00:00
So, of course, we’re going to do some tests
to confirm our clinical impression. We’ve
had the history, oh, this suggest heart failure,
the patient is short of breath, they have
peripheral edema. Oh, we listen to the heart
and we hear an extra sound, the S3 gallop.
00:14
Okay, we’re now pretty sure the patient
has heart failure, then we do a chest x-ray.
00:18
You can see the two examples here. The one…
on the one side is normal and the one on the
other side shows an enlarged heart. Sometimes
we will even see evidence of fluid in the
lungs. Pretty obvious on this chest x-ray,
this is called pulmonary edema. The left ventricle
has failed significantly and what we see is
fluid throughout the lungs.
00:39
And of course, this patient is very short
of breath. They might be breathing at 30 or
40 times a minute. Normal is about 12, 13,
14 times a minute and they may… you may
actually hear gurgling from this fluid that’s
collecting in the small alveolar sacs in the
lung and being transmitted into the… into
the bigger bronchial tubes. This can drop
the oxygen saturation in the blood, can lead
to fatal arrhythmias and people can die from
this. And this… this is a medical emergency
that requires urgent therapy.
01:14
And here is a chest x-ray showing a variety
of findings of a little less serious heart
failure. One can see edema in the lymphatics,
so called curly lines. One can see fluid collecting
in the pleura, you can see in the little angle
there where the heart meets the chest that
there’s a little sort of rounded area. That’s
actually fluid in the pleural space, the space
that surrounds the lungs. There’s a variety
of other findings that the radiologist will
often call you up and say, “Your patient
has heart failure.”
We often do an echocardiogram to see how bad
the heart failure is. For example, is it left
ventricular? Is it right ventricular? Is it
very advanced? Does the ejection fraction,
that is the percentage of blood squeezed out
by the heart very low? Or is it only modestly
reduced?
This is an echocardiogram from a patient with
a very advanced heart failure. The left ventricle
is markedly dilated, we don’t see the film
with it, but I’m sure if we saw the film,
instead of the ventricle squeezing normally
like this, it’s doing this. Hardly squeezing
at all and you can see also, in this echo,
the left ventricle is enlarged. So, this is
a patient with longstanding heart failure.
02:31
So, let’s talk a little bit about treatment.
Clearly, treatment goals are to reduce the
edema, to reduce the excess fluid volume and
to make the patient much more comfortable
and able to have full activity. You’d also
like to increase the pumping ability of the
heart. Sometimes, if it’s, for example,
in the patient we talked about in the last
lecture, somebody with aortic stenosis, taking
away the stenotic valve and putting in a good
valve allows the ventricle to recover.
In other settings, if it’s due to severe
ischemia - lack of blood flow in the heart,
coronary bypass or angioplasty may improve
the blood flow on the heart and may, not always,
but may improve the function of the ventricle
and again, lead to resolution of symptoms.
And there’s a variety of drugs that help
increase the removal of fluid from the body.
For example, diuretics that increase renal
excretion of water and salt will reduce the
excess volume of salt and water in the body
and often lead to marked improvement in the
symptoms.
03:38
Patients with heart failure, particularly
new heart failure, require hospitalization.
03:43
They require a number of tests to determine
why they're on heart failure and they also
require a number of drugs that are used to
improve, if possible, the function of the
heart and to decrease the work of the heart
and to increase fluid and salt excretion.
04:01
And what you do… this step diagram is a
complicated one. I’m not anticipating that
anybody needs to learn this right away, but
it shows you as the heart failure increases,
the aggressiveness of our therapy increases.
So, in the beginning, we use ACE inhibitors
that is they vasodilate the arterioles, they
decrease the blood pressure a bit and they
decrease the work of the heart.
In a sense, what we’re trying to do is rest
the heart. Make the heart’s job, the left
ventricle’s job a little easier, but as
you go along, there’s a variety of other
interventions that are used. Both improving
blood flow, for example, with angioplasty.
We also use drugs that rest the heart a little
bit by decreasing the heart rate - beta blockers.
And then eventually, you may even progress
to devices that increase the pumping ability
of the heart while you’re getting ready
to do something more aggressive. For example,
change a heart valve or even in the most severe
stages, do a heart transplant - give the patient
a new heart.
05:09
It‘s important that patients have lifestyle
changes, particularly with the milder forms
of heart failure because what we’re trying
to do is prevent heart failure from progressing.
05:20
So, what are those lifestyle changes?
Clearly, somebody who’s obese, you’ve
got a lot of extra weight around. If you have
a big belly that has 40 or 50 pounds of extra
weight, it’s like you’re carrying a 40
or 50 pound knapsack on your back and you’re
asking the heart to do that extra work. You
can imagine, that’s a bad idea. So, dieting
and reduction of obesity is important.
Number two, cutting back on salt because the
more salt you take in, the compensatory mechanisms
of the body hold on to that salt and of course,
increase blood volume. So, restriction of
salt. It turns out that regular, particularly
in the beginning, supervised exercise or physical
activity actually improve the whole cardiovascular
system and enable patients to do more work
with the same cardiac output that they had
before. So, and of course, stopping things
like cigarette smoking which are damaging
to the blood vessels and which can cause acceleration
of atherosclerosis, just as in we talked about
in patients with a heart attack or coronary
artery disease. There’s a whole variety
of lifestyle changes and often, these are
integrated between the cardiologist and a
good cardiac rehabilitation program.
06:36
Medication management is.
06:38
Tailored to the type of heart failure
that a patient has,
whether they have heart failure
with preserved ejection fraction
as we already heard called half HFpEF,
or whether the heart failure
patient has a reduced ejection
fraction, so called HFrEF.
06:54
And of course medication management
is tailored to the patient's symptoms and signs.
07:00
If a patient has volume overload with dyspnea
or peripheral edema, of course
they need diuresis, usually with a loop
diuretic to remove excess fluid.
07:10
For patients with a compelling indication
for a.
07:13
Specific type of
anti-hypertensive medication for example,
if a patient has diabetes
or chronic kidney disease,
then an ACE inhibitor or an energy tension receptor blocker
should used before starting HFpEF specific therapies
such as mineral coracoid blockers
or ACL two inhibitors.
07:33
Of course, you have to look carefully
at the patient's renal function.
07:37
If it is quite impaired, then
ACE inhibitors
or ARB's are contraindicated
because they might make the renal failure
worse for patients without diabetes,
then heart failure,
specific medications are indicated.
07:52
The next step is to add
a sodium and glucose
co transporter to inhibitor, SGLT2 inhibitor,
I like to call them flows arms
because that's part of their generic name
or of course,
and or a mineral,
a court acquired receptor antagonist.
08:10
SGLT2 inhibitors are medications
like empagliflozin and or dapagliflozin.
08:16
And you notice the term flows
in in the middle of those terms,
a mineral,
a quarter receptor antagonist or a mineral
or MRA, as it's often known,
such as spironolactone or eplerenone .
08:27
Known can be. Added if the.
08:29
Patient has a systolic
blood pressure below 100 or symptoms of.
08:33
Hypertension, such as dizziness.
08:35
or other orthostatic Symptoms.
08:37
Then other antihypertensive drugs
should be decreased or discontinued.
08:41
Otherwise you're liable to have severe
symptomatic hypertension.
08:42
Otherwise you're liable to have severe
symptomatic hypertension.
08:45
That's the primary therapies
for heart failure
with reduced ejection
fraction are ACE inhibitors.
08:50
Angiotensin receptor.
08:52
Angiotensin receptor blockers called ARB's
or the combination medication
of an angiotensin receptor blocker
and a neprilysin inhibitor
put together are called and ANRI`s
and the neprilysin inhibitor,
is known as sacubitril
and it's a blocker of the break down
enzymes for atrial peptides.
09:13
enzymes for atrial peptides.
09:15
Thus the ANRI drug is a double vasodilator.
09:19
And again, you have to be careful
about the blood pressure
beta blockers should be added
if there are no contraindications
and the specific three
that have been demonstrated.
09:29
To benefit patients with heart
failure are Carvedilol, Bisoprolol
and Extended-release metoprolol succinate.
09:36
If patients have contraindications to any of the renin
angiotensin systems and tarragon is.
09:42
An alternative is hydrolyzed
impressive long acting
nitrates, a typical contraindication
to the.
09:48
Renin angiotensin system.
09:49
Antagonist is advanced renal failure
because these drugs could increase
the level of renal insufficiency
In patients who still have symptomatic heart failure.
10:00
Secondary therapies may be added in.
10:03
Addition to the initial medivations.
10:05
And there's considerable current debate
about the order that we give these drugs,
which one should be first.
10:11
Which one second, and that.
10:13
Is the subject of current
ongoing heart failure research.
10:17
These include the additional drugs
These include the additional drugs
that could be used, for example, mineral
of course called receptor blockers.
10:24
As we've already said, sporran
lack tone in a player known on
or SLGT2 inhibitors
Just mentioned
in certain symptomatic patients.
10:34
We may need to consider
Cardiac risk synchronization therapy done
with a special
Cardiac risk synchronization therapy done
with a special
form of pacemaker that
also stimulates the left ventricle
as well as the right ventricle
or transcatheter mitral valve replacement
repair, for example, clipping
a loose mitral leaflet, this allowing
for severe mitral regurgitation.
10:55
You clipped that to another a leaflet
and thereby you decrease
the amount of mitral
further secondary therapies.
11:04
Newer medications include Vericiguat
or Ivabradine.
11:09
So Vericiguat is indicated for patients
with New York Heart Association
class two to four heart failure with.
11:15
An ejection Fraction
less than 45% who were either hospitalized
in the last six months
or require outpatient IV diuretics.
11:24
Ivabradine is a very interesting new class of medication
called hyper polarization activated cyclic
nucleotide gated channel blockers,
what they do
is they actually decrease the rate
at which the sodium channel leaks.
11:39
And that results in slowing of the Heard rate
It's indicated for patients with an ejection fraction.
11:46
Of 35% or less who are in sinus rhythm
with arresting heart rate,
that's at least 70 beats per minute.
11:51
with arresting heart rate,
that's at least 70 beats per minute.
11:53
And despite debate of blockers or in
beta blockers are either contraindicated
or caused problems.
12:00
Then you can substitute that the slowing drug
using Ivabradine
Digoxin can be added to patients
with end stage heart failure
who are not doing well despite optimal
other pharmacologic therapies
as well as cardiac synchronous zation
therapy.
12:17
Lastly, mechanical circulatory
support devices such as left ventricular
bypass pumps and inferiority balloons
and even cardiac transplantation
may be considered in so highly selected
patients with refractory heart failure.
12:33
And again, there’s patient counseling. We
already talked about the lifestyle. Alcohol
is a depressant on the heart so we want patients
drinking as little as possible. Smoking has
to stop, we want weight control, we want regular
exercise. All of the lifestyle things, again,
repeated to work with the medicines what we’re
giving or to work with the interventions.
12:58
For example, opening up a coronary artery
or replacing a heart valve.
13:03
And further patient counseling, of course,
involves the medications. Are the patients
taking the medications? And are they taking
them regularly and as appropriately prescribed?
This is a huge problem. In the United States,
many patients fail to take their medications.
13:18
If there are surgical or catheter interventions,
what these contain and what they can do and
what the potential complications are; one
wants to reduce stress in the patient’s
life, one wants the patient to keep track
of symptoms. Are they getting better, are
they getting worse, is there weight gaining
all of a sudden because of a marked increase
in fluid retention? And of course, we would
like patients to not overdulge in fluid intake
and certainly, come for follow up visits with
the doctor or the nurse clinician in order
for us to monitor how things are going with
therapy and if we have to make further adjustments
in therapy.
So, in conclusion, heart failure is a growth
industry particularly in older individuals.
It’s caused by many diseases, but in particular,
by atherosclerotic heart disease that causes
damage to the left ventricle. Again, left
ventricular systolic heart failure is the
commonest. The left ventricle doesn’t squeeze
as well and the commonest cause of that, ischemic
heart disease.
14:19
Prevention, of course, is better than cure.
I don’t have to tell you that. And how do
we prevent that? By controlling atherosclerotic
risk factors before they put the patient in
the heart failure situation.
Of course, there’s a whole variety of diagnostic
test that we use when the patient presents
with heart failure, but remember, the clue
is in the patient’s symptoms, with confirmation
by the exam and then we do some sophisticated
tests to see what’s the cause of the heart
failure and how severe is the ventricular
damage and then we introduce a whole variety
of therapies, both drugs and even some of
the newer device therapies. For example, we
can open up blood vessels and even in extreme
cases, we can take over with little pumps
for the heart while we’re trying to get
it to respond and come back to normal.
And of course, then we’re going to have
to do lifestyle changes. There’s a new pacing
protocol with a special pacemaker that, in
some selected patients, can improve the pumping
of the heart.
15:24
All of these are fairly extreme things done
right at the end. And again, we talked about
the fact that there’s a lot of technology
here. But, the best deal is to stop the heart
failure before it starts with reduction in
risk factors or identifying it early and getting
all of those things including the lifestyle
changes implemented before the patient progresses
to a point that they need things like biventricular
pacing and heart lung machines and so forth.
15:54
Thank you for listening to this lecture. I
look forward to seeing you with the next one.