Heart Failure

Heart failure part II

Prof . Oday alsalihi

In this lecture ; ( objectives )

We will discus the most important investigation used in HF
We will know what are the out lines of management of HF
How to treat acute heart failure ( pul. Odema )
Pharmacological and non pharmacological treatment

Invstigation ;

CXR
A chest X-ray should be performed in all cases. This may show abnormal distension of the upper lobe pulmonary veins with the patient in the erect position. Vascularity of the lung fields becomes more prominent and the right and left pulmonary arteries dilate.
Subsequently, interstitial oedema causes thickened interlobular septa and dilated lymphatics. These are evident as septal or kerely B line.

More advanced changes due to alveolar oedema cause a hazy opacification spreading from the hilar regions, and pleural effusions

Echocardiography

It is very useful and should be considered in all patients with heart failure in order to:
determine the aetiology
detect hitherto unsuspected valvular heart disease, such as occult mitral stenosis, and other conditions that may be amenable to specific management
identify patients who will benefit from long-term drug therapy.
It can help also in follow up of patient to assess the response

Blood test :

Serum urea, creatinine
Electrolytes ( Na , K , ca , Mg )
haemoglobin
thyroid function
these invetigation may help to establish the nature and severity of the underlying heart disease and detect any complications.
BNP is elevated in heart failure and is a prognostic marker, as well as being useful in differentiating heart failure from other causes of breathlessness or peripheral oedema.

Management of HF

Management of acute heart failure
(Pulmonary odema )

If previous measures fail – or patient blood pressure fall below 90mmhg systole

>>>>>Dobutamine or less effective dopamin
OR
>>>>> IABC ( intra aortic balloon counter pulsation machine )

If patient has Rapid AF / >>>> digoxin can be considered as line of management ..

Management of chronic HF ;

General meaures ( as in table next slide )
Pharmacological
Non pharmacological treatment ( device therapy )

Drug treatment

A wide variety of drug treatments are now available for the treatment of heart failure.
Drugs that reduce preload are appropriate in patients
with high end-diastolic filling pressures and evidence of pulmonary or systemic venous congestion,
whereas those that reduce afterload or increase myocardial contractility are more useful in patients with signs
and symptoms of a low cardiac output


Diuretics
Loop diuretics ( like frussemid ‘ lasix’ )
Thiazide
Mineralocorticoid receptors antagonist ( like spiranolacton ’ aldacton ‘)

ACE inhibitors ;

Like captopril , enalapril , lisonopril , ramipril …. Etc
ARBs :
Like losartan, valsartan , candisartan … etc
Beta blocker
Beta -blockers are more effective at reducing mortality than ACE inhibitors, with a relative risk reduction of 33% versus 20%, respectively , , like ( MBC ) = metoprolol , bisoprolol , carvidolol

Other drugs ;

Ivabradine ( SA node blocker )
Digoxin
Amiodarone
>>> the last two used in certain conditions when there is complication related to arrythmia
Vasodilators ;
Like - Nitrate and hydralazine


Neprilysin inhibitors ;
this is very new group of mediation like -Sacubtril , they are very effective specially if combined with ARBs
>> https://www.google.iq/search?sxsrf=ALeKk01wtLnDokKkgsTqt-nSiNUlQsrHQw%3A1586028734631&lei=vuCIXpGTJuaflwT246CgAg&q=sacubitril mechanism of action&ved=2ahUKEwiRoay-wc_oAhWkyIUKHQVaCGwQsKwBKAN6BAgDEAQ&biw=1199&bih=837

Non pharmacological treatment

• ICD ( intra cardiac Defibrillator )
• CRT ( cardiac resynchronization therapy )
• Coronary revascularization : stunned and hibernating myocardium
• VAD ( ventricular assistant device )
• Cardiac transplant