by Seema Nour, MD, FACC; Interventional Cardiologist, Abudhabi, UAE

1. Seema Nour MD
Interventional Cardiologist USA

2. Outline
Introduction
Incidence
Etiology
Diagnosis
Therapies

3. Introduction
Heart failure (HF) is a complex clinical
syndrome that can result from any structural
or functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject
blood
No longer use the term “congestive” because
all heart failure does not result in clinically
apparent volume overload

4. How to define heart failure?
Systolic Versus Diastolic Heart Failure
A. Systolic cardiac (heart) dysfunction (or
systolic heart failure) occurs when the heart
muscle doesn't contract with enough force,
so there is not enough oxygen-rich blood to
be pumped throughout the body.
B. Diastolic cardiac dysfunction (or diastolic
heart failure) occurs when the heart
contracts normally, but the ventricle doesn't
relax properly so less blood can enter the
heart.

5. What is the incidence of heart failure?
Estimated 500,000 new cases per year
Within 5 years, half of those diagnosed will be
dead
Over 1 million hospitalizations per year with
HF as primary diagnosis
Most common reason for hospitalization in
those >65 years old
Heart failure is 4th in a list of quality of care
initiatives in vulnerable older adults

6. Case-Mr Abdallah
45 yr old man with poorly controlled
hypertension, DM presents with 3 weeks of
progressive shortness of breath, LE edema
Exam remarkable for HR 150, BP 80/40, RR 26
Appears lethargic, Elevated JVP, PMI displaced,
irregular, S1, S2, S3 on exam, no murmurs, lungs
with crackles, Extremities cold with edema

7. EKG

8. What do you think caused Mr
Abdallah’s heart failure?

9. Causes of heart failure
Coronary artery disease (up to 70%)
Hypertension
Arrhythmias
Valvular heart disease
Viral myocarditis, etc
Congenital heart disease
Toxic substances (EtOH, cocaine)
Diabetes, thyroid problems, HIV
Restrictive causes-amyloid, radiation

10. Back to our patient
So Mr Abdallah has risk factors for CAD
Also has elevated BP-so hypertensive heart
No murmur on exam so valvular heart disease
unlikely
Arrythmias……..afib, tachycardia induced
cardiomyopathy
What about amyloidosis
ALWAYS LOOK FOR REVERSIBLE CAUSES

11. So how will we work up Mr
Abdallah?

12. Initial Workup
Basic labs, check for anemia-high output
failure, chem8, TSH, ferritin
EKG-look for acute MI or prior infarcts
CXR- pulmonary edema, heart size
Echocardiogram to assess LV function, assess
for diastolic dysfunction

13. Future workup
Coronary Angiogram
If flash pulmonary edema and severe HTN,
consider renal angiogram
If no clear cause in young patient consider
cardiac biopsy

14. Mr Abdallah tests showed
Normal CBC
Elevated BUN/Creatinine 45/1.8
Elevated LFTS ( AST/ALT)
CXR showed pulmonary edema
Echo showed an EF of 30% with diffuse global
hypokinesis

15. Now how are we going to treat Mr
Abdallah??

16. Management of Heart Failure
Acute
Chronic

17. Acute Treatment
Congestion?
Orthopnea, rales, JVD, edema, ascites
Warm and Dry Warm and Wet
Adequate
perfusion
Lethargy,
cool, pulse
pressure
Cold and Dry Cold and Wet
(Mr Abdallah)
Nohria, A. et al. JAMA 2002;287:628-640

18. Cardiogenic Shock
(Cold and Wet)
1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m²/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure >
18mmHg mmHg

19. Choice of Ionotropes
 Dopamine
<2 renal vascular dilation
<2-10 +chronotropic/inotropic (beta effects)
>10 vasoconstriction (alpha effects)
Dobutamine – positive inotrope, vasodilates,
arrhythmogenic at higher doses
Norepinephrine (Levophed): vasoconstriction,
inotropic stimulant. Should only be used for
refractory hypotension with dec SVR.
Vasopression – vasoconstriction
VASO and LEVO should only be used as a last
resort

20. If patient tachycardic, dopamine and
dobutamine are not great choices
So in Mr Abdallah would attempt to
cardiovert him as he will not sustain pressor
support
TEE to r/o left atrial appendage thrombus
Followed by Cardioversion

21. So Mr Abdallah underwent TEE
Was cardioverted
BP improved
HR stabilized
Still congested but now hemodynamically
stable
NOW WHAT??

22. Diurese, diurese, diurese!!!
Do you start an ACEI?
Do you start a beta blocker?

23. Furosemide Dosing
If patient is lasix naive start slow and titrate
up per urine output
Lasix dose usually 0.5-1mg/kg twice a day
Usually expect response in first 5-10mins with
IV
Usual start dose 40mg or 80mg IV q8hrs
Always give potassium supplements when
diuresing patient

24. Regular monitoring of electrolytes with IV
diuresis
Switch to PO when more euvolemic,
BUN/creatinine start rising
Remember 80mg PO =40mg IV
If patient already on PO lasix e.g 80mg PO
would start treating with higher IV dose (ie
80mg IV)
If poor response to lasix add thiazide diuretic

25. ACEI and Beta Blockers
Start ACEI in patients as soon
hemodynamically stable
Help reduce preload and afterload
Titrate up per patient, don’t look at BP!!
Beta Blockers-start low dose prior to discharge
Titrate dose as outpatient

27. Back to Mr Abdallah
So Mr Abdallah is doing well, he maintained
sinus rhythm and is being discharged
What medications should he be on long term
for a mortality benefit??

28. Long Term Therapy

29. Beta Blockers
34% reduction in all mortality with use of
beta-blockers
Decrease Cardiac Sympathetic Activity
Titrate slowly
Contraindications-bradycardia, heart block or
hemodynamic instability
Mild asthma is not a contraindication
Work irrespective of the etiology of the heart
failure

30. Three beta-blockers
Bisoprolol (Zebeta) -Trial CIBIS-II
Metoprolol (Toprol XL) –Trial MERIT-HF
(sustained release)
 Carvedilol (Coreg) Trial-COPERNICUS
6 RCT’s with > 9,000 pts already taking ACE-I
showed a significant reduction in total
mortality and sudden death (NNT 24, and 35
over 1-2 years) regardless of severity

32. Carvedilol vs. Metoprolol (COMET
2003)
3029 pts; carvedilol 25mg bid vs.
metoprolol 50 mg bid
Patient with NYHA Classes II-IV
Carvedilol –greater reduction in mortality
(NNT, 18 over 5 years) and cardiovascular
mortality (NNT, 16 over 5 years) than
metoprolol but hypotension was greater in
carvedilol (14 vs 11 percent)

33. Beta Blockers and concomitant
disease
Beta blocker therapy is recommended in the
great majority of patients with HF and
reduced LVEF—even if there is concomitant
diabetes, chronic obstructive lung disease or
peripheral vascular disease.
 Use with caution in patients with:
 Diabetes with recurrent hypoglycemia
 Asthma or resting limb ischemia.
 Use with considerable caution in patients with marked
bradycardia (<55 bpm) or marked hypotension (SBP < 80
mmHg).
 Not recommended in patients with asthma with active
bronchospasm.

34. HFSA 2010 Practice Guideline ACE
Inhibitors
ACE inhibitors are recommended for
symptomatic and asymptomatic patients
with an LVEF ≤ 40%
ACE inhibitors should be titrated to doses
used in clinical trials (as tolerated during
uptitration of other medications, such as
beta blockers).

35. ACEI
CONSENSUS-Enalapril 2.5-40mg (188 days) vs placebo
Pts were already taking digoxin and diuretics
253 Patient with NYHA Class IV
Dec mortality at:
6 months -40%
1 Year – 27%
SOLVD-Enalapril 20mg/day (41 mo)
2569 Patients with and EF <35%
Earlier stages of HF even asymptomatic
NYHA Class II-III
All cause mortality dec by 16%
Morality rate from HF dec by 16%

37. HFSA 2010 Practice Guideline
Angiotensin Receptor Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an LVEF ≤ 40%
who are intolerant to ACE inhibitors for
reasons other than hyperkalemia or renal
insufficiency.

38. ACEI+ARB
CHARM-Added (Lancet 2003)
2548 NYHA II-IV; LVEF < 40%
CV death, hospital admission
NNT=25
Second study found no benefit
But 23% discontinued due to side effects
(increased cr, hypotension, hyperkalemia)
Currently Ace + Arb is not recommended

39. Nitrates/hydralazine
A combination of hydralazine and isosorbide
dinitrate is recommended as part of standard
therapy, in addition to beta-blockers and ACE-
inhibitors, for African Americans with HF and
reduced LVEF:
NYHA III or IV HF
NYHA II HF

41. Pharmacologic Therapy:
Aldosterone Antagonists
An aldosterone antagonist is recommended
for patients on standard therapy, including
diuretics, who have:
 NYHA class IV HF (or class III, previously
class IV) HF from reduced LVEF (≤ 35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF <
40% who are on standard therapy, including
an ACE inhibitor (or ARB) and a beta blocker.

42. Aldosterone receptor antagonsists
Spironolactone (Aldactone; RALES 1999)
Pts 1,663 Class III/IV, ACE, Loop,Dig, EF < 35%
Decreased all cause mortality of 30%, NNT=10
Hyperkalemia, gynecomastia
Eplerenone (Inspra; EPHESUS 2003)
Pts 6,642 asym LV dysfunction, DM, or after MI
Dec CV mortality of 13%, NNT=43
Newer more selective inhibitor; fewer side effects
More pts on beta-blockers

43. Aldosterone Antagonists and Renal
Function
Aldosterone antagonists are not recommended when:
Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing
diuretics
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L Strength

44. Digoxin
Digoxin, given in combination with a diuretic
and an ACE inhibitor to people with heart failure
(NYHA grades II-IV) in normal sinus rhythm, has
been found to reduce hospitalization and clinical
deterioration, but not mortality
Consider digoxin if the person continues to be
symptomatic despite adequate doses of diuretic
and ACE inhibitor
Give digoxin to all people with heart failure
and atrial fibrillation who need control of the
ventricular rate.

45. So Mr Abdallah is going home
Which of the following medications has not been
shown to improve mortality in patients with
systolic heart failure?
1. Beta Blocker
2. ACEI
3. Aldosterone antagonist
4. Digoxin
5. ARB

46. What discharge instructions do we
give MR Abdallah
Low salt diet <2gm/day
No Faseekh or maloo7a
Take medications
Weigh yourself everyday
If weight increases over 3-5lb take extra lasix
dose and contact doctor

47. Mr Abdallah wishes to know if
there are any drugs he needs to
avoid
NSAIDs
Most antiarrhythmics
Most calcium channel blockers
Thiazolidinediones e.g Actos, Avandia

48. Further testing??
Remember presumed LV systolic dysfunction
from tachycardia and HTN
But has risk factors for CAD
So will need a coronary angiogram

49. Mr Abdallah underwent coronary angiogram
and showed no significant CAD,
Now what…………..
A. Continue with medical therapy only
B. Repeat echo in 1 year
C. Repeat echo in 3 months
D. Refer for Biv/ICD immediately

50. Device Therapy:
Prophylactic ICD Placement
Prophylactic ICD placement should be
considered in patients with an LVEF ≤35%
and mild to moderate HF symptoms:
 Ischemic etiology
 Non-ischemic etiology

51. MADIT II: Prophylactic ICD in
Ischemic LVD (LVEF ≤30%)

52. Device Therapy:
Biventricular Pacing
Biventricular pacing therapy is recommended for
patients with all of the following:
Sinus rhythm
A widened QRS interval (≥120 ms)
Severe LV systolic dysfunction (LVEF <
35%)
Persistent, moderate-to-severe HF
(NYHA III) despite optimal medical
therapy.

53. CRT Improves Quality of Life and
NYHA Functional Class

54. Effect of CRT Without an ICD on
All-Cause Mortality: CARE-HF

55. Back to Mr Abdallah
Repeat echo in 3 months showed
improvement in EF to 50%
So no indication for ICD or Biv-ICD

56. Thank you!!