HEART FAILUREABDUL HAFIZ ALIAS

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Heart failure (HF) is a clinical syndrome and represents the end stage of most heart diseases.

• Prevalence in Malaysia3-20 per 1000 population

• Age group ≥65 years 100 per 1000 population

• Coronary Artery Disease (CAD) and Hypertension (HTN) are the main causes of HF among adults in Malaysia70%

• POOR PROGNOSIS.5% to 52%

• Cause of hospitalization of all acute medical admissions in Malaysia.6% - 10%

• Hospital re-admissions within 30 days for acute decompensation.25%

INTRODUCTION 2

DEFINITION

• An abnormality of cardiac structure or function leading to an impairment of ventricular filling or ejection of blood. It is a clinical syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling and fatigue) and signs (e.g. elevated jugular venous pressure, ankle edema, pulmonary crackles, and displaced apex beat). Occasionally some patients may present without signs or symptoms of volume overload.

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PATHOPHYSIOLOGY 4

CO HR SV= X

AFTERLOAD

CONTRACTILITY

PRELOAD (EDV)

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AFTERLOAD CONTRACTILITY PRELOAD (EDV)

↑↑ AL → ↓ SV ↓↓ CONT → ↓ SV ↓ PL(EDV) → ↓ SV

EF SV

EDV

~ 55%=

↓SV

~↑EDV↓EF=Systolic HF(HFrEF)

↓SV

↓EDV= ~EF

Diastolic HF(HFpEF)

Chronic hypertension CAD/ chronic ischemic Constrictive pericarditis

• Pathophysiological Classification of Heart Failure (HF)

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CLASSIFICATION LVEF%

I. Heart Failure with Reduced Ejection Fraction (HFrEF)

≤40%

II. Heart Failure with Preserved Ejection Fraction (HFpEF),borderline

41-49%

III Heart Failure with Preserved Ejection Fraction (HFpEF)

≥50%

ETIOLOGY

Most common

• Coronary artery disease• Hypertension• Dilated cardiomyopathy-

idiopathic, familial • Valvular heart disease• Diabetic cardiomyopathy

Other causes

• Congenital heart disease• Cor pulmonale• Cardiac tamponade• Hypertrophic

cardiomyopathy• Viral myocarditis• Acute rheumatic fever• Toxic: Alcohol, adriamycin,

cyclophosphamide• Thyroid disease, acromegaly,

phaechromocytoma• SLE

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DIAGNOSIS

• A clinical diagnosis based on a careful history and physical examination.• Symptoms• Breathlessness with orthopnoea• paroxysmal nocturnal dyspnoea (PND)• reduced exercise tolerance• ankle swelling

• Signs • Elevated jugular venous pulse (JVP)• Third heart sound• Peripheral edema• Tachycardia• Narrow pulse pressure • Pulmonary crepitations• Hepatomegaly• Ascites.

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• Acute HF - rapid onset of symptoms and signs of HF due to an acute deterioration of cardiac function.

• Chronic HF - chronic state when patients have stable symptoms. In these patients an acute precipitating or aggravating factor(s) may cause acute cardiac decompensation.

• Older terms such as congestive cardiac failure may be used if patients present with both right and left ventricular fluid overload.

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INVESTIGATION

• 12 lead ECG • Chest radiograph • Blood tests• Echocardiography• Tests for myocardial ischemia and/or viability:• treadmill exercise test, stress echocardiography (exercise or

pharmacological), radionuclide studies, cardiac magnetic resonance imaging (CMR)

• Invasive tests: coronary angiography, cardiac catheterization, endomyocardial biopsy

• Others: Holter, pulmonary function tests

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PREVENTION

• Primary objective of management• What can be done?• Optimize underlying disease• Smoking cessation• Healthy lifestyle and diet• Regular physical exercise• Appropiate treat of coronary artery disease

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MANAGEMENT

• Divide into acute and chronic

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• CHRONIC HEART FAILURE • NON PHARMACOLOGICAL MEASURES

a) Education

b) Diet & Nutrition

c) Lifestyle

d) Exercise

e) Sleep Disorders

f) Social Support• PHARMACOLOGICAL MEASURES

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END OF LIFE CARE

• Recognize patients who appear to be approaching the terminal phase of their illness:• no identifiable reversible cause• been on optimum tolerated conventional drugs• worsening renal function• fail to respond to appropriate changes in diuretic and vasodilator drugs• sustained hypotension

• In these patients it is important to :• explore their wishes in terms of options for care and place of care. • provide symptom relief. • discuss with patient and family when it would be appropriate to switch off

devices such as ICD or CRT• avoid inappropriate invasive procedures• discuss issues of “Allow Natural Death (Do Not Resuscitate)” with patient

and family. • provide physical, psychological, social and spiritual support of patient and

family support

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REFERENCES

• CPG Management of Heart Failure (3rd Edition) 2014• http://

www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp

• 2013 ACCF/AHA Guideline for the Management of Heart Failure - http://circ.ahajournals.org/content/128/16/e240.extract

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-TQ-

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