Etiology of Heart Failure Pathology Heart - not able to pump - - PowerPoint PPT Presentation

Etiology of Heart Failure

Pathology

♥Heart - not able to pump effectively - ↓ Ex. Qc

♥ elevated LV filling pressure ♥ compensatory ventricular volume overload ♥ ↑ pulmonary and central venous pressure

♥Low Cardiac Output =

♥↓ Bd supply to vital organs (ie lower Bd to Kidneys = water retention = fluid build up in lungs, veins and swelling of ankles.

Volume Overload Pressure Overload Loss of Myocardium Impaired Contractility Heart Failure ↓ Cardiac Output Hypoperfusion ↑ End Systolic Volume ↑ End Diastolic Volume Pulmonary Congestion

30% 70%

Diastolic Dysfunction Systolic Dysfunction (EF < 40%) (EF > 40 %)

Heart Failure Classifications

• Systolic: Impaired contractility/ejection (HFREF)
• Diastolic: Impaired filling/relaxation (HFPEF)

Class I: No symptoms with ordinary activity Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Class IV: Unable to carry out any physical activity without

• discomfort. Symptoms of cardiac insufficiency may be

present even at rest

New York Heart Association Functional Classification

Meds

Diuretics

• Relieves fluid retention; ↑ exercise tolerance

ACE Inhibitors

• Prevents formation of potent vasoconstrictor (angiotension II) = ↓ SVR

Beta-Blockers Digoxin

Enhances inotropy of cardiac muscle

Exercise HF - Exercise Prescription -Aerobic

Intensity 50-80% of peak VO2; 40-60% HRR or VO2peak RPE 12-13 (20 point scale) 4-6 (10 point scale) Duration Daily = 20-30 minutes g Goal = 150min/week Prolong warm up and cool down Low intensity long duration interval exercise 1:1 or 1:2 work:rest ratio (e.g., 1-2 min/interval) Frequency 3-5 days/week Modes No specific recommendation something enjoyable Modes which facilitate easy monitoring Resistance training Hi Reps / lower intensity – bands machines and free weights Flexibility Tai Chia, yoga etc.

AHA Statement – Circ. 2003

Aerobic Interval Training in CHF

• Higher work intensity = greater total work,
• particularly in those with reduced functional capacities.
• La accumulation is ↓ compared to continuous work = less fatigue.
• Ex intensity, total work performed, and caloric expenditure can be

significantly ↑ using interval training.

WHAT ABOUT AEROBIC INTERVAL TRAINING?

METABOLIC RESPONSES

Aerobic Interval Training in CHF

5 10 15 20 25 NT CON INT

Pre Post

Peak VO2 (ml/kg/min)

(* p,.05 vs. pre; #, p<.05 vs. NT and CON)

* *# Wisloff et al 2007

Figure 3-Differences (in percent) of work rate and exercise parameters during interval training based on reference index (100 = intensity level at 75% of peak ·VO2) (values are mean ± SEM). From: MEYER: Med Sci Sports Exerc, Volume 29(3).March 1997.306-312

Aerobic Interval Training in CHF

Sign gns o

• f E

Exerti tional I Intolerance i in C CHF HF P Patient

• Persistent fatigue lasting more than 24 hours
• Worsening of Ex tolerance or dyspnea @ rest/exertion over previous 3-5 days
• Significant ischemia @ low P.O. (<2 METs)
• Nocternal dyspnea
• Unexplained weight gain> 2kg ↑ in body mass over previous 1 – 3 days
• Swelling in the periphery (check sock line)
• Supine resting HR > 100 bpm
• Acute systemic illness or fever
• ↓ SBP with exercise
• post Ex. Hypotension
• Complex ventricular arrhythmias @ rest or with exercise

From the working group on cardiac rehabilitation & exercise physiology and the working group on heart failure of the European Society of Cardiology 2001

WHY HY DO DON’T W WE DO DO IT?

General Healthy Populations

• 63%, falling to 50% @ 12 months

Martin & Sinden 2001

Cardiac Populations

Only 15-25% of eligible patients participate!

Am Heart J 2006; 152:835-841

CHF = 80% view exercise as important but only 39% do it.

van der Wal MHL et al., Eur Heart J 2006

61% of CR patients consider adhering to exercise more difficult relative to other recommendations

Evangelista LS et al., Am J Cardiol 2001

Daily Activity

• Why Should We Care?-

Background

• Daily PA closely linked to exercise capacity & HF clinical status/prognosis

(Belardinelli et al , 1999, Jehn et al 2009; Jehn et al 2011)

• Adherence to exercise training is a problem for HF patients

Piepoli MF et al., Eur J Heart Failure 2011; 13(4):347-357. Conraads VM, et al., Eur J Heart Failure 2012;14(5):451-458. van der Wal MH, et al., Eur Heart J. 2010;31(12):1486-1493

• Daily activity may be easier than exercise to fit into daily life
• Assessing daily PA = valuable in identifying patients at high risk and provides an objective

measure of incapacity during normal daily life

Walsh JT, et al., Am J Cardiol., 1997; 15;79(10):1364-9.

• Stronger index of mortality than lab based exercise testing variables such as VO2peak and

Exercise time (Seo et al., 2008)

Steps

• Healthy older adults take 6,500-8,500/day

Ayabe et al Cir J 2008; 299-303

• Chronic illnesses – take 3,500 – 5,500 steps/day

Tudor-Locke et al., Res Q Exerc Sport 2001;72(1):1-12

• CHF patients = 3,500-4,300

Walsh JT, et al Am J Cardiol. 1997;79:1364-1369 Houghton AR, et al., Eur J Heart Fail; 2002;4:289-295 Hoodles DJ, et al., Int J Cardiol 1994; 43:39-42

• <3,750 steps per day related to increased mortality

Walsh JT, et al., Am J Cardiol., 1997; 15;79(10):1364-9; (Seo et al., 2008)

Discussion

 HF patients are usually assessed using their exercise capacity but the variance in their daily PA should be considerable. (Contje 2013, Metra 1998)  No difference in daily activity between systolic and diastolic HF across all activity intensities  Daily Activity of HF patients = mainly in the mild intensity range,  Our HF sample averaged ∼3000 steps / day literature reports about 7000 steps / day. (Contje 2013,Izawa 2012, Jehn 2009)

Daily Activity Continuum in CRT patients 78% 70% 21%

16% 4%

80%

18% 4%

The End Thank you