Download chapter-5-hf-lecture

Heart Faliure
Prof . El Sayed Abdel Fattah Eid
Lecturer of Internal Medicine
Delta University
 Definition:
Heart failure occurs when an abnormality of cardiac function fails
to provide adequate blood flow to meet the metabolic needs of
the body’s tissues and organs.
 Causes of heart failure
1. Idiopathic dilated cardiomyopathy
2. Coronary Artery Disease
3. Pressure Overload (Hypertension, Aortic stenosis)
4. Volume Overload: (Mitral regurgitation, Aortic insufficiency
5. Toxins (Ethanol, Cocaine, lead, cobalt, Doxorubicin
(Adriamycin)
6.Metabolic-Endocrine (Thiamine deficiency, Diabetes,
Thyrotoxicosis)
7.Infiltrative (Amyloidosis, Hemochromatosis)
8. Inflammatory (Viral myocarditis)
• Idiopathic cardiomyopathy is a common cause of HF; defmed as a primary
myocardial disease of unknown etiology. Secondary cardiomyopathies often
the result of ischemic heart disease.
• Diseases of the pericardium, such as chronic pericarditis or pericardial
tamponade, can impair cardiac function without directly affecting the
myocardial tissue.
• Long-standing tachyarrhythrnias are associated with myocardial
dysfunction, especially in children.
• Arrhythmia precipitates heart failure in patients with underlying heart
disease.
Forms of Heart Failure:
 1- Systolic heart failure:
inability of the heart to contract strongly enough to provide adequate
blood flow to the periphery. Ex. Idiopathic cardiomyopathy.
 2- Diastolic dysfunction:
Abnormal relaxation of the left ventricle => ↓filling => ↑left ventricular,
left atrial and pulmonary venous pressures.
Causes: acute ischemia, chronic hypertension or severe aortic stenosis.
Presentation: HF, acute pulmonary edema.
Treatment: treatment of underlying cause
* Beta blockers & calcium blockers => ↓HR => ↑ filling time
* ACE inhibitors =>↓ hypertension & improve myocardial relaxation
* Diuretics and nitrates should be used with caution as they =>↓ left
ventricular
filling, a decrease in cardiac output, and hypotension
* Inotropes as digoxin are not used
3- High output failure:
 The heart is unable to meet the abnormally elevated metabolic
demands of the peripheral tissues. Ex. severe anemia or thyrotoxicosis.
4- Low-output failure :
 is characterized by insufficient forward output both at rest and during
times of increased metabolic demand.
5- Left ventricle failure:
 ex. large anterior myocardial infarction
6- Right ventricle failure:
 ex. acute pulmonary embolus or biventricular heart failure.
7-Acute heart failure:
 when an individual who is completely asymptomatic before the onset of
heart failure symptoms decompensates. ex. Myocardial infarction
8-Chronic heart failure:
 symptoms develop over a long period of time. Compensation for long
periods & heart failure develops after an acute insult.
Precipitants of Heart Failure:
1. Dietary (sodium and fluid) indiscretion
2. Noncompliance with medications
3.Development of cardiac arrhythmia
4.Uncontrolled hypertension
5.Superimposed medical illness (pneumonia, renal dysfunction)
6. New cardiac abnormality (acute ischemia, acute valvular lesion)
Evaluation of Patients with Heart
Failure
 History:
- Dyspnea: due to ft pulmonary venous pressure, first with exertion
later at rest.
- Orthopnea: dyspnea is worsened by recumbency (tVR).
- Paroxysmal nocturnal dyspnea:
- Fatigue in systolic HF with low cardiac output
- Peripheral edema worsens during the day and decreases overnight
Physical findings (mostly related to
the neurohormonal changes)
- ↑ heart rate (↑sympathetic)
- Narrow pulse pressure (peripheral vasoconstriction).
- Bilateral basal crackles (↑ left ventricular filling pressures)
- Distended necic veins (↑ right-sided filling pressures).
- Hepatojugular Reflux If the liver is congested
- Left ventricular enlargement.
- Left or right ventricular S3 or gallop (systolic dysfunction).
- Left or right ventricular S4 (noncompliant ventricle & not specific for
HF).
- Mitral and tricuspid regurgitation (CHF and ↑with decompensation).
- Peripheral edema (↑ venous pressure & ↑ sodium and water
retention).
 Investigations:
- ECG is not specific, important in old MI, LVH, or significant
arrhythmias.
- Chest X-ray: chamber enlargement and pulmonary congestion.
- ↓ serum sodium (water retention with activation of the RAS)
- Impaired Renal function (↓ renal perfusion and ↓ cardiac
output).
- ↑ Liver enzyme levels due to to hepatic congestion.
 Differential Diagnosis:
1-Pulmonary disease share many of the signs and symptoms of
heart failure.
2- Adult respiratory distress syndrome (ARDS): non-cardiac
pulmonary edema
3-Peripheral edema occurs in renal disease, especially nephrotic
Syndrome, cirrhosis, and severe venous stasis disease.
Treatment
Non-Pharamacological Treatment
- Restrict sodium intake to 2 g/day.
- Fluid intake should also be limited to avoid hyponatremia.
-Weight reduction in the obese ↓cardiac workload.
- Supervised exercise cardiac rehabilitation program
Pharamacological Treatment
1- Loop Diuretics: rapid relief of pulmonary congestion and peripheral edema
2- Vasodilators
3- ACE inhibitors: ↓symptoms through inhibiting angiotensin & ↓ afterload.
4-Calcium blockers are better avoided because of their negative inotropic effect and
activation of the sympathetic nervous system
5- Inotrpics (Digoxin): Symptomatic improvement in patients with systolic
dysfunction
- Indication: LV systolic dysfunction that remains symptomatic after treatment ACE
inhibitor and diuretic.
- Increase cardiac work and may induce further myocardial injury
6- Beta—Blocker: carvediol:
It has antioxidant and a blocker action
- Improve symptoms and reduce mortality in mild-to-moderate LVF.
- Used after stabilization with ACE inhibitor, diuretic, and digoxin but who remains mildly
to moderately impaired
7- Anticoagulants (long-term warfarin therapy)
- Chronic atrial fibrillation or flutter
- Mural thrombi
- Sinus rhythm with left ventricular ejection fractions less than 20%
Acute Pulmonary Edema
1. Supplemental oxygen
2.Intravenous loop diuretic.
3. Sublingual or intravenous nitroglycerin (venodilatation =>↓ preload)
4. Intravenous morphine
5. Arterial vasodilator nitroprusside: in severe ↑ BP to ↓ afterload.
6. Evaluation of response to treatment: assessment of BP, HR. end-organ
perfusion, and oxygen saturation
7. Refractory cases: Intravenous inotropic agent & Intra-aortic balloon
pump
Thank You