuretics
Na and H2O retention
arterio- constriction
digoxin
spironolactone
aldosterone
nor- epinephrine
cardiac output
nitrates
aortic blood flow
Renal blood flow
veno- constriction
RAS
B-blockers
SNS
ACE-I
angiotensin
naturetic peptides
NEP-I
15
Role of Diuretics
  • Side effects
  • dehydration
  • hypotension
  • hypokalaemia
  • hypomagnesaemia
  • hypouricaemia and gout
  • non-compliance issues
  • loops most effective
  • symptomatic relief
  • Na retention
  • H2O loss
  • preload ( ventricle filling pressure)
  • afterload (arterial dilatation)

16
Role of ACE-inhibitors
  • improves mortality (CONSENSUS)
  • better than vasodilator therapy (VeHFT I and II)
  • large well conducted trials
  • preload (inhibits effect)
  • afterload (inhibits vasoconstriction)
  • Side effects
  • hypotension (6)
  • hyperkalaemia (6)
  • cough (40)
  • dizziness (50)
  • raised serum creatinine (0.2)

17
Circulating Renin-Angiotensin System
angiotensinogen
renin
A C E
Ang II
Ang I
AT1/AT2 receptors
18
Potential Role of Angiotensin (1-7)
angiotensinogen
renin
N E P
Ang (1-7)
Ang I
ACE
Ang II
AT1
AT2
ATx
pressor trophic antinatriuretic
depressor antitrophic natriuretic
depressor antitrophic natriuretic
19
Potential Role of Angiotensin (1-7)
angiotensinogen
ACE inhibitor
renin
N E P
A C E
Ang (1-7)
Ang (1-5)
Ang I
ACE inhibitor
ACE
Ang II
AT1
AT2
ATx
pressor trophic antinatriuretic
depressor antitrophic natriuretic
depressor antitrophic natriuretic
20
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21
Landmark trials with ACE inhibitors in HF
22
Role of ARBs
  • improves mortality (ELITE I and II / CHARM)
  • added into conventional therapy (ValHeft / CHARM)
  • Less s/es

23
Role of Beta blockers
  • improves mortality (CIBIS 2)
  • added into conventional therapy
  • attenuates sympathetic drive (outweighs -ve
    ionotropic effect)
  • not all beta-blockers are equivalent (bisoprolol
    and carvedilol best supported by evidence)
  • Side effects
  • hypotension
  • bradycardia
  • peripheral vasoconstriction
  • impotence
  • bronchospasm

24
Role of vasodilator therapy
  • preload
  • (venodilators - nitrates)
  • afterload
  • (arterial dilators - prazosin)
  • large trials show good benefit but lots of side
    effects
  • Side effects
  • hypotension
  • headache
  • tachycardia
  • SLE (hydralazine)

25
Role of Digoxin
  • used in initial trials
  • myocardial contractility
  • lost favour because of toxicity
  • renally cleared - dependent on age, weight RF
  • Side effects
  • anorexia
  • N,V,D
  • abdominal pain
  • visual disturbances
  • drowsiness
  • arrythmias
  • heart block

26
Role of spironolactone
  • improves mortality (RALES)
  • added into conventional therapy
  • attenuates aldosterone effect
  • only small doses required
  • Side effects
  • hyperkalaemia
  • gi disturbances
  • impotence
  • gynocomastia
  • rash

27
Adjunct Therapy
  • Digoxin in SR
  • DIG trial no mortality benefit but reduction in
    hospitalisations and improved symptoms
  • useful in symptomatic patients where other drug
    therapy is optimised
  • should not be withdrawn from pts with HF
  • Anticoagulation
  • if prolonged bed rest prophylactic heparin
  • if LV dilatation / thrombus chronic warfarin
    therapy

28
Mortality remains high
  • ACEi Risk reduction 35 (mortality and
    hospitalizations)
  • ? Blockers Risk reduction 38 (mortality and
    hospitalizations)
  • Oral nitrates and hydralazineBenefit vs.
    placebo inferior to enalapril (mortality)

However 4-year mortality remains 40
Davies et al. BMJ 2000320428-431 Gibbs et
al. BMJ 2000320495-498
Davies et al. BMJ 2000320428-431 Gibbs et
al. BMJ 2000320495-498
29
Role of other treatments
  • ?? Ca channel antagonists - -ve ionotropic,
    amlodipine appears safe
  • ?? other antiarrythmics -
  • dobutamine - increases CO, but palliative
  • Levosimendan- severe CHF
  • naturetic peptide inhibitors / recombinant
    naturetic peptides- omapatrilat / neseritide
  • Biventricular pacing - severe CHF high cost
  • transplantation - 85 survival _at_ 5yrs

30
Congestive cardiac failurePharmaceutical Care
Plan
Need for Drug Diagnosis of CHF Selection of
Specific Drug Symptom control - diuretics
Decrease mortality ACE,
B-blockers Co-modibdity anticoagulation
Patient factors Selection of Regimen Loading
doses, maintenance dose Drug
factors Provision of Drug Timely,
accurate Administration of Drug Timing,
food Monitor Effectiveness Symptoms,
pulse,cholesterol, side effects Counsel /
Educate Expected effects, side
effects Risks vs benefits Evaluate
Effectiveness Beneficial effects gt detrimental
effects??
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