; Chronic heart failure Martin Radvan What we will talk about? • Patophysiology • Clinical signs • Diagnosis • Therapy Hemodynamics • Stroke volume • Ejection fraction • Cardiac output • Cardiac index Hemodynamics • Stroke volume = EDV-ESV • Ejection fraction = SV/EDV • Cardiac output = SV x HR • Cardiac index = CO/BSA 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 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 Signs and symptoms • breathlessness • ankle swelling • fatigue • elevated jugular venous pressure • pulmonary crackles • peripheral oedema • orthopnoe Signs and symptoms • breathlessness • ankle swelling • fatigue • elevated jugular venous pressure • pulmonary crackles • peripheral oedema • orthopnoe Signs and symptoms • breathlessness • ankle swelling • fatigue • elevated jugular venous pressure • pulmonary crackles • peripheral oedema • orthopnoe Signs and symptoms • breathlessness • ankle swelling • fatigue • elevated jugular venous pressure • pulmonary crackles • peripheral oedema • orthopnoe Signs and symptoms • breathlessness • ankle swelling • fatigue • elevated jugular venous pressure • pulmonary crackles • peripheral oedema • orthopnoe Patophysiology Hypertension Diastolic dysfunction Left atrial enlargement Atrial fibrilation (HFpEF) Stroke Invalidity Death Systolic dysfunction Aterosclerosis Coronay Artery Disease (HFrEF) HFrEF vs HFpEF HFrEF vs HFpEF HFrEF vs HFpEF Aetiology • HFrEF – CAD, DCMP • HFpEF • hypertension, diabetes, AF • CAD • HCMP • Right ventricle failure/PH • Valvular disease • High output HF • „zebras“ Diagnosis? Diagnosis • Anamnesis • Clinical signs • Ultrasonography • X-ray of the chest • Coronarography • Stress tests • Labs • … 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 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 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 Therapy of heart failure (HFpEF) • Prevention • Therapy of the cause (hypertension) • Diuretics – furosemid, thiazidy • Spironolakton, eplerenon • Heart transplant/MCS Therapy of heart failure (HFpEF) • Prevention • Therapy of the cause (hypertension) • Diuretics – furosemid, thiazidy • Spironolakton, eplerenon • Heart transplant/MCS β - blokátory • Bisoprolol • Carvedilol • Metoprolol sukcinát • Nebivolol • Lower risk especially of sudden heart death • All stuides made before ICD on the stage Renin-angitensin-aldosteron Renin-angitensin-aldosteron Renin-angitensin-aldosteron Renin-angitensin-aldosteron Renin-angitensin-aldosteron ACE inhibitory • Captopril (3x50mg) • Enalapril (2x10-20mg) • Ramipril (2x5mg) • Trandolapril (1x4mg) • Lisinopril (1x20-35mg) • Titration to the maximal dosage Sartans • Candesartan (1x32mg) • Losartan (1x150mg)? • Valsartan (2x160mg) • Only for ACEi intoletrant • Do not combine with ACEi Diuretics • Furosemid (two doses a day) • 20mg-1g/day • HCTH (12,5-25mg) MRA • Spironolactone 25mg (gynekomastie, mastodynie, erektilní dysfunkce) • Eplerenon 25-50mg MRA • Spironolactone 25mg (gynecomasty, mastodynie, erectile dysfunction) • Eplerenon 25-50mg MRA • Spironolactone 25mg (gynecomasty, mastodynie, erectile dysfunction) • Eplerenon 25-50mg 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 Gliflozins – SGLT2 inhibitors • Dapagliflozin, empagliflozin • Glycosuric agent • Originally in DM2 patients Gliflozins – SGLT2 inhibitors • Dapagliflozin, empagliflozin • Glycosuric agent • Originally in DM2 patients Gliflozins – SGLT1 inhibitors • Dapagliflozin, empagliflozin • Glycosuric agent • Originally in DM2 patients Digoxin • Symptomatic patient with normal GFR, especially in patients with atrial fibrilation to control frequency, symptomatic despite full therapy • Low dose (0,125mg/daily) Sacubitril/valsartan 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) Sacubitril/valsartan 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) Sacubitril/valsartan • Studies in HFpEF (Paragon, Paralax) - negative • Studies with initioation during hospitalisation for acute decompensation of HFrEF (Transition trial) - positive 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 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 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 MCS • LVAD • Total artificial heart • ECMO • Impella • Bridge to recovery/decision/transplantation • Destinantion therapy Transplantation • Age? • Life expectancy (except heart) • Spiroergometry VO2max • Imunosupression • Rejection, infection • Vasculopathy of the graft Conclusions ❑ Heart failure is syndrome (not disease) ❑ Blood preasure control ❑ Therapy of the cause ❑ Pharmacotherapy ❑ Vaccination ❑ MCS ❑ Transplantation Děkuji za pozornost