Orthopnea Edema in the feet, ankles, legs, liver, & abdomen. If the amount of fluid is fluid accumulates in the abdomen. Fluid accumulation in the liver or stomach nausea & loss of appetite. Eventually, food is not absorbed well loss of weight & muscle. This condition is called Cardiac Cachexia Paroxysmal nocturnal dyspnea Tiredness & weakness A sudden accumulation of a high amount of fluid in the lungs (acute pulmonary edema) extreme difficulty in breathing, tachypnea, cyanosis, & feelings of restlessness & anxiety. Bronchospasms & wheezing. Cheyne-Stokes respiration Stroke Depression & decline in mental function.
Tests & diagnosis 1. Medical history & physical examination. 2. Check for the presence of risk factors such as HTN. 3. Blood tests 1. kidney & thyroid function 2. BNP 4. Chest X-ray In HF:1. The heart may appear enlarged. 2. Fluid buildup may be visible in lungs. 5. ECG heart rhythm problems & damage to the heart from a heart attack that may be underlying HF. 6. Echocardiogram. 7. Ejection fraction (EF). Prevention 1. The key to preventing HF is to risk factors. 2. Control or elimination of many risk factors for heart disease (HTN, CAD) by making lifestyle changes along with the help of any needed medications. 1. Stop smoking.
2. Weigh loss for obese patients 3. dietary sodium 4. alcohol & fluids 5. fat & cholesterol 6. stress 7. Exercise 8. Sleep easy Values of therapeutic intervention Therapy Value ACE inhibitors Decrease afterload an Preload Aldosterone antagonists Oppose Aldosterone mediated effects: Renal Na+ retention Cardiac and vascular remodeling Inotropes (Digoxin, PDE inh. , Dobutamine) Increase myocardial cell contractility Beta blockers (Carvedilol, Bisoprolol, Metoprolol) Lower deleterious sympathetic nervous system effects: Slow Heart rate Decrease blood pressure Promote adaptive remodeling (reverse remodeling) Vasodilator therapy.
(Hydralazine + Nitrates) Decrease afterload and preload Neseritide (ANP analogue) Decrease preload Stages of HF and DOC Case 2 History W. N. is a 60 year old hypertensive man with a history of heart failure. He is a heavy smoker and consumes high sodium in his diet. He was admitted to the hospital after experiencing SOB , fatigue, Confusion and disorientation. His HF symptoms also appeared at rest. He is suffering from Pulmonary edema , bronchospasm and chyenestrokes respiration. Questions What stage is his HF? Stage IV Which side is his HF? Left sided What drug therapy do you recommend?
ACEI or ARB and diuretic and inotropic digoxin and spironolactone What is the beneficial triad of ACEI and what is its beneficial and non beneficial effect on kidney? Effects of ACEIs & ARBs on Kidney function of HF Patients 1. Beneficial Effect: ACEI/ARB pre- & afterload CO renal blood flow. 2. Non-beneficial Effect: Initial therapy rapid BP fall slow CO response worsening of renal function. Prediction of which event to occur is impossible ACEI/ARB therapy:Initiated with dose. Slow in dose. Careful BP & renal function monitor. Diuretic dose is adjusted to avoid volume depletion & hypotension. ACEIs Vasodilation, DIURESIS & REMODELING REGRESSION.
These are the beneficial triad for ACEI Vasodilation: Decreased Angiotensin II & NE & increased Bradykinin (BK) & substance P BK stimulates B1 receptors increased PGI2, NO & EDRF VD. BK increases natriuresis via direct tubular effect Mild diuresis: renal blood flow, via increased CO & locally through efferent arteriolar VD. aldosterone & vasopressin secretion. Cardiac & Vascular Remodeling inhibition: by lowering Angiotensin II type I Receptor- hypertrophic effects. What are the side effects of ACEI? What life style modification should he adopt? Stop smoking, weight loss, stop Na, avoid stress, exercise???????