Exploraciones complementarias

Exploraciones complementariasCriterios clnicos de Framingham

Evaluacin Diagnstica de la Insuficiencia Cardiaca de nueva instalacinEstudios iniciales:ECG (hipertrofia, arritmias, bloqueos, isquemia o necrosis)Serie radiolgica de corazn (tamao del corazon, congestion pulmonar)Laboratorio (funcion renal y hepatica, electrolitos, niveles de neurohormonas, niveles de farmacos)Ecocardiograma (modo M, bidimensional, con o sin doppler)Recent guidelines suggest that initial testing should include an ECG, chest x-ray, blood work, and echocardiography.ECG:Hypertrophy, arrhythmias, and conduction disturbances, such as an inter- or intraventricular conduction delay, are all commonly found in patients with heart failure, making the ECG an important diagnostic tool in these patients. In addition, the presence of infarct or ischemia, and the effects of certain cardiac drugs used n the treatment of heart failure can be monitored using the ECG.Chest X-ray:The chest x-ray is an important, inexpensive, and extremely useful tool in the evaluation and management of heart failure. Heart size and pulmonary congestion can be readily identified and help determine the severity of the patients heart failure.Blood Work:Laboratory blood work helps track important physiologic processes affected by heart failure, such as liver and kidney function, electrolyte balance, neurohormone levels, and drug levels, as well as reveal the presence of disorders or conditions that can lead to or exacerbate heart failure. Echocardiography:Echocardiography is probably the single most useful diagnostic test in heart failure. It uses ultrahigh frequency sound waves to evaluate the hearts structure and function. The basic equipment used to perform echocardiography consists of a transducer, a computer, and a visual display unit. The transducer, which (except for transesophageal echo) is placed on the chest wall and aimed at the heart, emits ultrahigh frequency sound waves through the chest wall. Some of the sound waves bounce back towards the hand-held transducer each time they pass through an object in their path. These echos are detected by the transducer, which sends them to the computer for processing. The resulting image, called an echocardiogram, is then displayed on the video screen. Several types are echocardiography are available, including M-Mode, two-dimensional (with or without Doppler flow studies), and transesophageal echocardiography.Cuadro ClnicoElectrocardiograma:

Importante buscar:

Signos de infarto previoHipertrofia del V.I.Arritmias

Derrame pericrdico (voltaje menor de 5 mm en derivaciones estndar y de 10 mm en las precordiales)

Amiloidosis cardiaca (patrones de bajo voltaje y seudoinfarto en las derivaciones anteriores)

Electrocardiograma basal de un paciente con insuficiencia cardaca rebelde al tratamiento y bloqueo completo de rama izquierda.Examen radiolgico

Estudios de laboratorioHiponatremia puede indicar descompensacin de la IC

Hiponatremia dilucional e hiperkalemia por reduccin de FG

Hipokalemia (uso de diurticos)

Pruebas de funcin heptica: Elevacin de transaminasas, bilirrubinas y DHL por la hepatomegalia congestiva.

Puede verse aumento del BUN en proporcin mayor a la creatinina

En el EGO: proteinuria, cilindros, aumento en la densidad.Realizar PFT y los necesarios para cada caso.

Estudios de laboratorioDeber realizarse estudio de laboratorio completo en pacientes de reciente diagnstico.

En la IC no descompensada prcticamente todo est dentro de lo normal

Electrolitos Sricos, pueden estar alterados por la propia enfermedad o por el tratamiento (diurticos)Tratamiento de laInsuficiencia Cardiaca crnicaTratamiento.Medidas GeneralesModificaciones al Estilode Vida:

Reduccin de pesoEliminar tabaquismoEvitar alcohol y otras substancias cardiotxicasEjercicioConsideraciones Medicas:

Tratar hiperlipidemia, diabetes, arritmiasRevascularizacin CoronariaAnticoagulacinVacunacinRestriccin SodioPeso diarioVigilancia EstrechaThe treatment of heart failure has changed considerably over the past decade, primarily because we now understand the importance of neurohormonal activation in the progression of this disease. In this section we will learn about the treatment of heart failure; however, the focus will be on the ever-expanding armamentarium the pharmacologic agents used to treat this disease.[Note: The material discussed in this section is based on the ACC/AHA Practice Guidelines 2001, Circulation December 2001.]General Measures:An important part of heart failure management is identifying and treating factors that are known to encourage heart failure and its progression. This often requires encouraging patients to adopt lifestyle changes to address these factors. Lifestyle Modifications:Weight ReductionObese patients should lose weightSmokingSmokers should stop smokingAlcoholExcessive alcohol use, and the use of other cardiotoxic substances, should be avoidedExerciseImprove physical conditioning where appropriateTratamiento FarmacolgicoDigoxinaAumenta el Inotropismo del msculo cardiacoReduce activacin del SNC y SRAA

Los estudios controlados han demostrado que el tratamiento crnico con digoxina produce:

Reduccin de sntomasAumento en la tolerancia al ejercicioMejora en la hemodinmicaReduccin del progreso de la ICReduce la hospitalizacin de IC descompensadaNo mejora la sobrevida.

DigoxinDigoxin has been used in the management of heart failure for more than 200 years, yet it wasnt formally approved by the FDA for this indication until 1997. Digoxin enhances inotropy (contractility) of cardiac muscle and, at the same time, reduces activation of the SNS and RAAS. These neurohormonal effects are sustained during prolonged treatment with digoxin.Randomized, double-blind, placebo-controlled trials such as PROVED (Prospective Randomized Study of Ventricular Failure and the Efficacy of Digoxin) and RADIANCE (Randomized Assessment of Digoxin and Inhibitors of Angiotensin-Converting Enzyme) have shown that long-term therapy with digoxin reduces symptoms and increases exercise tolerance1. These two trials demonstrated that patients with mild to moderate chronic heart failure due to left ventricular systolic dysfunction, who are clinically stable on either maintenance therapy of Digoxin and diuretics (PROVED), or with additional background therapy with ACE Inhibitors (RADIANCE), are at considerable risk for clinical deterioration if Digoxin is withdrawn.2 Unfortunately, the Digoxin Investigation Group (DIG) Trial demonstrated that digoxin had no effect on mortality; however, digoxin did reduce the hospitalization rate for decompensated heart failure3 . The ACC/AHA Guidelines support the use of digoxin in conjunction with diuretics, an ACE inhibitor, and a beta-blocker in patients with LV systolic dysfunction who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker, and in those in whom heart failure is accompanied by rapid atrial fibrillation.The usual digoxin dose is 0.125-0.25 mg per day, and should be adjusted for age, renal function, and body mass. The Guidelines note that although the adverse effects of digoxin, such as cardiac arrhythmias and gastrointestinal and neurologic complaints, occur primarily at high doses, these higher doses are usually not necessary to achieve clinical benefits in patients with heart failure. 1Young, J. Clinical Management of Heart Failure. Professional Communications, Inc. 2001. p 97.2McMurray, J and Cleland, J. Heart Failure in Clinical Practice. Second Edition. Martin Dunitz Ltd. p 232.3Young, J., p. 111Tratamiento FarmacolgicoDiurticos

Se usan para disminuir la retencin de lquidosMejoran la tolerancia al ejercicio, no la sobrevidaFacilitan el uso de otros frmacos indicados en insuficiencia cardiaca Most patients with heart failure require a diuretic to relieve fluid retention. In addition to rapidly decreasing symptoms such as pulmonary congestion and peripheral edema, diuretics improve exercise tolerance and facilitate the use of other drugs indicated for heart failure. Treatment with a diuretic is generally started at a low dose and then gradually tapered upward until a threshold dose is established. Some patients with heart failure can be taught to adjust their diuretic dose themselves based on changes in body weight, which should be monitored daily. After fluid retention has resolved, diuretic therapy is continued to prevent its recurrence.Electrolyte depletion is a frequent complication of long-term diuretic therapy; therefore, electrolyte levels need to be monitored frequently during initial stages of therapy and after increases in diuretic dose. Diuretics are usually used along with ACE inhibitors and beta-blockers in heart failure, and should never be used alone. Increased doses of diuretics have been associated with increased mortality. Tratamiento FarmacolgicoDiurticosA los pacientes se les puede ensear a regular la dosis de acuerdo a su peso corporalUna complicacin frecuente es el desequilibrio electrolticoNo deben usarse de manera aislada en la insuficiencia cardiacaLas dosis altas de diurticos se asocian con mortalidad altaMost patients with heart failure require a diuretic to relieve fluid retention. In addition to rapidly decreasing symptoms such as pulmonary congestion and peripheral edema, diuretics improve exercise tolerance and facilitate the use of other drugs indicated for heart failure. Treatment with a diuretic is generally started at a low dose and then gradually tapered upward until a threshold dose is established. Some patients with heart failure can be taught to adjust their diuretic dose themselves based on changes in body weight, which should be monitored daily. After fluid retention has resolved, diuretic therapy is continued to prevent its recurrence.Electrolyte depletion is a frequent complication of long-term diuretic therapy; therefore, electrolyte levels need to be monitored frequently during initial stages of therapy and after increases in diuretic dose. Diuretics are usually used along with ACE inhibitors and beta-blockers in heart failure, and should never be used alone. Increased doses of diuretics have been associated with increased mortality. Tratamiento FarmacolgicoInhibidores de la ECA

Bloquean la conversin de angiotensina I a angiotensina II; previenen el deterioro funcionalRecomendados para todos los pacientes con ICEliminan sntomas y mejoran la tolerancia al esfuerzoReducen el riesgo de muerte, hospitalizacion y enlentencen el progreso de la enfermedadLos efectos benficos se notan despus de 1-2 meses de tratamientoAngiotensin Converting Enzyme (ACE) inhibitors are recommended for all heart failure patients, whether they are symptomatic or not. Use of ACE inhibitors relieves symptoms and improves exercise tolerance in patients with chronic heart failure. Data from placebo-controlled trials show that ACE inhibitors can also reduce the risk of death and disease progression in heart failure patients.The benefits of ACE inhibitor therapy may not become apparent for 1-2 months after initiation of treatment. But even in the absence of symptomatic improvement, continued long-term ACE inhibitor therapy is recommended to reduce the risk of death or hospitalization.Most patients with heart failure tolerate long-term ACE inhibitor therapy. Potential side effects include a decrease in blood pressure, transient worsening of kidney function, hyperkalemia, and chronic cough. Angioedema, a disorder characterized by the development of large, edematous areas of the skin, mucous membranes, and organs, is an infrequent, but life-threatening complication of ACE inhibition, and obviously, ACE inhibitors should not be used in patients with a history of this condition.Enalapril (Vasotec) and Captopril (Capoten), have been shown to decrease mortality in large heart failure clinical trials. For this reason, these two are typically the drugs of choice.Tratamiento FarmacolgicoBloqueadores Beta

Tienen efecto cardioprotector al evitar la estimulacin excesiva del SNC A corto plazo, los bloqueadores beta deprimen la contractilidad miocrdica (respuesta paradjica); sta aumenta despus de 1-3 meses de tratamientoSu uso combinado con la terapia habitual para IC, reduce el riesgo de morbilidad, mortalidad y progreso de la enfermedad

Beta-BlockersBeta-blockers exert their cardioprotective effects through blockade of excessive sympathetic stimulation of the myocardium, peripheral vasculature, and kidneys. While a short-term fall in myocardial contractility is to be expected, it is usually followed by a rise in ejection fraction over the next 1-3 months of use. In the past, beta-blockers were believed to be contraindicated in patients with heart failure because of the LV depression that occurs with short-term use. More recently, the favorable long-term effects of beta-blockade on the heart have been recognized, and the ACC/AHA guidelines support the use of beta-blockers for patients with stable NYHA Class I, II or III heart failure related to LV systolic dysfunction.Beta-blockers are generally well-tolerated. Hypotension associated with dizziness, light-headedness, or blurred vision may occur within the first few days of treatment, but tends to subside with continued drug administration. Decreases in heart rate and alterations in cardiac conduction produced by beta-blockers may also lead to to bradycardia or heart block. These changes can be severe, causing symptomatic hypotension, especially when high doses are used. In these cases, the dose must be reduced or discontinued if the condition persists.Carvedilol (COPERNICUS Trial), bisoprolol (CIBIS-II Trial), and metoprolol CR/XL (MERIT-HF Trial) have all shown to decrease mortality in patients with mild to severe HF1. Currently, carvedilol and metoprolol-CR/XL are the only FDA approved beta-blockers for HF patients.1Young, J. Clinical Management of Heart Failure. Professional Communications, Inc. 2001. pp 96, 100, 178.Tratamiento FarmacolgicoBloqueadores Beta

El tratamiento a largo plazo puede disminuir los sntomas de falla cardiaca, mejorar el estado clnico y aumentar el sentido de bienestar general del paciente.

Adicionalmente, al igual que los IECAs, pueden reducir el riesgo de muerte y el riesgo combinado de muerte u hospitalizacin. Beta-BlockersBeta-blockers exert their cardioprotective effects through blockade of excessive sympathetic stimulation of the myocardium, peripheral vasculature, and kidneys. While a short-term fall in myocardial contractility is to be expected, it is usually followed by a rise in ejection fraction over the next 1-3 months of use. In the past, beta-blockers were believed to be contraindicated in patients with heart failure because of the LV depression that occurs with short-term use. More recently, the favorable long-term effects of beta-blockade on the heart have been recognized, and the ACC/AHA guidelines support the use of beta-blockers for patients with stable NYHA Class I, II or III heart failure related to LV systolic dysfunction.Beta-blockers are generally well-tolerated. Hypotension associated with dizziness, light-headedness, or blurred vision may occur within the first few days of treatment, but tends to subside with continued drug administration. Decreases in heart rate and alterations in cardiac conduction produced by beta-blockers may also lead to to bradycardia or heart block. These changes can be severe, causing symptomatic hypotension, especially when high doses are used. In these cases, the dose must be reduced or discontinued if the condition persists.Carvedilol (COPERNICUS Trial), bisoprolol (CIBIS-II Trial), and metoprolol CR/XL (MERIT-HF Trial) have all shown to decrease mortality in patients with mild to severe HF1. Currently, carvedilol and metoprolol-CR/XL are the only FDA approved beta-blockers for HF patients.1Young, J. Clinical Management of Heart Failure. Professional Communications, Inc. 2001. pp 96, 100, 178.Tratamiento FarmacolgicoBloqueadores Beta

Debido a los efectos favorables de los betabloqueadores en la sobrevida y progresin de la enfermedad, el tratamiento con un betabloqueador debera de ser iniciado tan pronto como sea diagnosticada la disfuncin sistlica del ventrculo izquierdoBeta-BlockersBeta-blockers exert their cardioprotective effects through blockade of excessive sympathetic stimulation of the myocardium, peripheral vasculature, and kidneys. While a short-term fall in myocardial contractility is to be expected, it is usually followed by a rise in ejection fraction over the next 1-3 months of use. In the past, beta-blockers were believed to be contraindicated in patients with heart failure because of the LV depression that occurs with short-term use. More recently, the favorable long-term effects of beta-blockade on the heart have been recognized, and the ACC/AHA guidelines support the use of beta-blockers for patients with stable NYHA Class I, II or III heart failure related to LV systolic dysfunction.Beta-blockers are generally well-tolerated. Hypotension associated with dizziness, light-headedness, or blurred vision may occur within the first few days of treatment, but tends to subside with continued drug administration. Decreases in heart rate and alterations in cardiac conduction produced by beta-blockers may also lead to to bradycardia or heart block. These changes can be severe, causing symptomatic hypotension, especially when high doses are used. In these cases, the dose must be reduced or discontinued if the condition persists.Carvedilol (COPERNICUS Trial), bisoprolol (CIBIS-II Trial), and metoprolol CR/XL (MERIT-HF Trial) have all shown to decrease mortality in patients with mild to severe HF1. Currently, carvedilol and metoprolol-CR/XL are the only FDA approved beta-blockers for HF patients.1Young, J. Clinical Management of Heart Failure. Professional Communications, Inc. 2001. pp 96, 100, 178.Tratamiento FarmacolgicoAntagonistas de la Aldosterona

Han demostrado reducir la morbilidad y mortalidad por insuficiencia cardiaca

Habitualmente reservados para pacientes en clases funcionales III-IV de la NYHA

Los efectos colaterales son hiperkalemia y ginecomastia. Los niveles de Potasio y creatinina deben vigilarse estrechamenteAldosterone AntagonistsSpironolactone, long known for its potassium-sparing diuretic effects, is an aldosterone antagonist, and the only aldosterone antagonist available for clinical use in the US. The RALES study (Randomized Aldactone Evaluation Study), a multi-center mortality trial examined the effect of adding low-dose spironolactone to standard diuretic/ACE inhibitor therapy in HF (NYHA Class III and IV patients) has shown to reduce mortality in heart failure patients1. ACC/AHA Guidelines recommends the use of spironolactone in patients with severe HF. The role of spironolactone in patients with mild to moderate HF has not been defined, and use of the drug cannot be recommended in such individuals 2.Hyperkalemia is a concern. Serum potassium and creatinine should be closely monitored, and patients with a potassium level >5 or creatinine >2.5 should not be treated with spironolactone.While therapy with spironolactone is generally well-tolerated, about 9% of patients in the Randomized Aldactone Evaluation Study experienced gynecomastia (swelling of the mammary glands in the male).1McMurray, J and Cleland, J. Heart Failure in Clinical Practice. Second Edition. Martin Dunitz Ltd. p 101.2Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 pp 23-24

Tratamiento FarmacolgicoBloqueadores del Receptor de Angiotensina (ARA II)

Bloquean los receptores AT1, que se unen a la angiotensina II circulanteLos estudios realizados en insuficiencia cardiaca muestran resultados semejantes a los IECADeben usarse en pacientes intolerantes a los IECA y en casos pueden agregarse al tratamiento habitualAngiotensin Receptor BlockersAngiotensin receptor blockers, or ARBs, are the newest class of drugs to be promoted as a potential treatment for patients with heart failure. ARBs are most often given when a patient cannot tolerate an ACEI. To understand how these unique drugs work, we must first take a closer look at angiotensin II and the receptors that bind it.Angiotensin II, as we learned previously in this program, is produced from angiotensin I by the action of angiotensin converting enzyme (ACE). As we now know, angiotensin II has a number of potentially adverse effects that contribute to the development and progression of HF, including vasoconstriction, salt and water retention, and activation of the SNS. In addition, angiotensin II is associated with collagen deposition, fibrosis, and myocardial and vascular hypertrophy, which contribute to cardiac remodeling.The effects of angiotensin II throughout the body are mediated via two receptor subtypes, designated AT1 and AT2, which bind angiotensin II. The AT1 receptor has been extensively studied, and has been shown to be widely distributed in the vasculature, heart, kidneys, adrenal glands, and brain. The AT1 receptor subtype is responsible for most of the physiologic effects of angiotensin II on blood pressure, salt and water balance, and cell growth, and therefore plays a central role in the pathogenesis of heart failure.

Enfoque teraputico hacia el paciente con Insuficiencia CardiacaEstadio AAlto riesgo, sin dao estructural

Estadio BDao estructural cardiaco, asintomtico

Estadio DIC refractaria que requiere tratamiento especializadoTerapiaTratar HipertensinTratar dislipidemiaPromover ejercicio regularEvitar alcohol en excesoInhibicin ECA

TerapiaTodas las medidas del Estadio AIECA en pacientes seleccionadosBeta-bloquedores en pacientes seleccionados

TerapiaTodas las medidas para el Estadio AMedicamentos:DiurticosIECABeta-bloqueadoresDigitalDieta y restriccin de sodioAntagonistas AldosteronaTerapiaTodas las medidas para los estadios A, B y CAsistencia mecnicaTransplante CardiacoUso continuo de medicacin endovenosa para mejora sintomticaCuidados domiciliariosEstadio CDao estructural cardiaco con sntomas previos o actuales de ICStages (as classified in ACC/AHA guidelines) in the evolution of heart failure and recommended therapy

Hunt, SA, Baker, DW, Chin, MH, Cinquegrani MP, Feldman AM, Francis GS, Ganiats TG, Goldstein S, Gregoratos G, Jessup ML, Noble RJ, Packer M, Silver MA, Stevenson LW. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, 2001.