Download Introduction to Heart Failure

9/22/2016
Introduction to Heart
Failure
Marshall Hyden, MD
Objectives
Define heart failure
Prevalence of heart failure
Outcomes of patients with heart failure
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Case
55 yo male who presents to clinic with shortness of breath on exertion.
Symptoms have been slowly progressing over the past 1 month to where he
can now walk only ½ block before stopping due to shortness of breath. Denies
chest pain. Is sleeping in a recliner now due to shortness of breath with lying
flat. History of coronary artery disease with stent placed to LAD 2 years ago.
What is heart failure?
Heart failure is a chronic, progressive condition in which the heart muscle is
unable to pump enough blood through to meet the body's needs for blood and
oxygen.
Two types of heart failure
• Systolic dysfunction – Decrease in ability of the heart to
contract and eject blood to the body
• Diastolic dysfunction – Inability of the ventricle of the heart to
relax to allow blood to enter the heart
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Why is it important?
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Nearly 6 million Americans are living with heart failure
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1 in 5 will develop heart failure during their lifetime
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Mortality at 5 years after diagnosis is about 50%
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Risk factors for heart failure
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Coronary artery disease
Hypertension
Diabetes
Obesity
Heart valve disease
Heart muscle disease
• Alcohol
• Viruses
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy
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How does heart failure cause symptoms?
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Decreased cardiac output
• Less blood is pumped out of the heart with each contraction in
heart failure. This leads to a drop in blood pressure and perfusion
to the vital organs
• Symptoms of decreased cardiac output include fatigue, end-organ
dysfunction such as acute kidney injury
Fluid retention
• The decrease in blood pressure leads to compensatory
mechanisms to increase blood pressure. These include retention of
sodium and water
• Retention of fluid is manifested symptomatically by peripheral
edema, jugular venous distention, pulmonary edema
Pulmonary edema
• When the heart is not able to pump efficiently, blood can back up
into the veins that enter the left atrium from the lungs. As the
pressure in these vessels increases fluid is pushed into the lungs.
• Symptoms of pulmonary edema include shortness of breath,
orthopnea and paroxysmal nocturnal dyspnea
Lund et al J of Heart and Lung Transplant 2016
How is heart failure diagnosed?
History and physical exam findings consistent with heart failure:
• Shortness of breath on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Fatigue
• Jugular venous distension
• Ascites
• Peripheral edema
• Rales
• S3
Diagnostic testing includes:
• Chest x-ray
• BNP
• Echocardiogram
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Classification of Heart Failure
A
B
C
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
NYHA Functional Classification
None
I
I
II
III
IV
D
Refractory HF requiring specialized
interventions.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
How does the body compensate for heart failure?
1) Enlarging
2) Increase in mass
3) Increase in heart rate
4) Narrowing blood vessels
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How is systolic heart failure treated?
The body’s response to heart failure to maintain blood pressure acutely
improves the situation but chronically are maladaptive. Medical treatment for
heart failure involves blocking hormonal responses to prevent remodeling of
the heart and diuretic medications to remove excess fluid.
• ACEI
• Beta blockers
• Aldosterone antagonists
• Loop diuretics
Device therapy with ICD is indicated for the prevention of sudden cardiac
death in patients on guideline directed medical therapy with LVEF <35%.
Biventricular pacing is indicated select patients with LVEF <35%
In patients whose symptoms progress despite these therapies or are unable to
tolerate these therapies and have progressive symptoms, Advanced heart
failure therapies should be considered
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