Heart Failure

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Heart Failure

• Supreena Devakumar

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Definition

• Heart failure is a clinical syndrome usually due
  to left ventricular dysfunction, resulting in
  acute or chronic symptoms of cardiac pump
  failure.
• The most common causes of heart failure are
  coronary heart disease, hypertension, alcohol
  abuse, and idiopathic dilated cardiomyopathy
• Other causes are valvular and pericardial
  disease or non-cardiac diseases causing
  high-output cardiac failure, such as anaemia,
  thyrotoxicosis, septicaemia, Paget's disease of
  bone, and arteriovenous fistulae.

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Incidence and Prevalence

• The incidence 1 in 1000 population per year
  increasing by about 10 every year. In gt85y
  incidence is 10 cases per 1000
• The prevalence ranges from 3-20 cases per 1000
  population, increasing to at least 80 cases per
  1000 in people aged 75 years and over

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Cont

• The male to female ratio is about 21.
• The median age of presentation is 76 years.
• The prevalence of heart failure is increasing
  because of the improved treatment of coronary
  heart disease (e.g. thrombolysis resulting in
  more people surviving a myocardial infarct but
  left with residual left ventricular dysfunction),
  and the ageing population

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Acute Heart Failure

• Often precipitated by a myocardial infarction.
• Signs include
• Severe breathlessness
• Frothy pink sputum
• Cold clammy skin
• Tachycardia
• Low blood pressure
• Lung crepitations
• Raised jugular venous pressure
• Third heart sound
• Confusion

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Chronic Heart Failure

• Making an accurate diagnosis of heart failure and
  determining its cause can be difficult
• Clinical diagnosis is confirmed to be accurate in
  approximately half of cases when investigated by
  echocardiography.
• The likelihood of heart failure in the presence
  of suggestive symptoms and signs is increased if
  there is a history of myocardial infarction (MI)
  or angina, an abnormal ECG, or a chest X-ray
  showing pulmonary congestion or cardiomegaly.
• Symptoms include
• Shortness of breath on exertion
• Decreased exercise tolerance (often simply
  'fatigue')
• Paroxysmal nocturnal dyspnoea
• Orthopnoea
• Ankle swelling

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Chronic Heart Failure

• The most specific signs are
• Laterally displaced apex beat
• Elevated jugular venous pressure
• Third heart sound
• Less specific signs include
• Tachycardia
• Lung crepitations
• Hepatic engorgement (tender hepatomegaly)
• Peripheral oedema

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Investigations

• Electrocardiogram (ECG) may show acute ischaemia,
  arrhythmias, left ventricular hypertrophy, left
  bundle branch block, or prior MI.
• Heart failure is unlikely if the ECG is normal,
  and the diagnosis should be reconsidered in this
  situation.
• Chest X-ray (CXR)
• pulmonary vascular congestion (upper lobe
  diversion),
• pulmonary oedema
• effusions
• cardiomegaly

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Chronic Heart Failure

• B-type natriuretic peptide (BNP) and its
  N-terminal fragment (NTproBNP)
• New diagnostic test
• A raised concentration of either has been shown
  to have a sensitivity of greater than 90 and a
  specificity of 80-90 for the diagnosis of heart
  failure.
• Heart failure is unlikely if the level of BNP or
  NTproBNP is normal, especially if the ECG is also
  normal, and the diagnosis should be reconsidered
  in this situation.

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Chronic Heart Failure

• A diagnosis of diastolic heart failure requires
  the presence of all the following features
• The presence of symptoms or signs of heart
  failure.
• The presence of normal or slightly reduced left
  ventricular (LV) systolic function.
• Evidence of abnormal LV relaxation and filling,
  diastolic distensibility, and diastolic
  stiffness.
• The second feature is readily diagnosed by
  routine echocardiography. The third, however, can
  only be diagnosed by Doppler echocardiography,
  which is not routinely available, or by cardiac
  catheterization.

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Differential Diagnosis

• Other causes of shortness of breath on exertion -
  e.g. pulmonary disease, obesity, unfitness,
  volume overload from renal failure or nephrotic
  syndrome, angina, anxiety.
• Other causes of peripheral oedema - e.g.
  dependent oedema, nephrotic syndrome.
• Non-cardiac diseases causing high-output cardiac
  failure - e.g. anaemia, thyrotoxicosis,
  septicaemia, Paget's disease of bone,
  arteriovenous fistulae

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Classification

• The New York Heart Association (NYHA) has
  classified chronic heart failure according to the
  following functional criteria
• Grade I - no limitation of physical activity
• Grade II - slight limitation of physical
  activity comfortable at rest, but ordinary
  physical activity results in fatigue,
  palpitation, or dyspnoea.
• Grade III - marked limitation of physical
  activity comfortable at rest, but less than
  ordinary activity causes fatigue, palpitation, or
  dyspnoea.
• Grade IV - unable to carry out any physical
  activity without discomfort symptoms of cardiac
  insufficiency at rest if any physical activity
  is undertaken.

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NICE guidelines

• Key recommendations the following
  recommendations have been identified as
  priorities for implementation.
• Diagnosis
• The basis for historical diagnoses of heart
  failure should be reviewed, and only patients
  whose diagnosis is confirmed should be managed in
  accordance with this guideline.
• Doppler 2D echocardiographic examination should
  be performed to exclude important valve disease,
  assess the systolic (and diastolic) function of
  the (left) ventricle and detect intracardiac
  shunts.

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Nice cont.

• Treatment
• All patients with heart failure due to left
  ventricular systolic dysfunction should be
  considered for treatment with an ACE inhibitor.
• Beta blockers licensed for use in heart failure
  should be initiated in patients with heart
  failure due to left ventricular systolic
  dysfunction after diuretic and ACE inhibitor
  therapy (regardless of whether or not symptoms
  persist).
• Monitoring
• a clinical assessment of functional capacity
• fluid status,
• cardiac rhythm
• Cognitive status
• nutritional status
• a review of medication, including need for
  changes and possible side effects
• serum urea, electrolytes and creatinine.

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Nice cont.

• Discharge
• Patients with heart failure should generally be
  discharged from hospital only when their clinical
  condition is stable and the management plan is
  optimised.
• The primary care team, patient and carer must be
  aware of the management plan.
• Supporting patients and carers
• Management of heart failure should be seen as a
  shared responsibility between patient and
  healthcare professional.

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Management

• Manage other risk factors
• Manage coexisting coronary heart disease
• Avoid aggravating factors
• Non-steroidal anti-inflammatory drugs
• Short-acting calcium-channel blockers
• Advise low salt diet
• Advise a moderate alcohol intake
• Limiting fluid intake may be appropriate in
  advanced heart failure, but care is needed to
  avoid dehydration.
• Vaccinate people against influenza annually and
  pneumococcus as a one-off, as they are at
  increased risk of infective complications.
• Consider cardiac rehabilitation, palliative care,
  and long-term social support if appropriate.

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Medication

• Drug treatments should be initiated in the
  following order
• ACE inhibitor - with diuretic if needed - for
  NYHA Grades I-IV.
• Angiotensin-II receptor antagonist - if
  intolerant of ACE inhibitor.
• Beta-blocker - for NYHA Grades I-IV.
• Spironolactone - for NYHA Grades III-IV.
• Digoxin - for NYHA Grades II-IV.

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ACE inhibitors

• Angiotensin-converting enzyme inhibitors (ACE
  inhibitors) relieve symptoms and improve
  prognosis and should be considered in all people
  with heart failure. Twenty-six people need to be
  treated for 3 years to prevent one death.
• ACE inhibitors are cost-effective. In a health
  authority of 250,000 people, around 40 deaths and
  300 hospital admissions could be prevented each
  year using ACE inhibitors.
• All ACE inhibitors are effective in treating
  heart failure, although most evidence is from
  clinical trials of enalapril.
• Treatment with an ACE inhibitor alone can be
  considered in people with NYHA grades I-II who do
  not have symptoms or signs of fluid overload.
  Diuretics should be added if fluid overload is
  present.
• Cough is common in heart failure but is also
  caused by an ACE inhibitor in a small percentage
  of people. Cough is not a reason to stop an ACE
  inhibitor unless it is troublesome.

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Diuretics

• Diuretics give rapid symptom relief and should be
  started early in symptomatic people with signs of
  fluid overload. Their long-term effects on
  mortality rates and other endpoints when given
  alone are not known (excluding spironolactone).
  An ACE inhibitor should always be added to
  diuretic therapy, unless contraindicated, as this
  improves prognosis.
• Loop diuretics are usually preferred to thiazide
  diuretics. Thiazides may be as effective as loop
  diuretics in treating oedema in people with mild
  failure who have preserved renal function.
• The combination of a thiazide with a loop
  diuretic gives a synergistic effect and may be
  useful in people with severe, persistent
  symptoms. Close monitoring of electrolytes is
  required and such treatment should usually be
  specialist initiated.

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B-Blockers

• Beta-blockers are recommended for all people with
  heart failure (NYHA grades I-IV) whose failure is
  stable, on standard treatment, unless there is a
  contraindication.
• Beta-blockers in combination with other
  treatments, such as ACE inhibitors, diuretics and
  digoxin, improve survival by more than 30
  compared to standard treatment alone in people
  with stable heart failure.
• Bisoprolol, carvedilol, and modified-release
  metoprolol have been shown to be beneficial.
  Bisoprolol and carvedilol are the only
  beta-blockers that are licensed for the treatment
  of heart failure.

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Spironolactone

• Spironolactone, should be considered for people
  with moderate to severe heart failure (NYHA
  grades III-IV) who are already on an ACE
  inhibitor and a loop diuretis.
• The Randomised Aldactone Evaluation Study (RALES)
  compared treatment with low-dose spironolactone
  (25 mg daily) added to standard care with other
  diuretics, ACE inhibitors and digoxin against
  standard care alone, in people with moderate to
  severe heart failure (NYHA III-IV). Mortality was
  reduced by 30, the risk of hospitalization for
  worsening heart failure was reduced by 35, and
  there was a significant improvement in symptoms.
  Over 2 years, one death was avoided for every 9
  people treated with spironolactone in addition to
  standard therapy.
• Careful monitoring for hyperkalaemia and
  hypovolaemia is required.

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Digoxin

• Digoxin, given in combination with a diuretic and
  an ACE inhibitor to people with heart failure
  (NYHA grades II-IV) in normal sinus rhythm, has
  been found to reduce hospitalization and clinical
  deterioration, but not mortality.
• Consider digoxin if the person continues to be
  symptomatic despite adequate doses of diuretic
  and ACE inhibitor.
• Give digoxin to all people with heart failure and
  atrial fibrillation who need control of the
  ventricular rate.

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Angiotensin II antagonists

• Candesartan, losartan, and valsartan are
  recommended for people intolerant of an ACE
  inhibitor (especially when that intolerance is
  due to ACE inhibitor-induced cough). Initial
  trial data appear comparable with ACE inhibitors
• Candesartan is now licensed for heart failure and
  impaired left ventricular dysfunction. Valsartan
  is now licensed for heart failure in post
  myocardial infarction patients. Losartan is not
  currently licensed for the treatment of heart
  failure.

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When to refer

• Heart failure due to valve disease, diastolic
  dysfunction or any other cause except left
  ventricular systolic dysfunction.
• Angina, atrial fibrillation or other symptomatic
  arrhythmia.
• Women who are planning a pregnancy or who are
  pregnant.
• The following situations also require referral.
• Severe heart failure.
• Heart failure that does not respond to treatment
  as discussed in this guideline and outlined in
  the algorithm.
• Heart failure that can no longer be managed
  effectively in the home setting.