Congestive Heart Failure

1
Congestive Heart Failure

• Larissa Bornikova, MD
• July, 2006

2
Objectives

• To review the basic pathophysiological mechanisms
  of congestive heart failure
• To review a diagnostic approach to the patient
  with suspected HF and initial work up of newly
  diagnosed HF.
• To summarize characteristics of diastolic heart
  failure
• To outline management strategies for CHF

3
Definition

• Heart failure is a clinical syndrome not a
  disease.
• Clinically defined as the inability of the heart
  at the normal filling pressures to maintain an
  output adequate to meet the metabolic demands of
  the body.

4
Epidemiology

• 5 million Americans have heart failure
• 500,000 new cases of symptomatic heart failure
  annually
• 20 of hospital admissions among persons older
  than 65
• 45 annual mortality in severe symptomatic heart
  failure
• More Medicare dollars are spent for diagnosis and
  treatment of heart failure than for any other
  single diagnosis.

5
The most common causes of CHF

• Remember that CHF is a syndrome, so always look
  for an underlying cause!
• Ischemic heart disease 40 percent
• Dilated cardiomyopathy 30 percent
• Primary valvular heart disease 15 percent
• Hypertensive heart disease 10 percent
• Other 5 percent

6
Etiology

• WHO Classification of Heart Failure Etiologies
• Dilated Cardiomyopathy (about 20-25 of cases are
  familial)
• Hypertrophic Cardiomyopathy (e.g. IHSS, HOCM)
• Restrictive Cardiomyopathy (infiltrating
  diseases)
• Arrhythmogenic Right Ventricular Cardiomyopathy
• Unclassifiable Cardiomyopathies (fibroelastosis,
  mitochondrial)
• Specific Cardiomyopathies (ischemic,
  hypertensive, valvular obstruction/insufficiency,
  myocarditis, endocarditis, Chagas disease, HIV,
  adenovirus, CMV, Enterovirus).
• Metabolic (thyrotoxicosis, hypothyroidism,
  pheochromocytoma, hemochromatosis, glycogen
  storage diseases, diabetes, kwarshiokor,
  beriberi, starvation, amyloidosis, Familial
  Mediterrenian Fever, etc.)
• General system disease (alcohol, anthracyclines,
  radiation, SLE, PAN, scleroderma,
  dermatomyositis, sarcoidosis, muscular
  dystrophies, neuromuscular disorders, peripartum
  cardiomyopathy, etc.)

7
Pathophysiological mechanisms of CHF

• Multiple compensatory responses over the
  long-term become deleterious.

8
Pathophysiological mechanisms of CHF

• CARDIAC ABNORMALITIES
• Frank-Starling Mechanism
• Compensatory hypertrophy
• Ventricular remodeling
• Coronary arteries
• Mitral regurgitation
• Arrhythmias
• OTHER MECHANISMS
• Redistribution of cardiac output

• NEUROHORMONAL
• Renin-angiotensin-aldosterone system
• Sympathetic nervous system
• Natriuretic peptides
• Vasodilator peptides
• Cytokines
• Matrix Metalloproteinases

9
Ventricular Remodeling after Infarction (Panel A)
and in Diastolic and Systolic Heart Failure
(Panel B)
Jessup M and Brozena S. N Engl J Med
20033482007-2018
10
Evaluation of the patient with suspected CHF

• Establish diagnosis
• Determine the etiology
• Assess acuity and severity

11
Clinical Manifestations of CHF

• SYMPTOMS
• Fluid overload
• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Cardiac asthma
• Cheyne-Stokes Respiration (aka cyclic
  respiration)
• Fatigue, weakness
• Exercise intolerance
• Decreased urine output
• Confusion
• Lethargy
• Nocturia
• Anorexia

• PHYSICAL SIGNS
• Rales
• Tachycardia
• Displaced PMI
• S3 (ventricular gallop)
• S4 (atrial gallop)
• Pulmonary HTN (loud P2)
• Neck vein distention
• Hepatic enlargement
• Peripheral edema
• Ascites
• Pleural effusion
• Cardiac Cachexia
• Jaundice
• Skin cold and clammy
• Pulsus alternans

12
Fun facts

• sensitivity specificity
• Dyspnea on exertion 100 17
• Orthopnea 22 74
• PND 39 80
• Peripheral edema 49 47
• Based on study of 259 patients referred for
  echocardiography

13
Diagnosis of HF

• CHF should be suspected on the basis of clinical
  presentation and radiographic findings.
• Its a clinical diagnosis. There is no diagnostic
  test!
• Depressed ventricular EF should be confirmed with
  echocardiography, radionucleotide
  ventriculography, or cardiac catheterization with
  left ventriculography.

14
Diastolic Heart Failure

• Diagnosis is based on the finding of typical
  symptoms and signs of heart failure in a patient
  who has a normal LVEF and no valvular
  abnormalities on echocardiography.
• Diagnostic findings on echocardiogram
• - normal EF
• - no evidence of acute MR, AR, or constrictive
  pericarditis
• - abnormal relaxation pattern as evidenced by
  abnormal E/A ratio in mild diastolic
  dysfunction, or by Doppler assessment of flow
  into the LA, or by tissue Doppler imaging.
• Insufficient data from randomized trials to
  assess the effects of various treatment
  modalities.

15
Patterns of Left Ventricular Diastolic Filling as
Shown by Standard Doppler Echocardiography
Aurigemma G and Gaasch W. N Engl J Med
20043511097-1105
16
Evaluation of the patient with suspected CHF
Mechanisms to consider

• Systolic vs. diastolic
• Low-output vs. high-output
• Acute vs. chronic
• Right-sided vs. left-sided
• Backward vs. forward

17
Evaluation of the patient with CHFestablish
etiology and assess acuity/severity.ACC/AHA
guidelines (class I)

• History/physical examination to identify
  disorders and behaviors that might cause or
  accelerate the development of progression of HF.
• History of current and past use of alcohol,
  illicit drugs, current or past standard or
  alternative therapies, and chemotherapy drugs
  should be obtained from the patients presenting
  with HF.
• Assessment of the patients ability to perform
  ADLs.
• Physical examination should include assessment of
  volume status, orthostatic blood pressure
  changes, measurement of weight and height, and
  BMI..
• Remember that CHF is a syndrome, so look for the
  underlying cause.

18
Initial evaluation of the patient with
CHFEtiological approach.ACC/AHA guidelines
(class I)

• CBC
• Serum electrolytes, BUN and creatinine
• LFTs
• Fasting blood glucose
• Lipid profile
• TSH
• Urinalysis
• CXR (cardiomegaly, Kerley B-lines, pleural
  effusions, pulmonary edema)
• EKG (assess for evidence of ischemia, LVH, a fib)
  
• Echocardiogram with Doppler (LV and RV
  function/mass/wall thickness, LVEDV, LA size, E/A
  ratio, valvular disease)
• Coronary angiography if applicable
• Based on clinical scenario/suspicion, may
  also consider plasma BNP, iron studies, ANA,
  serologies for SLE, evaluation for
  pheochromocytoma, viral serologies and antimyosin
  Ab, thiamine, carnitine, selenium, genetic
  testing (not class I).

19
Evaluation of the patient with suspected CHF
Role of BNP

• Low BNP level has a good negative predictive
  value to exclude CHF as a primary diagnosis in
  dyspneic patients who present to the Emergency
  Department. (N Engl J Med 2002 327 161)
• BNP levels correlate with the severity of HF
• BNP levels predict survival

20
New York Heart Association classification of
heart failure.

• Focuses on symptoms
• Class I No limitation of physical activity.
• Class II Slight limitation with ordinary
  exertion.
• Class III Marked limitation with less than
  ordinary exertion.
• Class IV Symptoms are present at rest.
• ACC/AHA Classification
• Emphasizes evolution and progression of heart
  failure.
• Class A At risk for CHF, but heart is
  structurally normal.
• Class B Structural abnormality of the heart,
  never had symptoms
• Class C Structural abnormality current or
  previous symptoms.
• Class D End-stage symptoms refractory to
  standard treatment.

21
Management of Heart Failure

1. General measures
2. Correct underlying cause
3. Remove precipitating cause
4. Prevention of deterioration of cardiac function
5. Control of congestive HF state

Jessup M and Brozena S. N Engl J Med
20033482007-2018
22
Nonpharmacologic therapy

• Exercise training for stable HF patients
  increased exercise capacity, decreased
  hospitalization rate, increased quality of life,
  decreased symptoms.
• Weight loss in obese patients
• Dietary Na restriction ( 2 g/day)
• Fluid and free water restriction ( 1.5 L/day)
  especially if hyponatremic
• Minimize medications known to have deleterious
  effects on heart failure (negative inotrops,
  NSAIDs, over-the-counter stimulants)
• Oxygen
• Fluid removal (dialysis, thoracentesis,
  paracentesis)

23
Stages of Heart Failure and Treatment Options for
Systolic Heart Failure
Jessup M and Brozena S. N Engl J Med
20033482007-2018
24
Pharmacologic therapy

• ? - - - - - diuretics - - - -?
• / digoxin - - - - - -?
• / spironolactone
• / beta-blockers / ?
• ACE I ? ARB ? Hydralazine/nitrates
• NYHA Class I II III IV
• no change in mortality

25
Drugs to avoid in HF patients

• NSAIDs. Induce systemic vasoconstriction,
  counteract ACE inhibitors, blunt effects of
  diuretics.
• Thiazolidinediones. Contribute to fluid
  retention. Should be avoided in severe (class
  III-IV) failure.
• Metformin. Increased (but small) risk of lactic
  acidosis.
• Cilostazole. (PDE inhibitor). Increases
  mortality.
• Calcium channel blockers (avoid Verapamil and
  Diltiazem). Trials with amlodipine and felodipine
  showed a neutral effect on mortality. V-HeFT
  trial. Circulation 1997 96 856.

26
Treatment of HF exacerbation Parenteral agents

• IV Vasodilators
• - Nitroglycerine
• - Nitroprusside
• - Recombinant BNP (nesiritide)
• IV Inotropic agents
• - Dopamine
• - Dobutamine
• - PDE inhibitors (amrinone, milrinone)
• IV Diuretics
• - Furosemide
• - Bumetanide

27
Other management considerations

• Anticoagulation. No RCT. Warfarin therapy may be
  considered in the absence of contraindications
  for patients who are in sinus rhythm and have EF
  lt30.
• Ventricular resynchronization therapy. Survival
  benefit in patients with NYHA class III-IV HF
  despite optimal medical therapy, who are in sinus
  rhythm, have EF 35, and a prolonged QRS ( 120
  msec). CARE-HF and COMPANION trial.
• ICD. Based on the SCD- HeFT trial. Significant
  benefit in NYHA class II - III HF and EF 35.
  Class IV patients have not been studied.
• Mechanical circulatory support.
• Cardiac transplantation.

28
References

• Jessup M, Brozena S. Heart Failure. N Engl J Med
  2003 348 2007 18.
• Aurigemma GP, Gaasch WH. Diastolic Heart Failure.
  N Engl J Med 2004 351 1097 105.
• Hunt SA, et al. ACC/AHA 2005 Guideline Update for
  the Diagnosis and Management of Chronic Heart
  Failure in the Adult. Circulation 2005 112.
• Harrisons Principles of Internal Medicine, 16th
  edition
• UpToDate