Heart Failure - DrCRaghu


Systolic versus Diastolic  

Ejection Fraction or EF is the most common parameter for the assessment of the efficiency of the  heart. The normal EF is 55-65 percent.  

EF less than 40 percent is considered as low ejection fraction.  

EF more than 50 percent is considered as normal ejection fraction. 

Heart failure with low Ejection Fraction is also known as Systolic heart failure. In this condition the  heart muscle gets thinned, the heart chambers get enlarged leading to a reduction in the heart  pumping efficiency. In this condition the heart is thin and enlarged.  

On the contrary the heart function might be normal but still the heart failure can happen if the heart  muscle gets thick and there is a inability to expand because of stiff heart. So, a thick and stiff heart is  called heart failure with preserved Ejection Fraction. In this condition the heart gets thick and stiff. 

Both types of heart failure present with identical symptoms whether it results from either a  

  • Thin, weak and enlarged heart (or) 
  • Thick, stiff and small heart 

(add image of stiff and thick versus thin and weak heart) 

If both entities present with similar symptoms – Is it relevant to differentiate these two types of  heart failure? 

It is very important to differentiate because the treatments are completely different for both  conditions.  

Left versus Right heart failure (add image of right and left heart failure) 

If the efficiency of the left heart is reduced that is called left heart failure. This is commonly due to a  heart attack or abnormal heart rhythm or valvular diseases affecting the left side of the heart. In this  condition there is fluid logging in the lungs predominantly because the fluid accumulates within the  lungs. This causes breathlessness predominantly either on walking or even at rest.  

On the contrary if the right side of the heart is damaged because of lung problem or blood clots in  the lungs or commonly due to left heart problem there will be fluid logging in the other organs of the  body notably the legs, face and abdomen. Fluid accumulation in the liver causes pain in upper part of  the abdomen on the right side and loss of appetite. Patients also observe and complain about the  neck veins engorgement and abnormal pulsations.  

What is Congestive heart failure? 

Congestive heart failure is an older term to describe heart failure where there is a failure of both the  right as well as the left side of the heart. In this condition, there is fluid accumulation both in the  lungs and the other organs of the body leading to the term “congestion” in congestive heart failure. 

Types of heart failure-Acute Vs Chronic Heart failure 

Acute heart failure means person who was completely normal previously suddenly develops  symptoms of heart failure such as breathlessness or fluid logging in the other organs of the body.  This usually happens over a period of few hours to days or at the maximum a week to 10 days.  

On the contrary, chronic heart failure is a condition where the heart pumping efficiency is reduced gradually over weeks to months or may be years. Patients with chronic heart failure despite having a  low pumping efficiency might remain without symptoms.  

In acute heart failure because of the suddeness of the insult the symptoms are florid. In chronic  heart failure because it is a gradually developing process the symptoms are very subtle.



Role of ECG in Heart Failure 

ECG is a simple inexpensive test to asses heart function. ECG is the short form for electrocardiogram  or electrocardiography.  

Add an image of ECG 

ECG equips the doctor with basic heart information such as 

  • Rhythm of heart – Regular or irregular. The most common irregular heart rhythm is atrial  fibrillation and frequently seen in heart failure patients. 
  • Heart rate – Normal heart rate is between 50-100 beats per minute. A slow heart rate (less  than 50) is called bradycardia and a fast rate (more than 100) is tachycardia.  Heart enlargement – Heart chambers enlargement can also be reasonably assessed. But the  best test to assess heart chamber enlargement is cardiac magnetic resonance imaging  (Cardiac MRI). 
  • Heart attack in the past can be identified by predefined patterns on ECG.  

Add an image and text about ECG invention.

Advanced information from ECG in Heart Failure 

  • Reduced blood supply to heart – if patient had a previous heart attack it usually can be  diagnosed through an ECG. It is not necessary that all patients with reduced blood supply  can be identified through ECG. Coronary angiography is a common test performed by  doctors to estimate the blood supply to the heart. 
  • Pumping efficiency of the heart – presence of an abnormal ECG usually indicates abnormal  heart efficiency. The common abnormalities on ECG include but not limited to – complete  bundle branch block, hemiblock, features indicating a previous heart attack or chamber  enlargement.  
  • Left bundle branch block (LBBB) – presence of LBBB (if the QRS duration is more than 150 m  seconds on ECG) and a reduced EF on echo (less than 35%) is a indication for specialised  therapies such as cardiac resynchronization therapy (CRT). Resynchronization means re  establishing the synchronous beating of the heart. (Add an image of LBBB ECG) 
  • Abnormal rhythm may indicate need for advanced therapies such as pacemaker in heart  block, implantable cardioverter defibrillator (ICD) if EF is less than 35% on echo, catheter  ablation in atrial fibrillation and abnormal ventricular rhythm.   
  • Unique and uncommon problems of the heart such as infiltrative disorder (amyloidosis,  restrictive cardiomyopathy) and rare diseases such as or arrhythmogenic RV dysplasia can be  identified on ECG. 

 

Does a normal ECG rule out a heart attack? 

An ECG is a simple yet powerful tool to assess the heart function. But at the same time a normal ECG  does not rule out a heart attack or other diseases if the disease is quite early stage. If the disease is  advanced the ECG remains a quite predictable and powerful tool. So, if the person had a heart  

attack, we do not entirely rely upon ECG but we additionally incorporate the value of high sensitive  troponin to make a confirmed diagnosis of heart attack. . 

ECG complements advanced investigations 

Information obtained from ECG is utilised while interpreting advanced tests such as  echocardiography (echo), coronary angiography, cardiac MRI, PET CT scan etc.  

ECG is a powerful tool in advanced disease but in the early disease too it could be used as an adjunct  to other tests. 
 

 



 

Let us know about Heart Failure 

What is Heart Failure? 

Heart failure is not a single disease instead it is a constellation of symptoms. In this disease the heart  is unable to meet the requirements of the body by its inability to pump or be able to do so by increasing the filling pressures so that it might pump effectively.

Heart Failure is not a disease but a  group of symptoms. It is the result of  many diseases affecting not only the  heart but other organs of body.

Heart Failure vs Heart attack vs Cardiac arrest

(heart attack and cardiac arrest images)

All the three terms refer to different medical issues.

  • Heart failure is consequent to inefficient functioning of heart.
  • Heart attack is due to the interruption of blood supply to the heart.

Cardiac arrest is a situation where the heart stops to beat.

 

Symptoms of heart failure

(heart failure image)

Inefficient functioning of the heart leads to fluid logging in the body

  • Fluid logging in the lungs – presents as breathlessness – Left Heart failure in medical parlance Early stages of heart failure – breathlessness can be present on walking.
  • Advanced stages of heart failure –Breathlessness can be present at rest or, Inability to lie flat or may be awakened from sleep.
  • Fluid accumulation in other organs of the body – Right heart failure in medical parlance Legs causing swelling of the feet, Swelling of face, abdomen, Pain in upper right abdomen.
  • Heart failure symptoms which are related to the lungs are called left heart failure symptoms, those symptoms which are related to other organs are called right heart failure symptoms.
  • Concept of left and right heart
  • failure is important in treatment

 

What causes heart failure?

Heart failure is a result of many disease processes in the body. Common among them being: Coronary artery disease

  • The most common disease that is responsible for heart failure is coronary artery disease. • Coronary artery disease means accumulation of cholesterol in the blood vessels supplying the heart leading to interruption of blood supply to the heart.
  • This interruption of blood supply can either directly reduce the blood supply to the heart resulting in dysfunction or can cause heart attack which can also reduce the heart pumping ability.
  • Common diseases – such as diabetes, hypertension and sometimes abnormalities of the valves of the heart and fast beating of the heart of which most commonly atrial fibrillation can all result in reduced efficiency of the heart.

In addition, advanced age itself beyond the age of 65-70 the efficiency of the heart reduces leading to heart failure.

 

What tests are required for diagnosis of heart failure?

The tests for the diagnosis of heart failure are

  • Imaging test
  • ECG
  • Blood test

Blood tests in heart failure :

  • The most common blood test that is done is a pro-BNP test. If it is less than 125, we can safely exclude heart failure as the cause for breathlessness. (pro BNP figure)
  • In addition, we look at presence of Anaemia, Renal dysfunction and blood glucose elevation in a patient with heart failure.

Electrocardiogram (ECG) : This remains an important test ( add ECG figure)

  • Can detect the presence of previous heart attack.
  • Irregular heart beat – most common is atrial fibrillation.
  • Presence of any Bundle branch block.

Echocardiogram : The most common and important test for the diagnosis of heart failure is the  echocardiogram where we estimate the left ventricular ejection fraction (measures the pumping  ability of the heart) or in short called as EF.

Other test done to manage heart failure are cardiac MRI and nuclear test.

Angiography not only identifies blocks but allows them to be

 

What is the role of Angiography in heart  failure?

(Add a figure of angiogram)

For every 3 patients with heart failure 2 have

removed as a continuation  procedure – angioplasty and stent.

underlying blocks in the blood vessels of heart. These blood vessels supplying the heart are the  coronary arteries and obstructions are called coronary artery disease. So, whenever there is a  coronary artery disease, we can identify that only by performing a coronary angiography.

The major advantage of this investigation is apart from diagnosis in coronary artery disease, in case  if any blocks in heart vessels are identified they can be treated by performing a balloon angioplasty  and a stent procedure.

The benefit of removing the cholesterol plaques in the heart vessels is that – there can be a strong  chance for the heart functioning to recover once the blood flow is restored back to the heart.


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Background
Management of Heart Failure (HF) continues to be challenging despite the formidable advances in medical and intervention therapy. Establishment of the four pillars – Angiotensin Converting Enzyme (ACE) inhibitors/Angiotensin Receptor Blockers (ARB)/Angiotensin Receptor blocker-Neprilysin inhibitor (ARNi), Beta blockers, Mineralocorticoid Receptor Antagonist (MRA) and Sodium Glucose Co-Transporter2 inhibitors (SGLT2i) in the recent decade has paved way for the effective management of HF. The adaptation of these drugs into clinical practice continues to be low despite the robust evidence in clinical trials. Agents that increase cardiac contractility (inotropes) for the treatment of Heart Failure with reduced Ejection Fraction (HFrEF) – defined as left ventricular ejection fraction (LVEF) of less than 40%, have paradoxically increased the mortality rates instead of improving1. This is due to the increase of myocardial oxygen consumption as well as myocardial injury whilst increasing contractility. The established four pillars of HFrEF management improve the efficiency of heart function through indirect mechanisms rather than directly improving the cardiac contractility.

The Drug
Omecamtiv Mecarbil belongs to a new class of cardiac positive inotrope agents called “myotropes” that improve cardiac contractility without increasing the myocardial oxygen consumption. Phase 2 trials – COSMIC HF and ATOMIC HF with this agent have established the efficacy of this agent. Considering the adverse effects observed previously with other inotrope agents a phase 3 study, is essential for this molecule to be adapted into clinical practice. The recently published Global Approach to Lowering Adverse Cardiac Outcomes through Improving Contractility in Heart Failure (GALACTIC-HF) trial, conducted on 8266 patients demonstrated a modest but significant benefit with this agent.

GALACTIC HF analysis
Patients with LVEF less than 35% who are on established medical therapies received Omecamtiv Mecarbil versus placebo in this study. The study agent showed an 8% reduction in the combined event rate of cardiac mortality and HF hospitalization over and above that achieved with the four pillars. At the same time, this agent did not increase myocardial injury or infarction or arrhythmia rates. The benefit of this agent was observed predominantly in those with LVEF <28% in the primary analysis2. Patients admitted into Intensive Care units were also benefitted despite their predicted poor expected outcomes. In a recent sub group analysis, the benefit was most pronounced when the LVEF < 25% and for those in sinus rhythm without increasing sudden cardiac death3. Improvement in LVEF in modest numbers was also found. The use of SGLT2i in only 2% of patients is the limitation for this trial – SGLT2i were not proven to be beneficial in the management of HF when GALCTIC HF trial was conducted.

Take Home Message
Omecamtiv Mecarbil is an important addition rather than an alternative to the established therapies for HFrEF4. Marked benefit seen in patients with LVEF <25% and sinus rhythm highlights the importance of using this agent in select groups leading to a personalized approach to HF therapy5.

References:

  1. Ahmad T, Miller PE, McCullough M, et al. Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials. Eur J Heart Fail 2019; 21: 1064-78.
  2. Swedberg K. Stimulation of Contractility in Systolic Heart Failure. N Engl J Med. 2021; 382: 178-179.
  3. Teerlink JR, Diaz R, Felker GM et al. GALACTIC-HF Investigators. Effect of Ejection Fraction on Clinical Outcomes in Patients Treated With Omecamtiv Mecarbil in GALACTIC-HF. J Am Coll Cardiol. 2021 Jul 13; 78: 97-108.
  4. Teerlink JR, Diaz R, Felker GM, et al. Cardiac myosin activation with omecamtiv mecarbil in systolic heart failure. N Engl J Med 2021; 384:105-16.
  5. Ferreira JP. Omecamtiv Mecarbil: A Personalized Treatment for Patients With Severely Impaired Ejection Fraction. J Am Coll Cardiol. 2021 Jul 13; 78: 109-111.

Key Words:

Heart Failure
Inotropes
Myotropes
GALCTIC HF trial
Personalized Heart Failure treatment












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