ΔΙΑΓΝΩΣΗ-ΚΛΙΝΙΚΗ ΠΟΡΕΙΑ ΚΑΡΔΙΑΚΗΣ ΑΝΕΠΑΡΚΕΙΑΣ Α. Η ΚΛΙΝΙΚΗ ΕΙΚΟΝΑ ΕΙΝΑΙ ΑΡΚΕΤΗ
ESC guidelines 2012
Επιδηµιολογία Πολύ συχνή πάθηση: 1-2% του γενικού πληθυσµού / >10% σε άτοµα >70 ετών 20% των εισαγωγών ατόµων >65 ετών οφείλεται σε Κ.Α. 550.000 νέα περιστατικά ετησίως µε Κ.Α. Clinical Epidemiology of heart failure. Heart 2007;93:1137-1146
Prognosis Annual mortality rate depends on patients symptoms and LV function 5% in patients with mild symptoms and mild in LV function 30% to 50% in patient with advances LV dysfunction and severe symptoms 40% 50% of death is due to SCD esc guidelines 2008
Signs and sxs of HF DOE, fatigue Orthopnea JVD, enlarged liver Nocturnal cough or DOE Displaced apical impulse S3 gallop Bilateral crackles at lung bases Lower extremity edema
HF is not Funny
Διαφορική διάγνωση Αρ. Καρδιακή ανεπάρκεια Πνευµονοπάθεια Δύσπνοια +++ +++ Ορθόπνοια +++ + Παροξυσµική νυκτερινή δύσπνοια +++ + Θωρακικοί πόνοι ++ + Παραγωγή πτυέλων + +++ Αιµόπτυση + +++ Κυάνωση ++ +++ Ταυτόχρονη δ. καρδιακή ανεπάρκεια ++ ++ Χρησιµοποίηση επικουρικών µυών + +++ Πιθοειδής θώρακας 0 ++ Πληκτροδακτυλία + ++ Υγροί ρόγχοι +++ +++ Συριγµός ++ +++ Καλπαστικός ρυθµός +++ +++ Υποξυγοναιµία +++ +++ Ακτινογραφία Μεγαλοκαρδία Φυσιολογική
HF is common in geriatric patients
HF and medical history
Main causes Ischemic heart disease, Cardiomyopathy, Hypertension Other causes: Valvular heart disease, Congenital heart disease, Alcohol and drugs, Hyperdynamic circulation (anaemia, thyrotoxicosis, haemochromatosis, Paget's disease), Right heart failure (RV infarct, pulmonary hypertension, pulmonary embolism, cor pulmonale (COPD), Arrhythmia and Pericardial disease.
Κλινική πορεία ΚΑ
New Classification of Heart Failure ACC/AHA Staging v/s NYHA Functional Class ACC/AHA HF Stage 1 NYHA Functional Class 2 AAt high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with HTN or coronary artery disease) BStructural heart disease but without symptoms of heart failure CStructural heart disease with prior or current symptoms of heart failure None I Asymptomatic II Symptomatic with moderate exertion III Symptomatic with minimal exertion DRefractory heart failure requiring specialized interventions IV Symptomatic at rest 1 Hunt SA et al. J Am Coll Cardiol. 2001;38:2101 2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al.jama.2002;287:890 897.
Acute heart failure The rapid onset of symptoms and signs secondary to abnormal cardiac function (reduced CO, tissue hypoperfusion + congestion, increase in PCWP) 1. With or without previous cardiac disease. 2. The cardiac dysfunction can be related: a) to systolic or diastolic dysfunction b) to abnormalities in cardiac rhythm c) to preload and afterload mismatch 3. Often life threatening and requires urgent treatment. The Task Force on Acute Heart Failure of the European Society of Cardiology 2012
Acute Heart Failure : Classification The patient with AHF may present with one of several distinct clinical conditions: Acute decompensated heart failure (de novo or as decompensation of CHF) : With mild signs and symptoms of AHF and do not fulfill criteria for cardio-genic shock, pulmonary oedema or hypertensive crisis. Hypertensive acute heart failure: Signs and symptoms of HF + high BP + preserved LVF + chest radiograph findings APO. Pulmonary oedema: Verified by chest X-ray, severe respiratory distress, orthopnoea with SaO2 <90%. Cardiogenic shock: Reduced BP (SBP<90mmHg or drop of mean AP >30mmHg) and/or low urine output (<0.5 ml/kg/h), with pulse rate >60 bpm with or without evidence of organ congestion. High output failure: High CO + HR, pulmonary congestion, sometimes low BP (arrhythmias, thyrotoxicosis, anaemia, Paget disease, iatrogenic etc) Right heart failure: Low CO + increased jugular venous pressure + increased liver size + hypotension. The Task Force on Acute Heart Failure of the European Society of Cardiology
Rapid Assessment of Hemodynamic Status in HF pts Low Perfusion at Rest No Yes Congestion at Rest No Yes I II Warm & Dry Warm & Wet III Cold & Dry IV Cold & Wet Signs/symptoms of congestion Orthopnea/PND JV distension Ascites Edema Rales (rare in CHF) Possible evidence of low perfusion Narrow pulse pressure Sleepy/obtunded Low serum sodium PND = paroxysmal nocturnal dyspnea; JV = jugular venous. Stevenson LW. Eur J Heart Fail. 1999;1:251 257. Cool extremities Hypotension with ACE inhibitor Renal dysfunction (one cause) dry: absence of signs of congestion, wet: elevated filling pressures, warm: adequate systemic perfusion, cold: inadequate systemic perfusion
The relation between and combined effect of Killip class and age in all patients treated with primary angioplasty on 30-day mortality. Henriques J P et al. Eur J Heart Fail 2003;5:291-294 2002 European Society of Cardiology
Diagnosis of HF is based on symptoms and signs Diagnosis can be difficult Demonstration of an underlying cardiac cause is central to the diagnosis and for therapeutic reasons ECG/ NT-proBNP /labtests /Echocardiography
Heart Failure Patient Evaluation Recommended evaluation for patients with a diagnosis of HF: Assess clinical severity and functional limitation by history, physical examination, and determination of functional class* Assess cardiac structure and function Determine the etiology of HF Evaluate for coronary disease and myocardial ischemia Evaluate the risk of life threatening arrhythmia Identify any exacerbating factors for HF Identify co-morbidities which influence therapy Identify barriers to adherence and compliance *Metrics to consider include the 6-minute walk test and NYHA functional class
Κλινική εικόνα ανεπάρκειας της αριστεράς κοιλίας Δύσπνοια Ορθόπνοια Νυκτερινή παροξυντική δύσπνοια Βήχας Μείωση αδρενεργικής δράσης του µυοκαρδίου Πνευµονικό οίδηµα Αφρώδης οροαιµατηρή απόχρεµψη Υγροί ρόγχοι Εύκολη κόπωση Αιµοπτύσεις Ολιγουρία Συλλογή πλευριτικού υγρού
Acute Heart Failure : Other Classifications In AHF after AMI, best applied to acute denovo heart failure: The Killip classification : based on clinical signs and chest X-ray findings (Stage I: No heart failure, Stage II: Heart failure, Stage III: Severe heart failure and Stage IV: Cardiogenic shock). The Forrester classification : based on clinical signs and haemodynamic cha-racteristics. In a cardiomyopathy service, best applied to chronic decompensated ed heart failure: Clinical severity classification : based on observation of the peripheral cir-culation and on auscultation of the lungs for congestion (Class I: dry and warm, Class II: wet and cold, Class III: cold and dry and Class IV: cold and wet). Nohria A et al: JACC 2003;41:1797-1804.
Ανεπάρκεια δεξιάς κοιλίας Προϋπάρχουσα ανεπάρκεια αριστεράς κοιλίας Στένωση µιτροειδούς Πνευµονική καρδιά από παθήσεις των πνευµόνων Συγγενείς καρδιοπάθειες Θυρεοτοξίκωση Ανεπάρκεια τριγλώχινος
Συµπτώµατα Αδυναµία κόπωση Ολιγουρία Οίδηµα σφυρών κνηµών κοιλίας Αίσθηµα βάρους στο επιγάστριο Εκδηλώσεις από το πεπτικό
Φυσικά σηµεία Αυξηµένη πίεση και σφύξεις φλεβών του τραχήλου Οίδηµα Διόγκωση ήπατος σπληνοµεγαλία σπανίως Ασκίτης πλευρική συλλογή Ολιγουρία νυκτουρία Ελαφρά ικτερική χροιά Λευκωµατουρία Αύξηση σωµατικού βάρους
Profiles and Therapies of Advanced Heart Failure Low Perfusion at Rest No Yes Congestion at Rest No Warm and Dry PCW and CI normal Cold and Dry PCW low/normal CI decreased Yes Warm and Wet PCW elevated CI normal Cold and Wet PCW elevated CI decreased Vasodilators Nitroprusside Nitroglycerine Nesiritide Nl SVR High SVR Inotropic drugs Dobutamine Milrinone Calcium Sensitizers R. Bourge, UAB Cardiology (adapted from L. Stevenson) Stevenson LW. Eur J Heart Failure 1999;1:251-257
Natural history of Congestive Heart Failure Index event Neurohormonal activation 60% EF % 20% Secondary damage Sympathetic system activity SNSnervous RAAS Endothelin Reninetc Angiotensin- Aldosterone System activity Asymptomatic Time (years) Symptomatic Mann DL.et al. Circulation 2005
ACC/AHA 2005 Guideline: HF Stages At Risk for Heart Failure Heart Failure Therapy: Goals All measures under Stages Therapy: A and B Stage AGoals Stage B Stage C Dietary salt restriction At Treat All high measures risk hypertension Structural under Stages A, Structural B, and Therapy: for CHF but Drugs Routine heart heart without Diuretics Encourage for smoking fluid disease retention but cessation disease with structural Discussion re: without appropriate Sx level prior or of ACEIs Treat heart care lipid disorders of HF current Sx disease β-blockers Therapy: Encourage or Options regular exercise of HF Therapy: Goals Therapy: Sx of HF Discourage Drugs Select Compassionate alcohol All measures end-of-life intake, Pts illicit under Stage A Therapy: Goals drug Therapy: Drugs All measures under Stages Therapy: Aldosterone Goals use antagonist ACEI or ARB in A and B Treat care/hospice hypertension appropriate patients Dietary salt restriction Encourage ARBs smoking Therapy: β-blockers Goals in appropriate Therapy: Drugs Routine Control Extraordinary metabolic measures syndrome cessation patients Diuretics for fluid retention Treat lipid disorders ACEIs Digitalis Encourage regular β-blockers exercise Heart All transplant measures under Stage A Therapy: Drugs Select Pts Therapy: Discourage Hydralazine/nitrates Drugs alcohol intake, Aldosterone antagonist illicit drug use ARBs Control metabolic Chronic Therapy: inotropes Drugs Digitalis Therapy: ACEI or syndrome Devices Select ARB appropriate Pts patients Hydralazine/nitrates Therapy: Drugs Therapy: Devices Select Permanent ACEI or mechanical ARB in appropriate support patients ACEI Biventricular for or ARB vascular in pacing disease or diabetes Pts appropriate patients for Biventricular pacing vascular disease or Implantable defibrillators diabetes Implantable Experimental β-blockers defibrillators surgery in appropriate or drugs patients Hunt SA, Abraham WT, Chin MH, et al, J Am Coll Cardiol, 2005 Stage D Refractory HF requiring specialized interventions Therapy: Goals All measures under Stages A, B, and C Discussion re: appropriate level of care Therapy: Options Compassionate end-of-life care/hospice Extraordinary measures Heart transplant Chronic inotropes Permanent mechanical support Experimental surgery or drugs
ESC recommended treatments for HF-PSF Drug Class ACE inhibitors Diuretics Beta blockers Verapamil-type calcium channel blockers ARBs ESC clinical recommendation To improve relaxation and cardiac distensibility Use cautiously when fluid overload present. Avoid excessive lowering of preload (reduces SV & CO) To lower heart rate and increase diastolic period To lower heart rate and increase diastolic period High doses can reduce hospitalisations Dickstein et al. Eur Heart J. 2008
Acute Decompensated Heart Failure: Treatment Goals for Hospitalized Patients Improve symptoms, especially congestion and low-output symptoms Optimize volume status Identify etiology Identify precipitating factors Optimize chronic oral therapy; minimize side effects Identify who might benefit from revascularization Education patients concerning medication and HF self-assessment Consider enrollment in a disease management program Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122
What is the optimal heart failure medical treatment in 2010? Neurohormonal modulators against: - RAS - SNS - Aldo Diuretics against symptoms Vasodilators in selected pts Digoxin against refractory symptoms (patients on SR) Careful management of volume status Treatment of co-morbidities
Effects of Ghrelin Administration on Left Ventricular Function and Geometry in Patients with Chronic Heart Failure Nagaya et al. Circulation 2004;110:3674
Πρόγνωση Δυσµενής ~ 50 % καταλήγουν εντός των πρώτων 4 ετών ~ 40% θα καταλήξουν ή θα επανεισαχθούν εντός του έτους ESC GUIDELINES 2005
Summary of drug treatment for CHF Asymptomatic Mild to moderate Moderate LV dysfunction CHF to severe CHF ACE inhibitor Digoxin Digoxin Beta blocker Diuretics Diuretics ACE inhibitor Beta blocker ACE inh Beta b Spironolactone
Profiles and Therapies of Advanced Heart Failure Low Perfusion at Rest No Yes Congestion at Rest No Warm and Dry PCW and CI normal Cold and Dry PCW low/normal CI decreased Yes Warm and Wet PCW elevated CI normal Cold and Wet PCW elevated CI decreased Vasodilators Nitroprusside Nitroglycerine Nesiritide Nl SVR High SVR Inotropic drugs Dobutamine Milrinone Calcium Sensitizers R. Bourge, UAB Cardiology (adapted from L. Stevenson) Stevenson LW. Eur J Heart Failure 1999;1:251-257