HEART FAILURE Study day November 2018 Sarah Briggs
Overview and Introduction • This course is an introduction and overview of heart failure. Normal heart function and basic pathophysiology of heart failure is explained. This will be then related to the diagnosis of heart failure and to the overall management of patients with heart failure. Device therapy will be explained, and also finally we will have discussion session about palliative care and heart failure.
Demographics of heart failure • Heart failure is serious • Heart failure is terminal • Heart failure is unpredictable • Heart failure causes severe symptoms • Heart failure outcomes are directly linked to good management and self monitoring. You can make a profound difference to a patient’s life
Plan of the Day • The normal heart • Pathophysiology of heart failure • Clinical presentation: History, assessment and clinical examination • Differential diagnosis, Investigations and Diagnosis • Pharmacological Management • Non medical Management • Palliative care • Device therapy
1. The Normal Heart
1. Normal Heart Function • The Cardiac Circulation • The Cardiac Valves • The Coronary Circulation • The Cardiac Electrical System
The Heart = A house!
Cardiac Valves
Coronary circulation
Coronary circulation
2. Pathophysiology of Heart Failure
2. Pathophysiology of heart failure The two types of heart failure affecting the left ventricle. • HFrEF – can’t pump • HFPEF – can’t relax
2. Pathophysiology of heart failure Causes : Myocardial Infarction
Ischaemia
2. Pathophysiology of heart failure Causes : Hypertension and aortic stenosis
Hypertension
Hypertension
Aortic Stenosis
Left Ventricular Hypertrophy
Other causes include: • Mitral regurgitation • Atrial fibrillation • Cardiomyopathies • Chemotherapy …….
Neurohormonal Activation • Increased Sympathetic activation • Reduction in renal perfusion results in activation of the RAAs • Brain natriuretic peptide release
Neurohormonal Activation
The Natriuretic Peptide System
Heart failure is unpredictable!
3. History, Assessment and Clinical Examination
History • Presenting Complaint: • History of Presenting Complaint: • Past Medical History:
Its Systemic • Fatigue • Cool extremities • Pallor • Heavy leaden legs • Renal dysfunction • Anaemia • Acute/increasing breathlessness • Presents/punctuated with unpredictable episodes of fluid retention…..
3. Clinical Presentation Signs of Heart Failure - General Appearance – distress, gait, mobility, colour, pallor, tachypnoea, breathlessness, audible breath sounds,habitus, • Tachycardia/irregular • Hypertension/hypotension • Pallor/mallor flush • Elevated JVP (>5cm) • Heart Sounds – third heart sound • Added Breath Sounds – Crepitations/wheeze • Abdominal distension • Oedema – legs/sacral
Pulmonary Oedema
Ascites
Pitting Oedema
The Burden of Heart Failure
Warning Signs
Weight Gain!!
Lets Talk about it!!.......
5. Differential Diagnoses
??? Is it ? Or is it? • Chest • Heart Failure? infection/pneumonia? • Pulmonary Embolism? • COPD? • N/AFLD? • Obesity? • Reduced Venous Return? • Lymphoedema?
6. Investigation
Investigations • U&Es, LFT, FBC, Iron Profile, TSH, hba1C • BNP • ECHO • ECG • CXR • Holter monitor • 24hour BP • Also Cardiac MR, MPS, Angiography
7. Diagnosis
Heart Failure?? Lets review the ECHO………
ECHO 1. Summary • Mild to moderate left ventricular hypertrophy with echogenic walls. The left ventricle is normal in size with severely reduced systolic function. LVEF - 31% (Teicholz). • The right ventricle is dilated, mildly hypertrophied with moderate to severely reduced systolic function. • Mild to moderate mitral regurgitation into a severely dilated left atrium. • Moderate tricuspid regurgitation into a severely dilated right atrium. • Mild pulmonary regurgitation. Trivial aortic regurgitation. • Right ventricular systolic pressure is 56-61 mmHg assuming a RAP of 10-15 mmHg. • Echo findings suggestive of pulmonary hypertension
ECHO 2 Summary • Overall left ventricular systolic function is severely reduced. LV ejection fraction is visually estimated at 30%. Right ventricle global systolic function is moderately reduced . • Aortic valve appears tricuspid, mildly thickened with reduced cusp excursion/mobility. ? mild aortic sclerosis. • Moderate mitral regurgitation. Moderate tricuspid regurgitation.. Mild pulmonary regurgitation. • RV / RA gradient 39 mmHg. Estimated PA systolic pressure is > 59 mmHg, (assuming RAp >20 mmHg). Pulmonary hypertension • indicated. • Large pleural effusion noted.
ECHO 3 • Left Ventricle Normal LV cavity size is seen with moderate systolic impairment. EF is estimated using biplane Simpson's method at 41%. • Global longitudinal strain is severely impaired at 10.6%. • There is evidence of global hypokinesis with more marked impairment inferior/ inferolaterally/ apical laterally ?significance. • Mild concentric LVH is seen with reversed E:A ratio of diastolic filling.
ECHO 4 • Summary • Moderate LV dilatation with moderate towards severe impairment - EF 36%. GLS- 10.5%. • Mild MR. • Gross LA dilatation. • Mild RV enlargement with mild impairment
ECHO 5 Summary • Severe LV dilatation is seen with severe LV systolic impairment. • There is thinned akinesis affecting the inferior and mid inferolateral region. Marked hypokinesis is seen elsewhere. • EF is unable to accurately quantified due to poor image quality and AF. • Visually EF is 15-20%. • Mild LVH is seen in the non-thinned regions. • Thin MV leaflets- opens well. • There is annular stretch seen (5.0cm). • Reduced MV leaflet apposition is seen with moderate MR. • Moderate RV impairment.
8. Pharmacological Management
Neurohormonal deactivation 1. A drenaline • Beta Blockers Dose Side Effects Monitoring
Neurohormonal Deactivation 2. A ngiotensin II • ACE Inhibition Dose Side Effects Monitoring
ARNI – Angiotensin receptor/Neprilysn Inhibition
ARNI
Neurohormonal Deactivation 3. A ldosterone • MRA Dose Side Effects Monitoring
Symptomatic management • Diuretics Loop/thiazide Dose Side Effects Monitoring
Other Pharmacological agents and contraindications • Digoxin • Oral Anticoagulations – NOACS • Ivabradine • Antianginals • Antihypertensives • Palliative Medications • Contraindications
Challenges in giving HF DMT • Hypotension • Dizziness • CKD • Hyperkalaemia • Non compliance • Incontinence • Immobility • Insufficient support • Insufficient education • Clinician anxieties/insufficient support/education
Do you have any questions about medication?
9. Non Pharmacological Management
Non Pharmacological Management • DAILY WEIGHT • Anxiety/stress management • Depression/low mood • Support Groups • Hospice • Education • Salt intake • Fluid intake • Dry mouth
Non Pharmacological Management • Exercise • General weight management • Smoking, alcohol • Fatigue management – goal setting • Sleep – nocturia – important meds at night (BP) • Caffeine intake • Vaccinations • Holidays
11. Palliative Care – Lets discuss the challenges of palliative care in heart failure
10. Device Therapy
CRT and ICD NYHA class QRS interval I II III IV <120 milliseconds ICD if there is a high risk of sudden ICD and CRT not cardiac death clinically indicated 120 – 149 milliseconds ICD ICD ICD CRT-P without LBBB 120 – 149 milliseconds ICD CRT-D CRT-P or CRT-P with LBBB CRT-D ≥150 milliseconds with CRT-D CRT-D CRT-P or CRT-P or without LBBB CRT-D LBBB, left bundle branch block; NYHA, New York Heart Association
• https://www.youtube.com/watch?v=7hEw4o06Fwc • http://www.bostonscientific.com/en-US/patients/about- your-device/crt-devices/how-crts-work.html
CRT
Thank you so much!!
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