Systolic Heart Failure
Systolic Heart Failure
NYHA Functional
Classification
Class I - pts with disease but no symptoms that
limit activity
Class II - pts with slight limitations of physical
activity related to symptoms of HF (dyspnea,
fatigue)
Class III - pts with marked limitations of
physical activity, but no symptoms at rest
Class IV- pts cannot carry out any physical
activity without limitation and may have
symptoms even at rest
Norepinephrine
Angiotensin II
Aldosterone
Endothelin
Vasopressin
Tumor necrosis
factor
Good Players
Natriuretic peptides
Nitric oxide
prostacyclin
Etiologies:
CAD (65%)
Idiopathic dilated cardiomyopathy
Alcoholic/toxin-induced cardiomyopathy
Infectious/Inflammatory process
Familial dilated cardiomyopathy
Peripartum cardiomyopathy
Stress-induced cardiomyopathy
Endocrine/Nutritional causes
Iron overload cardiomyopathy
Tachycardia mediated cardiomyopathy
Etiologies
CAD
Most common cause (65%)
Reversible
Revascularization can markedly improve
outcomes
Etiologies
Idiopathic dilated cardiomyopathy
Diagnosed when all other causes have
been excluded
Etiologies
Alcohol/toxin induced cardiomyopathy
Alcoholic CM prevalence is estimated at
20% of all DCM
Alcohol has a direct acute and chronic
toxic effects on the myocardium (> 7
drinks/day for >5 years)
Cocaine and other catecholaminergic
drugs
Chemotherapeutic drugs (anthracyclines)
Etiologies
Infectious/Inflammatory
Coxsackie B(#1)
HIV, mycoplasma, HCV, Lyme
Chagas disease, endemic in South and
Central America
Lupus, scleroderma, RA, Kawasaki, ChurgStrauss and others
Etiologies
Familial dilated cardiomyopathy
at least 20-30% of all DCM
Can be autosomal dominant or recessive, Xlinked, or mitochondrial
Associated with myscular dystrophies
Etiologies
Peripartum cardiomyopathy
Development of clincal HF in the last
month of pregnancy or the first 5 months
after peripartum
Half of all women normalize within 6
months and have a good prognosis
NO ACE/ARB if pregnant or breast feeding
Etiologies
Stress-induced cardiomyopathy
Other names include tako-tsubo, apical ballooning,
or broken heart syndrome
Reversible cause of acute systolic dysfunction
resembles a large anterior wall MI
Associated with emotional, surgical, or dramatic
stresses and catecholamine surge
Improves over days to weeks, usually with
complete resolution of LV function
Etiologies
Endocrine/Nutritional causes
Rare
Hypothyroidism/thyrotoxicosis
Diabetes/obesity (risks, stage A)
Acromegaly and GH deficiency
Pheochromocytoma
Thiamine (wet beriberi - high output form)
Carnitine, selenium
Etiologies
Iron overload cardiomyopathy
Can be primary (hereditary) or secondary
Hereditary hemochromatosis is common in
Northern Europeans and results in iron
deposition in the heart, joints, liver, skin
(bronze diabetes)
Gold standard for diagnosis is liver biopsy
Etiologies
Tachycardia mediated cardiomyopathy
Often difficult to discern whether
tachycardia is primary force driving the
cardiomyopathy or secondary
phenomenon
Treatment of heart rate improves and can
normalize LV function
Pharmacologic, cardioversion, or ablation
Clinical Evaluation
History
Clinical Evaluation
Physical
Volume status
Hemodynamics
Murmurs
Vitals with orthostatics
Clinical Evaluation
Laboratory
Chemistries
Renal function
CBC with dif
LFT
TSH
HbA1c
Lipids
BNP
Clinical Evaluation
Studies
CXR
ECG (Holter)
Echocardiogram
Clinical Evaluation
Rule out CAD since it is the most
common cause and is reversible
Patients should have angiography if the
have angina or known ischemia, or if they
have a high likelihood of CAD
Clinical Evaluation
Endomyocardial biopsy is not part of a
routine evaluation
It is only useful if the results will influence
therapy, such as in the following conditions
Sarcoidosis, amyloidosis
Hypereosinophillic syndrome
Fulminant myocarditis
Giant cell myocarditis
Drug toxicities
Management
Any patient who presents with first
either the first episode of heart failure or
with acute decompensation of
previously stable heart failure they
should be evaluated for the cause of
their deterioration
Clinical Evaluation
Drugs to avoid in heart failure
NSAIDs
Most antiarrhythmics
Most calcium channel blockers (felodipine,
amlodipine are likely safe)
thiazolidinediones
Management
Drugs in Heart Failure
Diuretics
loop diuuretics are preferred over thiazides if
renal function is impaired
Management
Drugs in Heart Failure
ACE inhibitors
ACE inhibitiors, start at low dose and titrate
slowly following creatinine and potassium levels
ACE inhibitors are first line, but ARB may be used
instead if history of cough or angioedema
Evidence is soft for addition of ARB to ACE
Management
Drugs in Heart Failure
Beta blockers
carvedilol, metoprolol, succinate and bisoprolol)
Start low and titrate slowly
Relative contraindications include reactive
airway disease, aymptomatic bradycardia, SM
with recurrent hypoglycemia, resting limb
ischemia
Management
Drugs in Heart Failure
Aldosterone antagonists
Management
Drugs in Heart Failure
Digoxin
Symptomatic improvement with reduced
hospitalizations in patients with mild to
moderate heart failure
Less effective in women than men
Optimal target level is 0.6 - 0.9, above which
there is an increase in mortality
Drug interactions: amiodarone
Management
Drugs in Heart Failure
Nitrate-Hydralazine
Inferior to ACE/ARB but should be used for
patients who are intolerant of these drugs
Should be used in addition to ACE-I and beta
blockers in African-American patients who have
persistent NYHA class II-IV symptoms
Management
Drugs in Heart Failure
Warfarin may be sued in patients with low
ejection fraction and
Atrial fibillation
Intracardiac thrombus
Previous thromboembolism
Prophylactic use is controversial
Management
Drugs in Heart Failure
Aspirin if the patient has ischemic
cardiomyopathy or atherosclerotic vascular
disease
If the patient has non-ischemic
cardiomyopathy do not use aspirin
Management
Non-pharmacologic treatment
Nutritional counseling regarding sodium
restriction, fluid restriction and alcohol
Daily weight and symptom assessment
with an understanding of how to take action
if there is a change
Regular physical activity
Education on the importance of compliance
Device Therapy
ICD
Half of pts with HF die suddenly from
arrhythmias
Implantation of and internal cardioverter
defibrillator may improve survival in centain
subsets of patients
Device Therapy
Cardiac resynchronization therapy
Used for patients with a conduction delay,
meaning the walls of the ventricle contract
at different times
Allows contraction of the ventricle to be
more efficient because it forces all walls of
the heart to contract at the same time
Management
Device Therapy
ICD
EF < 30-35%
History of inducible arrhythmia, sudden cardiac
death
BiVentricular pacemaker
QRS >120
EF< 35%
NYHA III-IV
Guidelines
Chronic stable Heart Failure Therapy
Stage A:
Treat all underlying disorders, such as HTN,
DM, lipids, thyroid dysfunction and CAD
Modify all social factors, such as alcohol, diet,
smoking
Consider starting ACE-I if patient has diabetes,
CAD or HTN
Guidelines
Chronic stable Heart Failure Therapy
Stage B:
All therapies listed under stage A
Utilize beta blocker and ACE-I in all patients with a
history of AMI or any patient with reduced EF
Evaluate patients for valvular heart disease and
recommend surgery for any hemodynamically significant
valvular disorders
Consider ICD for patients after AMI with EF < 30%
Guidelines
Chronic Stable Heart Failure Therapy
Stage C:
All therapies listed under stages A and B
Aldosterone antagonists should be started in patients with
NYHA III-IV and a reduced EF
Institute diuretics and salt/fluid restriction
Consider the addition of hydralazine/imdur in AfricanAmerican patients, may also be used in place of ACE-I in
patients unable to take ACE-I
Consider digoxin in patients with symptoms and EF<30%
ICD if EF<30-35%
CRT if EF<35%, NYHA III-IV, QRS>120
Guidelines
Refractory Heart Failure
Stage D
All therapies listed under stages A, B and C
Refer eligible patients for transplant/heart
failure center
Consider LVAD for destination therapy
Consider Swan placement to guide therapy
End-of-life care should be discussed, including
option of deactivating ICD
Management
Acute Decompensated Heart Failure
Patients need to be evaulated regarding
congestion(wet versus dry) and for
adequate perfusion (cold versus warm)
Most patients are wet and warm, others
may be in shock and are wet and cold
Management
Acute Decompensated Heart Failure
Wet and warm treatment
Diuresis
vasodilators
Management
Acute Decompensated Heart Failure
Wet and warm treatment
Diuresis
inotropes
vasodilators
Management
ADHF: Vasolilators
Nitroprusside
Arterioral and venodilator, avoid in ischemic patients
Nitroglycerin
Primarily venodilator, best if ischemie cause of HF
Nesiritide
Allows for diuresis and improved relaxation, concerns for
mortailiuty and dosing
Management
ADHF: inotropes
Milrinone/Dobutamine
Limited role
Use with low output state with marginal
blood pressure despite adequate filling
pressure
Risk of tachyarrhythmias and hypotension
Management
ADHF Device therapy
LVAD(left ventricular assist device), device
connected to the left ventricle to
mechanically pump blood and rest the
heart
Ventricular reconstruction surgery
Heart transplant
LVAD
Case 1
55 year old male presents with mild dyspnea
on exertion. He denies angina or dizziness.
There is no significant past medical history.
He drinks 2-3 glasses of wine per week
On physical exam BP 134/70, HR 125. There
is no JVD. Lungs are clear. Heart is
tachycardic with irregular rhythm. Routine
labs are normal. EKG shows AF. Echo
demonstrates global hypokinesis with ejection
fraction of 35%
I
II
III
IV
A
B
C
D
Nitroglycerin
Milrinone
Dobutamine
diltiazem
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