Heart failure with reduced ejection fraction

heart failure with preserved ejection fraction

• mortality:

  • in first year after diagnosis 30-40% die; 10% per year thereafter

  • highest

    • heart failure associated with:

      • Acute MI

      • arrhythmia

      • hypotensive

      • NYHA class IV

      • repeated hospitalisation

• M>F

  • but F:

    • older than males when develop heart failure

    • have heart failure with a preserved ejection fraction

    • live longer than males with heart failure

    • more pronounced symptoms of heart failure compared to males

abnormality of structure or function of heart that leads to a failure of the heart to deliver sufficient oxygen to the metabolising tissues (or when heart can only do so with elevated diastolic filling pressures)

compensatory mechanisms eventually fail:

• increase HR

• increase cardiac muslce mass

• increase cardiac filling pressures and blood volume

• complex clincila syndrome

  • typical signs and symptoms

• risk factos:

  • IHD

    • LV dysfunction

  • HTN

    • 75% with heart failure

  • Valvular heart disease

  • Rhythm/conduction AbN

  • Cardiomyopathy

  • DM

  • Male

  • excessive Etoh

    • increase CVRA

    • direct cardiotoxin

  • Smoking

    • direct cardiotoxin

  • Obesity

  • Dyslipidaemia

  • Respiratory condition

  • Thyroid disorders

  • Medicines

  • Cardiotoxins

  • Infections/inflammation

  • Congenital heart disease

• evaluation undertaken:

  • new onset SOBOE

  • orthopnoea

  • PND

  • unless non cardiac cause

Symptoms

Typical

• dyspnoea

• orthopnoea

• PND

• reduced exercise tolerance

• Fatigue, weakness, more time needed to recover oafter exercise

• ankle oedema

  • consider varicose veins

  • medicines: CCB

  • decrease mobility

Less typical

• nocturnal cough

• wheezing

• Weight gain of >2kg

• bloated feeling

• anorexia, nausea

• cerrebral symptoms

  • reduced cardiac output

• depression

• palpitations, chest pain or pressure

• syncope

signs

• more specific

  • elevated JVP

  • prolonged hepatojugular reflex

  • third heart sound (gallop rhythm)

  • laterally displaced apicle impulse

  • cardiac murmur

• less specific

  • peripheral oedema

  • crepitations

  • decrease AE (pleural effusion)

  • tachycardia

  • irregular pulse

  • Tachypnoea

  • Hepatomegaly

  • Cachexia

• careful attention causative factors:

  • htn

  • MI

  • valvular heart disease

  • atrial fibrillation

• low specificity

  • exertional SOB

  • ankle swelling

• more specific

  • orthopnoea

  • PND

Heart failure with preserved ejection fraction

• 50% of people with symptoms and signs of heart failure have been shown to have preserved or relatively preserved (≥ 45-50% LVEF)

• definition

  • Symptoms typical of heart failure

  • Signs typical of heart failure

  • Normal or only mildly red. LVEF and no LV dilatation

  • relevant structural heart disease:

    • LV hypertrophy

    • LA enlargement

    • diastolic dysfunction

• more frequently seen in:

  • elderly

  • females

  • obese

• more likley to have

  • AF

  • hypertension

• underlying causes;

  • constrictive pericarditis

  • cardiomyotphay

  • hypertrophic cardiomyopahty

  • restrictive cardiomyopahty

    • amyloidosis

    • sarcoidosis

Heart failure with reduced ejection fraction

• impaired LV systolic function

• definition

  • typical symptoms and signs

  • evidence of reduced LVEF on ECHO

Investigations

MICE rule:

• increase diagnostic vaule of BNP and guide decisiions for ECHO

• Male

• Infarction

• Crepitations

• Edema

• symptomatic patients who have ≥1 of above

  • refer for ECHO without need for BNP

  • else order BNP and refer based on above

• studies underway to validate use in primary care

ECHO

• gold standard

• all patients should have ECHO

• can get guidance from ECG and BNP

  • 2 weeks

    • if history of previous MI and elevated BNP

  • 6 weeks

    • if no history of MI and moderately raised BNP

BNP

• assists in diagnosis

• ‘rule out’ test

• cannot differentiate between HF-REF and HF-PEF

• high levels associated with poorer prognosis

• unlikely:

  • \<100

• likely

  • >500

• grey zone

• may be elevated in absence of HF:

  • atrial fibrillation

  • COPD

  • ACS

  • pulmonary embolism

  • pulmonary hypertension

  • renal impairment

• may be normal/marginaly elevated:

  • obese

  • recently commenced on diuretics

  • sudden onset (“flash”) pulmonary oedema

• if diagnosis likely from clinical and other tests:

  • ecg

  • cxr

  • do not require BNP

ECG

• long term left ventricular dysfunction

  • LA enlargement

  • LV hypertrophy

• normal ECG usually rulse out heart failure

• assess other cardiac pathology

CXR

• most useful in apatient who is acutely unwell with pulmonary oedema

• may help differentiate from pulmonary causes of SOB

Classification

• worsening prognosis as move down classes;

• NYHA

• Class I:

  • asymptomatic

• Class 2:

  • mild symptoms

  • comfortable at rest

  • dyspnoea, fatigue, palpitations with ordinary physical activity

• Class 3:

  • moderate symptoms

  • comfortable at rest

  • develops dyspnoea, fatigue, palpitations with less than ordinary phsycial activity

• class 4:

  • severe symptoms

    • unable to do any psycal activity

Management

goal =

• improve symptoms and signs

• decrease hospital admission

• improve longevity

HF-REF

• diuretic

  • reduce fluid overload to improve patient’s symptoms

  • no evidence improve mortality

  • loop diurectic

    • more effective

    • frusemide 20-40mg daily

    • improvement and weight loss of 1.0kg/day

    • bumetanide alternative who don’t respond

      • 0.5-1mg/day

      • max = 5mg/day

  • too little;

    • blunt repsonse to ACEi

    • increase risk of decomensation when Bblocker introduced

  • too much;

    • increase risk of hypotension and rnal impairment

      • especially when ACEi started

• add ACEi and beta-blocker

  • improve both morbidity and mortality

  • ACEi

    • reduce symptoms

    • assis wtih LV remodelling

    • any medicine from ACEi class

    • if hypotension going to occur - will occur @ low doses; increasing dose wont’ make a difference

    • acceptable:

      • K \<5.5

      • eFGR \<50% increase in baseline

        • if Cr >30% then change dose in CKD

    • if elevation:

      • reduce dose of diuretic, stop nephrotoxic

        • if remain raised

          • halve dose of ACEi

          • check in 2 weeks

  • beta-blocker

    • improve ventricular function

      • markedly improve ejection fraction

    • no clear evidecne that any one more superior

      • bisoprolol

        • more cardioselective

        • reduces hr more than other betablockers

        • 1.25mg OD gradually increasing

          • aim for maintenance dose of 10mg od

    • start at low dose

      • ‘go slow, aim high’

• Add spironolactone

  • aldoseterone receptor antagonist

  • remain symptomatic or EF\<35%

  • reduce both morbidity and mortality

  • used in caution with impiared renal function and may cause hyperkalaemia

• Digoxin

  • slow ventricular rate

    • improve symptoms

      • symptomatic HF and AF

  • Use CHA2DS2 - VASc

  • digoxin didn’t improve survival

    • 64% improvement symptoms

      • NNT 9

    • 23% reduction in hospitalisation

    • DIG trial

  • toxicity increase by hypokalaemia

• nitrates

  • V-HEFT

    • improve mortality in chronic heart failure

HF-PEF

• evidence limited

• should usually be referred to cardiologist for initial management

• usually more brittle

  • require careful control of fluid balance

• beta blockers

  • prolonging diastole

  • rate limiting CCB can be used as an alternative

    • may improve symptoms and exercsie tolerance

    • NOT HF-REF

• ACEi

• Digoxin

Non-pharmacological

• weight themselves daily

  • establish “dry weight”

• Participate in regular exercise

• Avoid excessive salt and etoh

• monitor fluid intake

  • 1.5-2L/day restrict

• maximise adherence to medicines

• annyal influenza vaccination

Referral

• valvular heart disease

• heart failure and syncope

  • PPM

• HF and LBBB and wide QRS

  • associated with dyssyncrony

  • Caridac resynchronisation therapy/biventricular pacing may be indicated

• history of cardiac arrest of VT

Left ventricular systolic dysfunction

• LVEF \<45%

• patient education

• self managmenet

• non pharmacological

• pharmacotherapy

  • ACEi / ARB

  • Diuretics

  • beta- blockers

  • spironolactone

• Device

  • cardiac resynchronisation therapy

  • implantable cardioverter defibrillator

• Additional pharmacotherpy

  • Digoxin

  • nitrate

• management of co-existing AF

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