HEART FAILURE Study day November 2018 Sarah Briggs Overview and - - PowerPoint PPT Presentation

▶
heart failure
SMART_READER_LITE
LIVE PREVIEW

HEART FAILURE Study day November 2018 Sarah Briggs Overview and - - PowerPoint PPT Presentation

Jul 19, 2023 358 likes •1.04k views

HEART FAILURE Study day November 2018 Sarah Briggs Overview and Introduction This course is an introduction and overview of heart failure. Normal heart function and basic pathophysiology of heart failure is explained. This will be then

slide-1
SLIDE 1

HEART FAILURE

Study day November 2018 Sarah Briggs

slide-2
SLIDE 2

Overview and Introduction

  • This course is an introduction and overview of heart
  • failure. Normal heart function and basic pathophysiology
  • f heart failure is explained. This will be then related to

the diagnosis of heart failure and to the overall management of patients with heart failure. Device therapy will be explained, and also finally we will have discussion session about palliative care and heart failure.

slide-3
SLIDE 3

Demographics of heart failure

  • Heart failure is serious
  • Heart failure is terminal
  • Heart failure is unpredictable
  • Heart failure causes severe symptoms
  • Heart failure outcomes are directly linked to good

management and self monitoring. You can make a profound difference to a patient’s life

slide-4
SLIDE 4

Plan of the Day

  • The normal heart
  • Pathophysiology of heart failure
  • Clinical presentation: History, assessment and clinical

examination

  • Differential diagnosis, Investigations and Diagnosis
  • Pharmacological Management
  • Non medical Management
  • Palliative care
  • Device therapy
slide-5
SLIDE 5
  • 1. The Normal Heart
slide-6
SLIDE 6
  • 1. Normal Heart Function
  • The Cardiac Circulation
  • The Cardiac Valves
  • The Coronary Circulation
  • The Cardiac Electrical System
slide-7
SLIDE 7

The Heart = A house!

slide-8
SLIDE 8

Cardiac Valves

slide-9
SLIDE 9

Coronary circulation

slide-10
SLIDE 10

Coronary circulation

slide-11
SLIDE 11
  • 2. Pathophysiology of Heart

Failure

slide-12
SLIDE 12
  • 2. Pathophysiology of heart failure

The two types of heart failure affecting the left ventricle.

  • HFrEF – can’t pump
  • HFPEF – can’t relax
slide-13
SLIDE 13
  • 2. Pathophysiology of heart failure

Causes: Myocardial Infarction

slide-14
SLIDE 14

Ischaemia

slide-15
SLIDE 15
  • 2. Pathophysiology of heart failure

Causes: Hypertension and aortic stenosis

slide-16
SLIDE 16

Hypertension

slide-17
SLIDE 17

Hypertension

slide-18
SLIDE 18

Aortic Stenosis

slide-19
SLIDE 19

Left Ventricular Hypertrophy

slide-20
SLIDE 20

Other causes include:

  • Mitral regurgitation
  • Atrial fibrillation
  • Cardiomyopathies
  • Chemotherapy …….
slide-21
SLIDE 21

Neurohormonal Activation

  • Increased Sympathetic activation
  • Reduction in renal perfusion results in activation of the

RAAs

  • Brain natriuretic peptide release
slide-22
SLIDE 22

Neurohormonal Activation

slide-23
SLIDE 23

The Natriuretic Peptide System

slide-24
SLIDE 24
slide-25
SLIDE 25

Heart failure is unpredictable!

slide-26
SLIDE 26
  • 3. History, Assessment and

Clinical Examination

slide-27
SLIDE 27

History

  • Presenting Complaint:
  • History of Presenting Complaint:
  • Past Medical History:
slide-28
SLIDE 28

Its Systemic

  • Fatigue
  • Cool extremities
  • Pallor
  • Heavy leaden legs
  • Renal dysfunction
  • Anaemia
  • Acute/increasing breathlessness
  • Presents/punctuated with unpredictable episodes of fluid

retention…..

slide-29
SLIDE 29
  • 3. Clinical Presentation

Signs of Heart Failure

  • General Appearance – distress, gait, mobility, colour, pallor,

tachypnoea, breathlessness, audible breath sounds,habitus,

  • Tachycardia/irregular
  • Hypertension/hypotension
  • Pallor/mallor flush
  • Elevated JVP (>5cm)
  • Heart Sounds – third heart sound
  • Added Breath Sounds – Crepitations/wheeze
  • Abdominal distension
  • Oedema – legs/sacral
slide-30
SLIDE 30

Pulmonary Oedema

slide-31
SLIDE 31

Ascites

slide-32
SLIDE 32

Pitting Oedema

slide-33
SLIDE 33

The Burden of Heart Failure

slide-34
SLIDE 34

Warning Signs

slide-35
SLIDE 35

Weight Gain!!

slide-36
SLIDE 36

Lets Talk about it!!.......

slide-37
SLIDE 37
  • 5. Differential Diagnoses
slide-38
SLIDE 38

???

Is it ?

  • Chest

infection/pneumonia?

  • Pulmonary Embolism?
  • COPD?
  • N/AFLD?
  • Obesity?
  • Reduced Venous Return?
  • Lymphoedema?

Or is it?

  • Heart Failure?
slide-39
SLIDE 39
  • 6. Investigation
slide-40
SLIDE 40

Investigations

  • U&Es, LFT, FBC, Iron Profile, TSH, hba1C
  • BNP
  • ECHO
  • ECG
  • CXR
  • Holter monitor
  • 24hour BP
  • Also Cardiac MR, MPS, Angiography
slide-41
SLIDE 41
  • 7. Diagnosis
slide-42
SLIDE 42

Heart Failure??

Lets review the ECHO………

slide-43
SLIDE 43

ECHO 1.

Summary

  • Mild to moderate left ventricular hypertrophy with echogenic
  • walls. The left ventricle is normal in size with severely reduced

systolic function. LVEF - 31% (Teicholz).

  • The right ventricle is dilated, mildly hypertrophied with

moderate to severely reduced systolic function.

  • Mild to moderate mitral regurgitation into a severely dilated left

atrium.

  • Moderate tricuspid regurgitation into a severely dilated right

atrium.

  • Mild pulmonary regurgitation. Trivial aortic regurgitation.
  • Right ventricular systolic pressure is 56-61 mmHg assuming a

RAP of 10-15 mmHg.

  • Echo findings suggestive of pulmonary hypertension
slide-44
SLIDE 44

ECHO 2

Summary

  • Overall left ventricular systolic function is severely reduced. LV

ejection fraction is visually estimated at 30%. Right ventricle global systolic function is moderately reduced .

  • Aortic valve appears tricuspid, mildly thickened with reduced

cusp excursion/mobility. ? mild aortic sclerosis.

  • Moderate mitral regurgitation. Moderate tricuspid regurgitation..

Mild pulmonary regurgitation.

  • RV / RA gradient 39 mmHg. Estimated PA systolic pressure is >

59 mmHg, (assuming RAp >20 mmHg). Pulmonary hypertension

  • indicated.
  • Large pleural effusion noted.
slide-45
SLIDE 45

ECHO 3

  • Left Ventricle Normal LV cavity size is seen with moderate

systolic impairment. EF is estimated using biplane Simpson's method at 41%.

  • Global longitudinal strain is severely impaired at 10.6%.
  • There is evidence of global hypokinesis with more marked

impairment inferior/ inferolaterally/ apical laterally ?significance.

  • Mild concentric LVH is seen with reversed E:A ratio of

diastolic filling.

slide-46
SLIDE 46

ECHO 4

  • Summary
  • Moderate LV dilatation with moderate towards severe

impairment - EF 36%. GLS- 10.5%.

  • Mild MR.
  • Gross LA dilatation.
  • Mild RV enlargement with mild impairment
slide-47
SLIDE 47

ECHO 5

Summary

  • Severe LV dilatation is seen with severe LV systolic

impairment.

  • There is thinned akinesis affecting the inferior and mid

inferolateral region. Marked hypokinesis is seen elsewhere.

  • EF is unable to accurately quantified due to poor image quality

and AF.

  • Visually EF is 15-20%.
  • Mild LVH is seen in the non-thinned regions.
  • Thin MV leaflets- opens well.
  • There is annular stretch seen (5.0cm).
  • Reduced MV leaflet apposition is seen with moderate MR.
  • Moderate RV impairment.
slide-48
SLIDE 48
  • 8. Pharmacological Management
slide-49
SLIDE 49

Neurohormonal deactivation

  • 1. Adrenaline
  • Beta Blockers

Dose Side Effects Monitoring

slide-50
SLIDE 50

Neurohormonal Deactivation

  • 2. Angiotensin II
  • ACE Inhibition

Dose Side Effects Monitoring

slide-51
SLIDE 51

ARNI – Angiotensin receptor/Neprilysn Inhibition

slide-52
SLIDE 52

ARNI

slide-53
SLIDE 53

Neurohormonal Deactivation

  • 3. Aldosterone
  • MRA

Dose Side Effects Monitoring

slide-54
SLIDE 54

Symptomatic management

  • Diuretics

Loop/thiazide Dose Side Effects Monitoring

slide-55
SLIDE 55

Other Pharmacological agents and contraindications

  • Digoxin
  • Oral Anticoagulations – NOACS
  • Ivabradine
  • Antianginals
  • Antihypertensives
  • Palliative Medications
  • Contraindications
slide-56
SLIDE 56

Challenges in giving HF DMT

  • Hypotension
  • Dizziness
  • CKD
  • Hyperkalaemia
  • Non compliance
  • Incontinence
  • Immobility
  • Insufficient support
  • Insufficient education
  • Clinician anxieties/insufficient support/education
slide-57
SLIDE 57

Do you have any questions about medication?

slide-58
SLIDE 58
  • 9. Non Pharmacological

Management

slide-59
SLIDE 59

Non Pharmacological Management

  • DAILY WEIGHT
  • Anxiety/stress management
  • Depression/low mood
  • Support Groups
  • Hospice
  • Education
  • Salt intake
  • Fluid intake
  • Dry mouth
slide-60
SLIDE 60

Non Pharmacological Management

  • Exercise
  • General weight management
  • Smoking, alcohol
  • Fatigue management – goal setting
  • Sleep – nocturia – important meds at night (BP)
  • Caffeine intake
  • Vaccinations
  • Holidays
slide-61
SLIDE 61
  • 11. Palliative Care – Lets discuss

the challenges of palliative care in heart failure

slide-62
SLIDE 62
  • 10. Device Therapy
slide-63
SLIDE 63

CRT and ICD

NYHA class QRS interval I II III IV <120 milliseconds ICD if there is a high risk of sudden cardiac death ICD and CRT not clinically indicated 120–149 milliseconds without LBBB ICD ICD ICD CRT-P 120–149 milliseconds with LBBB ICD CRT-D CRT-P or CRT-D CRT-P ≥150 milliseconds with

  • r without LBBB

CRT-D CRT-D CRT-P or CRT-D CRT-P LBBB, left bundle branch block; NYHA, New York Heart Association

slide-64
SLIDE 64
  • https://www.youtube.com/watch?v=7hEw4o06Fwc
  • http://www.bostonscientific.com/en-US/patients/about-

your-device/crt-devices/how-crts-work.html

slide-65
SLIDE 65

CRT

slide-66
SLIDE 66

Thank you so much!!