Heart Failure: Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

HEART FAILURE
Departemen Kardiologi FK USU

RSUP. H. Adam Malik
Medan
Definition
Heart failure is defined as the inability of the
heart to pump blood forward at a sufficient
rate to meet the metabolic demands of the
body (forward failure), or the ability to do so
only if the cardiac filling pressures are
abnormally high (backward failure), or both.
Pathophysiology
loss of fibers or contractility
reduced cardiac output
arrhythmia reduced renal

perfusion
cardiac
dilatation venous
increased renin increased
congestion
secretion sympathetic
tone
increased
filling pressure
Na+, H2O increased arteriolar
retention heart rate constriction
increased capillary
hydrostatic pressure increased
resistance
incomplete
edema diastolic cardiac
filling hypertrophy
Causes of left ventricular failure
Volume over load: Regurgitate valve
High output status
Pressure overload: Systemic hypertension
Outflow obstruction
Loss of muscles: Post MI, Chronic ischemia
Connective tissue diseases
Infection, Poisons
(alcohol,cobalt,Doxorubicin)
Restricted Filling: Pericardial diseases, Restrictive

cardiomyopathy, tachyarrhythmia
Diagnosis
IDENTIFICATIONS OF HF PATIENTS
With a Syndrome of Decrease Exercise

Tolerance
With a Syndrome of Fluid Retention
With No Symptoms or Symptoms of Another
Cardiac or Non Cardiac Disorder
(MI, Arrythmias, Pulmonary or Systemic
Thromboembolic Events)
SYMPTOMS AND SIGN
Breathlessness, Ankle Swelling, Fatique

Characteristic Symptoms
Peripheral Oedema, JVP , Hepatomegaly

Signs of Congestion of Systemic Veins
S3 , Pulmonary Rales , Cardiac Murmur

Framingham Criteria
Major Criteria:
PND
JVD
Rales
Cardiomegaly
Acute Pulmonary Edema
S3 Gallop
Positive hepatic Jugular reflex
venous pressure > 16 cm H2O
Framingham Criteria
Minor Criteria:
Extremitas edema
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion
vital capacity by 1/3 of normal
Tachycardia
Weight loss 4.5 kg over 5 days management
Precipitating Factors
Increased metabolic demand
Increased circulating volume
Condition that increased afterload
Condition that impaired contractility
Failure to take prescribe medication
Arrhytmia
ECG
A low Predictive Value
LAH and LVH maybe Associated wit LV
Dysfunction
Anterior Q-wave and LBBB a good predictors
of EF
Detecting Arrhytmias
CHEST X-RAY
A Part of Initial Diagnosis of HF

Cardiomegaly, Pulmonary Congestion
Relationship Between Radiological Signs and
Haemodynamic Findings may Depend on the
Duration and Severity HF
HAEMATOLOGY & BIOCHEMISTRY
A Part of Routine Diagnostic
Hb, Leucocyte, Platelets
Electrolytes, Creatinine, Glucose, Hepatic Enzyme,
Urinalysis
TSH, C-RP, Uric Acid
ECHOCARDIOGRAPHY
The Preferred Methods
Helpful in Determining the etiology
Follow Up of Patients Heart Failure
PULMONARY FUNCTIONS
A Little Value in Diagnosis Heart Failure
Usefull in Excluding Respiratory Diseases
EXERCISE TESTING
Focused on Functional, Treatment Assessment and

Prognostic
STRESS ECHOCARDIOGRAPHY
For Detecting Ischaemia
Viability Study
NUCLEAR CARDIOLOGY
Not Recommended as a Routine Use
CMR
( CARDIAC MAGNETIC RESONANCE IMAGING)
Recommenmded if Other Imaging Techniques not

Provided Diagnostic Answer
INVASIVE INVESTIGATION
Elucidating the Cause and Prognostic Informations
Coronary Angiography :
in CADs Patients
Haemodynamic Monitoring :
To Assess Diagnostic and Treatment of HF
Endomyocardial Biopsy :
in Patients with Unexplained HF
NATRIURETIC PEPTIDES
Cardiac Function (LV Function )
Plasma Natriuretic Peptide Concentration
(Diagnostic Blood Use for HF)
Natriuretic Peptide :
Greatest Risk of CV Events
Natriuretic Peptide :
Improve Outcome in Patients with
Treatment
Identify Pts. With Asymptomatic LV

Dysfunction (MI, CAD)
ALGORITHM FOR THE DIAGNOSIS OF THE HF
(ESC, 2001)
Suspected Heart Failure Because
of symptoms and signs
If Normal
Assess Presence of Cardiac Disease by ECG, X-Ray Heart Failure
or NatriureticPeptides (Where Available) Unlikely
Tests Abnormal
Imaging by Echocardiography (Nuclear If Normal

Angiography or MRI Where Available) Heart Failure
Unlikely
Tests Abnormal
Assess Etiology, Degree, Precipitating

Factors and Type of Cardiac Dysfunction
Additional Diagnosis Tests
Where Appropriate (e.g.
Coronary Angiography)
Choose Therapy
Aims of treatment
1. Prevention
a) Prevention and/or controlling of diseases leading
to cardiac dysfunction and heart failure
b) Prevention of progression to heart failure once
cardiac dysfunction is established
2. Morbidity
Maintenance or improvement in quality of life
3. Mortality
Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure

European Heart Journal (2001) 22, 1527-1560
Treatment options
Non-pharmacological management
General advice and measures
Exercise and exercise training
Pharmacological therapy
Angiotensin-converting enzyme (ACE) inhibitors
Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
Angiotensin receptor antagonists
Cardiac glycosides
Vasodilator agents (nitrates/hydralazine)
Positive inotropic agents
Anticoagulation
Antiarrhythmic agents
Oxygen
Devices and surgery
Revascularization (catheter interventions and surgery), other forms of surgery
Pacemakers
Implantable cardioverter defibrillators (ICD)
Heart transplantation, ventricular assist devices, artificial heart
Ultrafiltration, haemodialysis
Pharmacological therapy
Angiotensin-Converting Enzyme Inhibitors
Recommended as first-line therapy.

Should be uptitrated to the dosages shown to be
effective in the large, controlled trials, and not
titrated based on symptomatic improvement.
Moderate renal insufficiency and a relatively low blood
pressure (serum creatinine 250 mol.l-1 and systolic
BP 90 mmHg) are not contraindications.
Absolute contraindications: bilateral renal artery
stenosis and angioedema.

Diuretics
Essential for symptomatic treatment when

fluid overload is present and manifest.
Always be administered in combination

with ACE inhibitors if possible.

-Blocker
Has been traditionally contraindicated in pts with

CHF
Now they are the main stay in treatment on CHF
& may be the only medication that shows
substantial improvement in LV function
In addition to improved LV function multiple
studies show improved survival
Contraindication: decompensated HF,
Bradicardia/ AV Block, Asma bronchiale
Aldosterone Receptor Antagonists - Spironolactone
Recommended in advanced HF (NYHA III-IV),

in addition to ACE inhibition and diuretics to
improve survival and morbidity

Angiotensin II Receptor Antagonists
ARBs could be considered in patients who do

not tolerate ACE inhibitors for symptomatic
treatment.
It is unclear whether ARBs are as effective as

ACE inhibitors for mortality reduction.
In combination with ACE inhibition, ARBs may

improve heart failure symptoms and reduce
hospitalizations for worsening heart failure.

Cardiac Glycosides
indicated in atrial fibrillation and any degree of

symptomatic heart failure.
A combination of digoxin and beta-blockade

appears superior than either agent alone.
In sinus rhythm, digoxin is recommended to

improve the clinical status of patients with
persisting heart failure despite ACE inhibitor and
diuretic treatment.

Vasodilator Agents In Chronic Heart Failure
No specific role for vasodilators in the treatment of HF
Used as adjunctive therapy for angina or concomitant
hypertension.
In case of intolerance to ACE inhibitors ARBs are
preferred to the combination hydralazinenitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE
Hydralazine (up to 300 mg) in combination with ISDN (up to 160

mg) without ACE inhibition may have some beneficial effect on
mortality, but not on hospitalization for HF.
Nitrates may be used for the treatment of concomitant angina or

relief of acute dyspnoea.

Positive Inotropic Therapy
Commonly used to limit severe episodes of

HF or as a bridge to heart transplantation
in end-stage HF.
Repeated or prolonged treatment with oral
inotropic agents increases mortality.
Currently, insuffcient data are available to
recommend dopaminergic agents for heart
failure treatment.

Anticoagulation
Recommendation
1. All pts with HF and AF should be treated with

warfarin unless contraindicated.
2. Patients with LVEF 35% or less.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Antiplatelet Drugs
Recommendation
There is insufficient evidence concerning the

potential negative therapeutic interaction
between ASA and ACE inhibitors.
Antiplatelet agent for pts with HF who have

underlying CAD.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Antiarrhythmics
No indication for the use of antiarrhythmic agents in HF
Indications for antiarrhythmic drug therapy include AF

(rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS
should be avoided
CLASS II ANTIARRHYTHMICS
Beta-blockers reduce sudden death in heart failure
CLASS III ANTIARRHYTHMICS
Amiodarone is the only antiarrhythmic drug without
clinically relevant negative inotropic effects.

Classification of HF
Activity Levels (NYHA Classification)
I asymptomatic at rest
symptoms with heavy exercise
II asymptomatic at rest
symptoms with moderate exercise
III asymptomatic at rest
symptoms with activities of daily living
IV symptoms at rest
Exercise testing and O2 consumption

ACC/AHA A New Approach To The Classification of HF
Stage Descriptions Examples
A Patient who is at high risk for Hypertension; CAD; DM;
developing HF but has no rheumatic fever; cardiomyopathy.
structural disorder of the heart.
B Patient with a structural disorder LV hypertrophy or fibrosis;

of the heart but who has never LV dilatation; asymptomatic VHD;
developed symptoms of HF. MI.
C patient with past or current Dyspnea or fatigue ec LV systolic

symptoms of HF associated with dysfunction; asymptomatic
underlying structural heart patients with HF.
disease.
D Patient with end-stage disease Frequently hospitalized pts ; pts

awaiting heart transplantation etc
ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure in the Adult 2001
Stages in The Evolution of HF and Recommended Therapy by Stage
Stage A Stage B Stage C Stage D
Pts with : Pts with : Pts with : Pts who have

Hypertension Previous MI Struct. HD marked symptoms
CAD Struct. LV systolic Develop Refract. at rest despite
DM Heart dysfunction Symp.of Shortness of Symp.of maximal medical
breath and fatigue,
Cardiotoxins Disease Asymptomatic HF HF at rest therapy.
reduce exercise
FHx CM Valvular disease
tolerance
THERAPY THERAPY THERAPY THERAPY

Treat Hypertension All measures under All measures under All measures under
Stop smoking stage A stage A stage A,B and C
Treat lipid disorders ACE inhibitor Drugs for routine use: Mechanical assist
Encourage regular Beta-blockers diuretic device
exercise ACE inhibitor Heart transplantation
Stop alcohol Beta-blockers Continuous IV
& drug use digitalis inotrphic infusions for
ACE inhibition palliation
ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure in the Adult 2001
Chronic Heart Failure Choice of
A Pharmacological Therapy
Aldosterone
LV systolic dysfunction ACE inhibitor Diuretic Beta-blocker
Antagonist
Asymptomatic LV
Indicated Not indicated Post MI Not indicated
dysfunction
Indicated if
Symptomatic HF (NYHA II) Indicated Indicated Not indicated
Fluid retention
Indicated Indicated
Worsening HF (NYHA III-IV) Indicated Indicated
comb. diuretic
Indicated Indicated
End-stage HF (NYHA IV) Indicated Indicated
comb. diuretic

Chronic Heart Failure Choice of
B Pharmacological Therapy
Angiotensin Vasodilator
(hydralazine/ Potassium -sparing
LV systolic dysfunction II receptor Cardiac glycosides
isosorbide diuretic
antagonists dinitrate)
Asymptomatic LV
Not indicated With AF Not indicated Not indicated
dysfunction
(a) when AF If ACE inhibitors
If ACE inhibitors If persisting
and angiotensin
are not tolerated (b) when improved hypokalaemia
Symptomatic HF (NYHA II) from more severe II antagonists
and not on beta-
HF in sinus are not
blockade
rhythm tolerated
If ACE inhibitors
and angiotensin
are not tolerated hypokalaemia
Worsening HF (NYHA III-IV) indicated II antagonists
and not on beta-
are not
blockade
tolerated
If ACE inhibitors
End-stage HF (NYHA IV) and angiotensin
are not tolerated hypokalaemia
indicated II antagonists
and not on beta-
are not
blockade
tolerated

Intervention
Surgical
Revascularization
Non Surgical
Pts with heart failure of ischaemic origin revascularization
symtomatic improvement.
A strong negative correlation of operative mortality and LVEF,
a low LVEF (<25%) was associated with increased
operative mortality. Advance HF symptoms (NYHA IV)
resulted in a greater mortality rate.
Off pump coronary revascularization may lower the surgical
risk for HF.
Heart Transplantation is an accepted mode of treatment for
end-stage HF.
Algorithm for Management HF
Conclusion
DIAGNOSIS OF HEART FAILURE
Clinical Signs and Symptoms

Echocardiography (LVEF) The Preferred
Method
Natriuretic Peptide Helpful in The Diagnosis
Process
Additional Test Should be Perfomed
Where Diagnosis Doubt Persist
Conclusion
Management of HF must be starting from

the earlier stage (AHA/ACC stage A).
Treatment at each stage can reduce
morbidity and mortality.
Before initiating therapy :

Established the correct diagnose.
Consider management outline.
NO MATTER WHAT,
PREVENTION
IS BETTER THAN
TREATMENT
Thank YoU

Heart Failure: Departemen Kardiologi FK USU RSUP. H. Adam Malik Medan

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HEART FAILURE

Departemen Kardiologi FK USU

reduced cardiac output

arrhythmia reduced renal

Restricted Filling: Pericardial diseases, Restrictive

With a Syndrome of Decrease Exercise

Breathlessness, Ankle Swelling, Fatique

Peripheral Oedema, JVP , Hepatomegaly

S3 , Pulmonary Rales , Cardiac Murmur

A Part of Initial Diagnosis of HF

Focused on Functional, Treatment Assessment and

Not Recommended as a Routine Use

Recommenmded if Other Imaging Techniques not

Elucidating the Cause and Prognostic Informations

Identify Pts. With Asymptomatic LV

Imaging by Echocardiography (Nuclear If Normal

Assess Etiology, Degree, Precipitating

Guidelines for the diagnosis and treatment of chronic heart failure

Recommended as first-line therapy.

Guidelines for the diagnosis and treatment of chronic heart failure

Essential for symptomatic treatment when

Always be administered in combination

Guidelines for the diagnosis and treatment of chronic heart failure

Has been traditionally contraindicated in pts with

Recommended in advanced HF (NYHA III-IV),

Guidelines for the diagnosis and treatment of chronic heart failure

ARBs could be considered in patients who do

It is unclear whether ARBs are as effective as

In combination with ACE inhibition, ARBs may

Guidelines for the diagnosis and treatment of chronic heart failure

indicated in atrial fibrillation and any degree of

A combination of digoxin and beta-blockade

In sinus rhythm, digoxin is recommended to

Guidelines for the diagnosis and treatment of chronic heart failure

Hydralazine (up to 300 mg) in combination with ISDN (up to 160

Nitrates may be used for the treatment of concomitant angina or

Guidelines for the diagnosis and treatment of chronic heart failure

Commonly used to limit severe episodes of

Guidelines for the diagnosis and treatment of chronic heart failure

1. All pts with HF and AF should be treated with

2. Patients with LVEF 35% or less.

There is insufficient evidence concerning the

Antiplatelet agent for pts with HF who have

Indications for antiarrhythmic drug therapy include AF

Guidelines for the diagnosis and treatment of chronic heart failure

Exercise testing and O2 consumption

B Patient with a structural disorder LV hypertrophy or fibrosis;

C patient with past or current Dyspnea or fatigue ec LV systolic

D Patient with end-stage disease Frequently hospitalized pts ; pts

ACC/AHA Guidelines for the

Stage A Stage B Stage C Stage D

Pts with : Pts with : Pts with : Pts who have

THERAPY THERAPY THERAPY THERAPY

ACC/AHA Guidelines for the

Guidelines for the diagnosis and treatment of chronic heart failure

Guidelines for the diagnosis and treatment of chronic heart failure

Clinical Signs and Symptoms

Management of HF must be starting from

Before initiating therapy :

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