Heart Failure and Pulmonary Hypertension: How it can be treated

50 %
50 %
Information about Heart Failure and Pulmonary Hypertension: How it can be treated
Health & Medicine

Published on February 24, 2014

Author: SpringfieldClinic

Source: slideshare.net

Description

Heart failure means that your heart isn’t pumping enough blood to keep up with the needs of the other organs. So what are the warning signs of heart failure? What can be done to treat it? Springfield Clinic Cardiologist, Dr. Singla answers those questions and more. Please join us for an in-depth discussion about a topic that is becoming all too familiar as heart disease continues to be the leading cause of death for men and women.

Heart Failure & Pulmonary Hypertension: What you need to know Ish Kumar Singla , MD

National Heart Failure Awareness Week February 9-15, 2014

What you need to know • Heart Failure • Pulmonary Hypertension

A Word of Anatomy • Right side of heart gets blood from body. • Right Ventricle sends blood to Lungs via pulmonary arteries for oxygenation. • Left side of heart gets oxygenated blood from lungs. • Left Ventricle pumps oxygen rich blood to body.

What is Heart Failure • Not able to pump enough blood to body “ Heart failure is NOT heart attack” • Muscle weakness or stiffness

Heart Failure is Very common • Affects nearly 5 million • 1% of Adults 50-60 • 10% of Adults over 80 • 8 million by 2030( 46% increase) • 400,000 -700,000 new cases each year • 5%-10% of all hospital admissions

Types of Heart Failure • Systolic HF ( Muscle weakness ) - Not able to pump enough blood • Diastolic HF(Muscle thickening and stiffness) - Not able to pump blood in normal way • Right Sided Heart failure

Risk factors for Heart Failure • • • • • • • Coronary Artery Disease (Heart attack ) Heart valve damage(Leaky or narrow valves) Cardiomyopathy Congenital heart disease Hypertension Obesity Aging

Symptoms of Heart Failure • • • • • • Shortness of Breath Fatigue Leg edema Weight gain Cough Not able to lie flat due to difficulty breathing

NYHA Classification of symptoms • Class I: No Symptoms. No limitation in physical activity. Ordinary physical activity does not cause dyspnea or fatigue. • Class II: Mild symptoms and Slight limitation in physical activity. Ordinary physical activity causes undue dyspnea or fatigue. • Class III: Marked limitation in physical activity due to symptoms. Less than ordinary physical activity causes undue dyspnea or fatigue. • Class IV: Severe limitations. dyspnea and/or fatigue may be present at rest.

Systolic Heart Failure • Etiology - Coronary artery Disease ( CAD) Myocardial Infarction (MI) Cardiomyopathy ( Viral, Familial etc) Valvular heart disease

Diagnosis of Heart Failure • • • • • • Echocardiogram ( Heart Ultrasound) EKG Chest X ray Labs Heart catheterization Stress test

Diagnosis of Heart Failure • Echocardiogram - Heart Ultrasound Outpatient office procedure To measure EF(Ejection Fraction) Normal EF is 55%-60% Evaluate Heart valves Evaluate Pressures in heart

Diagnosis of Heart Failure • Left heart catheterization - Outpatient procedure ,done at hospital - Radial (wrist) or Femoral (groin) approach - Dye test to look at the heart arteries

Treatment of Systolic Heart Failure • • • • • • Diet Restriction Exercise regimen Lifestyle changes Medications Treatment of specific etiology Surgical Rx

Dietary Modifications • Salt Restriction - 2000 mg sodium/ day - 1 teaspoon of salt=2000 milligrams (mg) • Fluid restriction - 2000 ml/day

How to Restrict Salt intake

How to Restrict Salt intake • • • • • • Stop using salt shaker Salt substitutes Eliminate salty foods Read the labels Eliminate canned foods Fresh fruits and vegetables “ Don’t eat anything that tastes good”

Fluid restriction • 2000 ml /day ~ 64 oz of fluid a day • 1 cup ~ 250 ml of water

Fluid Retention • Weigh daily • Call your doctor for weight gain more than 3 lbs

Lifestyle changes • • • • Quit smoking Limit alcohol intake Exercise regimen Weight loss

Exercise • Start aerobic exercise • Avoid lifting weights more than 15-20lbs.

Medications • Diuretics ( Fluid pills) - Furosemide, Torsemide, Bumetanide • Beta blockers - Carvedilol, Metoprolol succinate • Ace- Inhibtors - Lisinopril, Captopril, Enalapril

Medications • • • • Angiotensin Receptor Blockers Aldosterone Inhibtors Hydralazine and Nitrates Digitalis

Cardiac Arrest • - EF < 35%-40% ICD( Implantable cardiac defibrillator) BiV- pacemaker Combined BiV- ICD

Diastolic Heart Failure • Etiology - Hypertension Obesity Diabetes Lack of exercise Sleep Apnea

Diastolic Heart Failure • Tests - Echocardiogram Heart Catheterization EKG Sleep study Labs

Treatment • • • • • • • Diet Restriction Exercise regimen Loose weight Quit smoking Treatment of sleep apnea Treatment of primary disease ?? Medications

Medications • Diuretics ( Fluid pills) - Furosemide, Torsemide, Bumetanide • ?? Beta blockers - Carvedilol • ?? Aldosterone antagonist - Spironolcatone

Surgical Treatment of Heart Failure • Heart Transplant - Needed for more than 4000 patients - 2500 heart donors yearly - Scarcity of donors - “It is not a cure, it is an exchange of one set of problems for the other” (Dr Bourge) • Left Ventricle Assist Device ( Mechanical Heart Pump)

Right Sided Heart Failure • • • • Pulmonary Hypertension Cardiomyopathy Congenital heart disease Heart attack

Pulmonary Artery Hypertension

Pulmonary Hypertension • • • • • • Definition Epidemiology Classification Symptoms Etiology Treatment

Pulmonary Hypertension • Normal Mean PA pressures are 12-16. • Definition: Mean Pulmonary Artery (PA) pressure > 25 mm Hg at rest • Chronic condition with no cure. • Without treatment only 34% survival at 5 years.

Severity • Degree of disease ( Mean PAP mmHg) • Mild : 25 – 40 • Moderate: 41 – 55 • Severe: >55

Pulmonary Hypertension

Pulmonary Hypertension Lesion 2.Pulmonary Venous HTN 1.Arterial VC RA RV PA Mitral Valve Disease PV PC LA LV Ao Aortic Valve Disease Left sided heart failure 4. Embolic 3. Hypoxic Lung Diseases HTN

Epidemiology • • • • • Pulmonary Venous HTN - very common PAH - rare disease Hypoxic - 1-2% Embolic - 5% Miscellaneous

PH Classification • Based on similarities in their pathophysiology and responses to treatment. • Classify patients accurately to ensure appropriate treatment.

PH Classification • Group I (Arterial ) Idiopathic, Familial, HIV, Scleroderma, drugs, toxins, Congenital heart disease, Sickle cell disease • Group II (Venous ) Pulmonary venous hypertension due to left sided heart disease. • Group III (Hypoxia) COPD, Interstitial lung disease, Sleep apnea • Group IV (Embolic) Chronic thromboembolic disease • Group V (Misc) Sarcoidosis, Compression of pulmonary artery by tumor

Pulmonary Artery Hypertension • Idiopathic - Incidence 2-3 /million per year Female: Male 3:1 • Common with Rheumatological diseases - Scleroderma 50% Rheumatoid Arthritis 20% Lupus 10% • Congenital heart disease : 30% - 50%

Pulmonary Artery Hypertension • • • • Sickle cell disease 25% Liver disease 5% HIV 0.5% Dexfenfluramine (fen-phen) Risk 20 times if taken for more than 3 months • Cocaine or amphetamine use risk by 3 fold

Symptoms • Gradual onset of Shortness of breath - Often results in delayed diagnosis ~ 18 months • Fatigue • Chest pain • Syncope/presyncope • Peripheral edema or ascites • Raynaud’s in about 10%

Diagnosis • Echocardiography is excellent screening tool • No treatment based on echocardiography alone • Right heart catheterization for accurate diagnosis and appropriate treatment • Labs • CT scan

Pathogenesis of Pulmonary Arterial Hypertension NORMAL REVERSIBLE DISEASE IRREVERSIBLE DISEASE

WHO functional classification PAH • Class I: No limitation in physical activity. Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain or near syncope. • Class II: Slight limitation in physical activity. Ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. • Class III: Marked limitation in physical activity. Less than ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. • Class IV: Inability to perform any physical activity without symptoms. Signs of right heart failure. Dyspnea and/or fatigue may be present at rest. H/o Syncope.

Clinical Sequeale • Increased pressure load on Right Ventricle. • Right Ventricle failure. • Once RV failure is present prognosis poor.

Goals of Therapy • Alleviate symptoms, improve exercise capacity and quality of life • Delay time to clinical worsening • Reduce morbidity and mortality

Treatment of Pulmonary Hypertension • • • • • Lifestyle modifications Oxygen Treatment of specific etiology Medications Transplantation

Dietary Modifications • Salt Restriction - 2000 mg sodium/ day - 1 teaspoon of salt=2000 milligrams (mg) • Fluid restriction - 2000 ml/day

Lifestyle Modifications • Sodium restriction • Abstinence from smoking • Avoid high altitude • <4,000 feet above sea level • Avoid physical exertion in setting of presyncope sx • Avoid pregnancy

PAH: Therapy • Supplemental O2 • Anticoagulation • Diuretics • Vasodilators Therapy

Targets for Therapy in PAH Endothelin cells

PAH: Therapy • Calcium-channel blockers -pills • Endothelial receptor antagonists (ERAs) - pills • Phosphodiesterase-5 Inhibitors (PDE5-I) -pills • Prostanoids -Inhalers, intravenous, subcutaneous

Epoprostenol (Flolan) • Intravenous Prostacyclin • First drug, became available in 1990s. • Delivered via continuous infusion • PPH study • Improvement in survival

SQ or IV Treprostinil (Remodulin) • Stable Prostacyclin, t ½ 4 hours. • Continuous subcutaneous infusion • Approved 2002 • Significant pain at infusion site limits use • NYHA class II,III,IV • Group I PAH • Stable at room temperature.

Bosentan (Tracleer) • Endothelin Receptor Antagonist • First oral Drug,Approved 2002 • Dose 125mg BID • Risk of Liver Toxicity • Group I PAH (Idiopathic, CTD and congenital)

Ambrisentan (Letairis) • • • • • • Selective Type A ERA. Oral dose 10 mg once daily Much less risk of liver toxicity Monthly monitoring not required Approved 2005 Group I PAH (Idiopathic and CTD ) Badesch et al. J Am Coll Cardiol. 2005;46(3):529.

Macitentan (Opsumit) • • • • • • Non-selective ERA Dose 3mg or 10mg po daily Approved 2013 CBC and LFTs monitoring Group I PAH (Idiopathic,congenital,CTD) Improvement in mortality and morbidity. Pulido et al. N Engl J Med Aug 2013; 369:809-818

Sildenafil (Revatio) • • • • • • • PDE-5 inhibtor FDA approved dose 20 mg po tid Approved 2005 Hypotension, Sudden hearing loss First dose in monitored setting Contraindicated with nitrates Group I PAH(Idiopathic,CTD,Congenital)

Tadalafil ( Adcirca ) • • • • • • PDE-5 inhibtor FDA approved dose 40 mg po daily Approved 2009 Hypotension, Headaches, Myalgias Contraindicated with nitrates Group I PAH(Idiopathic and CTD)

Riociguat (Adempas ) • • • • • • Oral sGC stimulant. First in Class Dose 1.5mg to 2.5 po TID Approved 2013 Group IV PAH Group I PAH

Inhaled Iloprost ( Ventavis ) • Synthetic PGI 2 • Selective pulmonary vasodilator • Inhaled form 6-9 times while patient awake • Approved 2002 • Exerts preferential vasodilatation in well- ventilated regions. • No known contraindications.

Inhaled Treprostinil (Tyvaso) • • • • • • • Synthetic Prostacyclin Inhaler,4 doses used 4 hrs apart while awake. Approved 2011 Group I PAH (Idiopathic, CTD, HIV,Fen-phen) NYHA III pt Background therapy with oral drugs SE: dizziness,cough,headache,flushing

Simplicity Efficacy & Cost Treatment Summary

Conclusion Progressive disease Significant morbidity and mortality Right heart failure marks disease progression Therapies with proven benefit in improving hemodynamics, functional class and exercise tolerance Continuous IV Flolan is reserved for advanced (class IV) disease where there is a proven survival benefit

Acknowledgements • Dr Robert C. Bourge (Vice Chair ,Dept of Medicine ,UAB, Birmingham) • UAB Heart Failure and Transplant Division • Springfield Clinic

References • • • • • • • • • • • • www.heart.org www.phaassociation.org www.abouthf.org www.escardio.org http://www.nutrition411.com www.hfsa.org http://lungs.wikispaces.com http://www.acponline.org http://www.cardiachealth.org https://encrypted-tbn0.gstatic.com/images http://www.lsuagcenter.com/ https://www.unitypoint.org

Thank You

Add a comment

Related presentations

Related pages

Heart Failure and Pulmonary Hypertension: How It Can Be ...

Heart Failure and Pulmonary Hypertension: ... signs of heart failure? What can be done ... "Pulmonary Hypertension, Heart Failure and the ...
Read more

How Is Pulmonary Hypertension Treated? - National Heart ...

How Is Pulmonary Hypertension Treated? ... Heart Failure; ... pressing on the pulmonary arteries also can cause group 5 PH.
Read more

What is Pulmonary Hypertension? - American Heart ...

The numbers in pulmonary hypertension. Pulmonary blood pressure is normally a ... eventually the heart can't ... How is pulmonary hypertension treated?
Read more

Hypertension and Heart Failure - YouTube

Hypertension and Heart Failure ... Heart Failure and Pulmonary Hypertension: How It Can Be Treated ... Heart Failure & Pulmonary Hypertension ...
Read more

Pulmonary hypertension - Wikipedia, the free encyclopedia

Pulmonary hypertension can be ... hypertension) should not routinely be treated ... right heart failure due to pulmonary hypertension.
Read more

What Is Pulmonary Hypertension? - National Heart, Lung ...

Pulmonary hypertension ... cells that line your pulmonary arteries. Other factors also can affect the ... Heart failure is the most common ...
Read more

Secondary Pulmonary Hypertension in Chronic Heart Failure

Secondary Pulmonary Hypertension in Chronic ... in Heart Failure. Pulmonary hypertension is ... in chronic heart failure patients treated ...
Read more

Pulmonary Hypertension - American Heart Association ...

... congenital heart defects can lead to Pulmonary Hypertension. ... for Heart Failure. ... pulmonary arterial hypertension associated with ...
Read more

Heart failure - NHS Choices - NHSChoices Home Page

... which over time can lead to heart failure ; coronary heart ... (pulmonary hypertension) can also lead to heart failure. ... how heart failure is treated.
Read more