; Chronic heart failure Martin Radvan [USEMAP] What we will talk about? •Patophysiology •Clinical signs •Diagnosis •Therapy • [USEMAP] Hemodynamics •Stroke volume •Ejection fraction •Cardiac output •Cardiac index [USEMAP] Hemodynamics •Stroke volume = EDV-ESV •Ejection fraction = SV/EDV •Cardiac output = SV x HR •Cardiac index = CO/BSA [USEMAP] Definition of HF •HF is a clinical syndrome characterized by typical symptoms that may be accompanied by typical signs caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress [USEMAP] Definition of HF •Low cardiac output despite normal heart filling (not enough for peripheral tissues) •Normal filling only under condition of elevated filling preasurres •BNP, NT-proBNP [USEMAP] Signs and symptoms •breathlessness •ankle swelling •fatigue • •elevated jugular venous pressure •pulmonary crackles •peripheral oedema •orthopnoe • [USEMAP] Signs and symptoms •breathlessness •ankle swelling •fatigue • •elevated jugular venous pressure •pulmonary crackles •peripheral oedema •orthopnoe • [USEMAP] Signs and symptoms •breathlessness •ankle swelling •fatigue • •elevated jugular venous pressure •pulmonary crackles •peripheral oedema •orthopnoe • • [USEMAP] Signs and symptoms •breathlessness •ankle swelling •fatigue • •elevated jugular venous pressure •pulmonary crackles •peripheral oedema •orthopnoe • • [USEMAP] Signs and symptoms •breathlessness •ankle swelling •fatigue • •elevated jugular venous pressure •pulmonary crackles •peripheral oedema •orthopnoe • • [USEMAP] Patophysiology • • Hypertension Diastolic dysfunction Left atrial enlargement Atrial fibrilation (HFpEF) Stroke Invalidity Death Systolic dysfunction Aterosclerosis Coronay Artery Disease (HFrEF) [USEMAP] HFrEF vs HFpEF [USEMAP] HFrEF vs HFpEF [USEMAP] HFrEF vs HFpEF [USEMAP] Aetiology •HFrEF – CAD, DCMP • •HFpEF •hypertension, diabetes, AF •CAD •HCMP •Right ventricle failure/PH •Valvular disease •High output HF •„zebras“ • • • • [USEMAP] Diagnosis? [USEMAP] Diagnosis •Anamnesis •Clinical signs •Ultrasonography •X-ray of the chest •Coronarography •Stress tests •Labs •… [USEMAP] Therapy of heart failure •Prevention •Therapy of the cause (CAD, myocarditis, DKMP..) •Diuretics – furosemid, thiazidy •Spironolakton, eplerenon •βblokátory, ACEi a AT II •Digoxin •CRT/D •Vaccination – flu, pneumococi •Ivabradin •Sacubitril/valsartan, gliflozins •Heart transplant/MCS [USEMAP] Therapy of heart failure (HFrEF) •Prevention •Therapy of the cause (CAD, myocarditis, DKMP..) •Diuretics – furosemid, thiazidy •Spironolakton, eplerenon •βblokátory, ACEi a AT II •Digoxin •CRT/D •Vaccination – flu, pneumococi •Ivabradin •Sacubitril/valsartan, gliflozins •Heart transplant/MCS • [USEMAP] Therapy of heart failure (HFrEF) •Prevention •Therapy of the cause (CAD, myocarditis, DKMP..) •Diuretics – furosemid, thiazidy •Spironolakton, eplerenon •βblokátory, ACEi a AT II •Digoxin •CRT/D •Vaccination – flu, pneumococi •Ivabradin •Sacubitril/valsartan, gliflozins •Heart transplant/MCS [USEMAP] Therapy of heart failure (HFpEF) •Prevention •Therapy of the cause (hypertension) •Diuretics – furosemid, thiazidy •Spironolakton, eplerenon •Heart transplant/MCS • [USEMAP] Therapy of heart failure (HFpEF) •Prevention •Therapy of the cause (hypertension) •Diuretics – furosemid, thiazidy •Spironolakton, eplerenon •Heart transplant/MCS • [USEMAP] β - blokátory •Bisoprolol •Carvedilol •Metoprolol sukcinát •Nebivolol • •Lower risk especially of sudden heart death •All stuides made before ICD on the stage [USEMAP] Renin-angitensin-aldosteron [USEMAP] Renin-angitensin-aldosteron [USEMAP] Renin-angitensin-aldosteron [USEMAP] Renin-angitensin-aldosteron [USEMAP] Renin-angitensin-aldosteron [USEMAP] ACE inhibitory •Captopril (3x50mg) •Enalapril (2x10-20mg) •Ramipril (2x5mg) •Trandolapril (1x4mg) •Lisinopril (1x20-35mg) • •Titration to the maximal dosage [USEMAP] Sartans •Candesartan (1x32mg) •Losartan (1x150mg)? •Valsartan (2x160mg) • •Only for ACEi intoletrant •Do not combine with ACEi [USEMAP] Diuretics •Furosemid (two doses a day) •20mg-1g/day •HCTH (12,5-25mg) [USEMAP] MRA •Spironolactone 25mg (gynekomastie, mastodynie, erektilní dysfunkce) •Eplerenon 25-50mg [USEMAP] MRA •Spironolactone 25mg (gynecomasty, mastodynie, erectile dysfunction) •Eplerenon 25-50mg [USEMAP] MRA •Spironolactone 25mg (gynecomasty, mastodynie, erectile dysfunction) •Eplerenon 25-50mg [USEMAP] Ivabradin •Selective binding: If receptor in sinoatrial node •Decrease of HR in SR •Symptomatic patient with HFrEF, SR above 70-75/min, symptomatic despite full heart failure therapy inclusive BBlokru •5mg BID → 7,5mg BID •Well tolerated [USEMAP] Gliflozins – SGLT2 inhibitors •Dapagliflozin, empagliflozin •Glycosuric agent •Originally in DM2 patients [USEMAP] Gliflozins – SGLT2 inhibitors •Dapagliflozin, empagliflozin •Glycosuric agent •Originally in DM2 patients [USEMAP] Gliflozins – SGLT1 inhibitors •Dapagliflozin, empagliflozin •Glycosuric agent •Originally in DM2 patients [USEMAP] Digoxin •Symptomatic patient with normal GFR, especially in patients with atrial fibrilation to control frequency, symptomatic despite full therapy •Low dose (0,125mg/daily) [USEMAP] Sacubitril/valsartan [USEMAP] Sacubitril/valsartan •HFrEF: EF LK ≤35% (40) •NYHA ≥ II •Doses 24/26, 49/51, 97/103mg BID •Mortality and hospitalisation for HF: 20% decrease (Paradigm-HF) [USEMAP] Sacubitril/valsartan [USEMAP] Sacubitril/valsartan •Renal functions – GFR ≤ 30 (20)ml/min/m2 •Hypotension •Potasium level (combination with spironolactone) •Wash-out period: 36h after last dose of ACEi •Risk of angioedema (low) • [USEMAP] Sacubitril/valsartan •Studies in HFpEF (Paragon, Paralax) - negative •Studies with initioation during hospitalisation for acute decompensation of HFrEF (Transition trial) - positive [USEMAP] CRT a CRT-D •EF LK ≤ 35%, NYHA II, III despite full therapy • •EF LK ≤ 35%, NYHA II, III despite full therapy, QRS wider then 0,12-0,15, ideally LBBB • [USEMAP] CRT a CRT-D •EF LK ≤ 35%, NYHA II, III despite full therapy • •EF LK ≤ 35%, NYHA II, III despite full therapy, QRS wider then 0,12-0,15, ideally LBBB • [USEMAP] CRT a CRT-D •EF LK ≤ 35%, NYHA II, III despite full therapy • •EF LK ≤ 35%, NYHA II, III despite full therapy, QRS wider then 0,12-0,15, ideally LBBB • [USEMAP] MCS •LVAD •Total artificial heart •ECMO •Impella • •Bridge to recovery/decision/transplantation •Destinantion therapy [USEMAP] Transplantation • •Age? •Life expectancy (except heart) •Spiroergometry VO2max • •Imunosupression •Rejection, infection •Vasculopathy of the graft • [USEMAP] Conclusions qHeart failure is syndrome (not disease) qBlood preasure control qTherapy of the cause qPharmacotherapy qVaccination qMCS qTransplantation [USEMAP] Děkuji za pozornost [USEMAP]