Treating Heart failure
Behavioral Changes
Cardiac rehabilitation programs
•Education (fluid control, etc)
•Psychosocial support
•Exercise training
Drug therapy
Beta blockers
•+ve chronotropic response, +ve dromotropic effect (increase electrical velocity in heart), +ve inotropic response (contractility).
•Increase fluid retention.
•Lower mortality.
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Spironolactone
•Diuretic
•Works on sympathetic NS and increases urinary output.
•Works on potassium levels- risk of developing hyperkalemia – associated with arrhythmias
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Digoxin
•Lowers HR, increases contractility
•Not appropriate for AV block
Device Therapy
Overview
•Pacemakers may be used for bradyarrhythmias
•Biventricular pacemaker or cardiac resynchronisation therapy (CRT) +- defibrillator
•Cardiac Contractility Modulation (CCM)
Cardiac resynchronisation therapy
CRT devices provide
•Atrial-ventricular synchrony
•Intraventricular synchrony
•Interventricular synchrony
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Cardiac Contractility Modulation (CCM)
OPTIMIZER system consists of
•an implantable pulse generator with a rechargeable battery,
•+-1 atrial
•2x ventricular pacing screw-in leads
CCM signals are nonexcitatory electrical signals applied during the cardiac absolute refractory period that enhance the strength of cardiac muscular contraction
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Indicated for HF pts of any QRS width
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A biphasic high voltage stimulus is delivered to the RV septum during ARP.
When applied for 5-12 hours per day, dp/dt is acutely augmented (without raising 02 demand), improving cardiac efficiency
Other - End stage options
Options
•Left ventricular assistance devices
•Heart transplants
•Palliation
LVADs
Used for pts with end stage HF
LVADs are surgically implant and are a battery-operated, mechanical pump, which helps the LV pump blood to the rest of the body.
Patients with an LVAD have a high risk of VA, particularly those with a history of arrhythmias.
increased risk may be due to myocardial irritation from insertion of the LVAD inflow cannula, LV compression due to a suctioning effect from the LVAD, inotropic support frequently needed by some patients, & repolarization changes that can occur after LVAD placement.
Heart transplant
1st heart transplant (HTx) was in South Africa 1967
Patient selection determined via several assessments
•Sick enough heart: NYHA IV, LVEF <35%, not responding to optimal medical therapy +-CRT.
•Can accept new lifestyle: Compliant with medical advice and therapy. Healthier lifestyle.
•Well enough other parts: no significant comorbidities (e.g., malignant cancer, severe lung disease, etc.
Donors
•Donors generally come from patients who are brain dead.
•Donor selection is determined via several assessments
•Initial echo: no significant structural disease (HCM, etc), occlusive CAD, valvular dysfunction or congenital lesions.
•Angiography: Only required if considered high risk. In some countries is mandatory for people over a certain age (e.g., males >45 years, females >50 years).
•Must not have active malignancy: cancers, severe systemic infections, etc.
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•Donor heart can be placed
•On ice (up to 4 hours) (heart pumped with potassium to stop APs)
•Or in heart in a box (7-9 hours) (transmedics)
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Surgical excision of the heart results in immediate denervation of both parasympathetic and sympathetic nervous fibers, resulting in
•Unable to experience angina due to ischemia (can still have hypotension or bradycardia due to MI)
•Diminished exercise capacity due to the heart relying on non cardiac circulating catecholamines
•Loss of decline in nocturnal BP
•Potential for more arrhythmias due to dependence on circulating catecholamines
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Palliation
Refractory end stage HF
Evidence that continuous outpatient support with inotropes may be an acceptable treatment option
Opioids may be used to improve symptoms for patients with end stage heart failure in end-of-life situations (where no further therapeutic options are available).
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