Heart Failure due to Systolic Dysfunction

Basic Principals
• Heart failure has a poor prognosis, worse than most forms of cancer
• Major risk factor - Goldman
• Seek aetiology
• Avoid it happening in the first place
– Modify risks
– Treat Myocardial infarction

Aims
• Reduction of mortality
• Relief of symptoms

Some advances in disease modification improved both morbidity and mortality
Aetiology
• IHD
• VHD
• Idiopathic – dilated cardiomyopathy
• Hypertension
• C2H5OH
• Viral - Coxsackie’s
• Systemic disease Haemochromatosis, Sarcoidisis
• Connective tissue disorders – SLE etc

Epidemiology
• Increases with age
• Men > Women
• 3% of population 65-74 years
• 9% over 90 years
• 2,9% 25-74 impaired ejection fraction
• ??? Tip of Iceberg

Pathophysiology
• Definition not of much use – “inability…oxygen…metabolising tissue…adequate filling pressure”
• A Syndrome – not a diagnosis
• Breathlessness, fatigue, fluid retention
• Secondary to adrenergic and Renin-AT-Aldosterone
Treatment directed at antagonism of these systems

Investigations
• ECG
• CXR
• ECHO
• Biochem – Haematolgy
• Angiogram
• Nuclear Imaging
• Exercise ECG, VO2, MET’s
• MRI
• BNP – strong negative predictive value

Investigations
• ECG
– Abnormal in 93%
• Previous MI
• Non specific ST and T changes
• Conduction abnormalities
• ST
• Dysrythmias – AF, VE

Investigation
• ECHO
– Dilation of Ventricles
– Global dysfunction
– Wall motion
• CXR
– Cardiac enlargement
– Pulmonary Oedema

Management
Disease modifying therapy
ACE-I
1st line drugs – given to all patients with systolic dysfunction whether symptomatic or not – 25% relative risk reduction
Combined with diuretic with evidence of cardiac compression – fluid retention
Disease modifying therapy
B-Blockers
Many trials showed benefit with all grades of CHF, post MI
Must be free of decompensation and titrated up – start slow go slow
COPD – without reversible component - not contraindicated

Disease modifying therapy
Aldosterone Antagonists
Spironolactone been shown as effective in reduction of M&M with moderate to severe CHF
In addition to ACE/B-blocker
Caution – renal impairment – hyper K

Disease modifying therapy
AT-II receptor antagonists
ACE intolerant patients – shown to be effective
In addition - Mortality reduced 15%

Management
Symptomatic Therapy
Diuretics
Well established place
Over treatment can have adverse effect on outcome – low dose
Fluid restriction may be needed
Monitor renal function

Symptomatic Therapy
Digoxin
Role less clear
Introduce when symptomatic despite maximal medical therapy or AF
Studies excluded AF – no benefit
For symptomatic, frequent hospitalisation, large hearts
Avoid in Ventricular Dysrythmias
Other Pharmacological Therapy
IHD – Aspirin (AF – Warfarin)
Statin – Benefit in prevention IHD proven – recently safety aspects.
Anaemia – Predicts mortality independently
EPO and Iron therapy been shown to be of benefit
Avoid NSAID’s, Ca antagonists, steroids, TCA, class I anti-arrhythmic - exacerbate

Non Pharmacological Intervention
• Lifestyle modifications
• Smoking
• C2H5OH
• Weight loss
• Exercise
• Immunisation Influenza, Pneumococcus
• Fluid/salt restriction – daily weighing

Device Therapy
Automatic Implantable Cardioverter
Defibrillators (AICD’s)
When L-V-dysfunction, EF < 35%, IHD – benefits in terms of mortality
Cost implications
Currently only if dysrythmias

Device Therapy
Cardiac Resynchronisation Therapy (CRT)
Combine with optimal medical therapy may improve well being by correcting ventricular dysynchrony
Pacing in DDD mode

Device Therapy
LV Assist Devices
Help – take over pump function in series
Bridge to transplantation
Surgical Options
Revascularization
Ventricular remodelling
Transplantation
Significant 1 year mortality – 19%
Life expectancy 10 years
Must be otherwise well