Download Heart failure

HEART FAILURE
Definition:
A
state in which the heart cannot provide
sufficient cardiac output to satisfy the
metabolic needs of the body
Causes of left ventricular failure
Volume over load:
Regurgitate valve
High output status
Pressure overload:
Loss of muscles:
Systemic hypertension
Outflow obstruction
Post MI, Chronic ischemia
Connective tissue diseases
Infection, Poisons (alcohol,cobalt,Doxorubicin)
Restricted Filling:
Pericardial diseases, Restrictive
cardiomyopathy, tachyarrhythmia
Classification of heart failure
Pathophysiology
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Hemodynamic changes
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Neurohormonal changes
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Cellular changes
Hemodynamic changes
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systolic dysfunction
diastolic dysfunction
Neurohormonal changes
N/H changes
Favorable effect
Unfavor. effect
 HR , contractility,
vasoconst.   V return,
 filling
Arteriolar constriction 
After load  workload
 O2 consumption
 Renin-Angiotensin –
Aldosterone
Salt & water retention VR
Vasoconstriction 
 after load
 Vasopressin
Same effect
Same effect
 interleukins &TNF
May have roles in myocyte
hypertrophy
Apoptosis
Vasoconstriction VR
 After load
 Sympathetic activity
Endothelin
Cellular changes
 Changes in Ca+2 handling.
 Changes in adrenergic receptors:
• Slight  in α1 receptors
• β1 receptors desensitization  followed by down regulation
 Changes in contractile proteins
 Program cell death (Apoptosis)
 Increase amount of fibrous tissue
Symptoms
• SOB, Orthopnea, PND, cough with frothy sputum
• Low cardiac output symptoms
• Abdominal symptoms:
Anorexia, nausea,
abdominal fullness,
Rt hypochondrial pain
NYHA Classification of heart failure
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Class I: No limitation of physical activity
Class II: Slight limitation of physical activity
Class III: Marked limitation of physical activity
Class IV: Unable to carry out physical activity
without discomfort
Physical Signs

High diastolic BP & occasional decrease in
systolic BP (decapitated BP)
JVP
Rales (Inspiratory)
Displaced and sustained apical impulses
Third heart sound –
low pitched sound that is heard

Fourth heart Sound (S4)
during rapid filling of ventricle.
Usually at the end of diastole
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Pale, cold sweaty skin
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Framingham Criteria for Dx of Heart
Failure
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Major Criteria:
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PND
JVP
Rales
Cardiomegaly
Acute Pulmonary Edema
S3 Gallop
Positive hepatic Jugular reflex
↑ venous pressure > 16 cm H2O
Dx of Heart Failure (cont.)

Minor Criteria
Lower Limb edema,
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion
↓ vital capacity by 1/3 of
normal
Tachycardia 120 bpm
Weight loss 4.5 kg over 5 days
management
Forms of Heart Failure
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Systolic & Diastolic
High Output Failure
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Low Output Failure
Acute
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Pregnancy, anemia, thyrotoxisis, A/V fistula, Beriberi,
Pagets disease
large MI, aortic valve dysfunction---
Chronic
Forms of heart failure
( cont.)

Right vs Left sided heart failure:
Right sided heart failure :
Most common cause is left sided failure
Other causes included :
Pulmonary embolisms, pulmonary
hen,
RV infarction's
Usually presents with:
LL edema, ascites, hepatic congestion
cardiac cirrhosis (on the long run)
Differential diagnosis
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Pericardial diseases
Liver diseases
Nephrotic syndrome
Protein losing enteropathy
Laboratory Findings
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Anemia
Hyperthyroid
Chronic renal insuffiency, electrolytes abnormality
Pre-renal azotemia
Hemochromatosis
Electrocardiogram
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Old MI or recent MI
Arrhythmia
Some forms of Cardiomyopathy are tachycardia related
LBBB→may help in management
ECG showing Entopic
ECG showing LVH
Chest X-ray
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Size and shape of heart
Evidence of pulmonary venous congestion (dilated or
upper lobe veins → perivascular edema)
Pleural effusion
Chest X-Ray
Upper lobe diversion
B/L hilar congestion
Fluid in transverse
fissure
cardiomegaly
Echocardiogram
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Function of both ventricles
Wall motion abnormality that may signify CAD
Valvular abnormality
Intra-cardiac shunts
Cardiac Catheterization
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When CAD or valvular is suspected
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If heart transplant is indicated
TREATMENT
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Correction of reversible causes
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Ischemia
Valvular heart disease
Thyrotoxicosis and other high output status
Shunts
Arrhythmia
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A fib, flutter, PJRT
Medications
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Ca channel blockers, some antiarrhythmics
Diet and Activity
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Salt restriction
Fluid restriction
Daily weight (tailor therapy)
Gradual exertion programs
Diuretic Therapy
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The most effective symptomatic relief
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Mild symptoms
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HCTZ, Chlorthalidone, Metolazone
More severe heart failure → loop diuretics
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Lasix (20 – 320 mg QD), Bumex (Bumetanide 18mg),Torsemide (20-200mg)
+
K
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Sparing Agents
Triamterene & amiloride – acts on distal tubules to ↓ K
secretion
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Spironolactone (Aldosterone inhibitor)
recent evidence suggests that it may improve survival in CHF patients due to
the effect on renin-angiotensin-aldosterone system with subsequent effect on
myocardial remodeling and fibrosis
Angiotensin Converting Enzyme Inhibitors
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They block the R-A-A system and ↓ Bradykinin
degradation
Delay onset & progression of HF in pts with
asymptomatic LV dysfunction
 ↓ cardiac remodeling
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Angiotensin II receptor blockers
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Can be used in certain conditions when ACE I are
contraindicated (angioneurotic edema, cough)
Side effects of ACE inhibitors
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Angioedema
Hypotension
Renal insuffiency
Rash
cough
Digitalis (cont.)
Mechanism of Action
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+ve inotropic effect
Vagotonic effect
Arrhythmogenic effect
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Digitalis Toxicity
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Anorexia,Nausea, vomiting, Headache, Xanthopsia
scotoma, Disorientation
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Digitalis Toxicity
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Cardiac manifestations
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Sinus bradycardia and arrest
A/V block (usually 2nd degree)
Atrial tachycardia with A/V Block
Development of junctional rhythm in patients with a fib
PVC’s, VT/ V fib (bi-directional VT)
β Blockers
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Has been traditionally contraindicated in pts
with CHF
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In addition to improved LV function multiple
studies show improved survival
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The only contraindication is severe
decompensated CHF
Vasodilators
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Reduction of afterload By arteriolar vasodilatation
hydralazin
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Reduction of preload
Nitrates
By venous dilation
Positive inotropic agents
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β adrenergic agonists, dopaminergic agents
dopamine, dobutamine, milrinone, amrinone
Several studies showed ↑ mortality with oral inotropic
agents
So the only use for them now is in acute sittings as
cardiogenic shock
New Methods
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Implantable ventricular assist devices
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Biventricular pacing (only in patient with LBBB
& CHF)
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Artificial Heart
Cardiac Transplant
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It has become more widely used since the advances in
immunosuppressive treatment
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Survival rate
 1 year 80% - 90%
 5 years 70%
Prognosis
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Annual mortality rate depends on patients symptoms
and LV function
5% in patients with mild symptoms and mild ↓ in LV
function
30% to 50% in patient with advances LV dysfunction
and severe symptoms
40% – 50% of death is due to SCD
Learning strategies
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Student should be able to
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Differentiate b/w Rt and Lt sided heart failure
Identify the clinical features of heart failure
Pick up the abnormailities on investigations
Know emergency and long term treatment plan
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Psychomotor skills
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Student should
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Demonstrate method of looking at raised JVP
Look for chest and CVS abnormalities
Identify the risk factor by history taking and
examining the patient
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MCQ
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The following chest radiograph signs suggest
left ventricular failure:
(a) Cardiomegaly.
(b) Upper lobe blood diversion.
(c) Pleural effusion.
(d) Oligaemic lung fields.
(e) Kerley B lines.
Answer
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a, b, c, and e.
CASE SCENARIO
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A 50 year old female is seen in the emergency
department with complaints of shortness of
breath for 2 weeks and bony pain, particularly in
the hips, for several months. she as progressive
dyspnea on exertion,orthopnnea and paroxysmal
nocturnal dysnea, she takes no medications an
has no allergy.
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What is your clinical impression ?
CASE SCENARIO
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On physical exam she has elevated jugular
venous pressure and peripheral edema as well as
tachycardia without a third heart sound.
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Electrocardiogram ,besides sinus tachycardia is
normal. A chest radiograph shows mild
pulmonary vascular congestion, and plain film
of the hips show severe and diffuse bony
changes consistent with Pagets disease.
CASE SCENARIO
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WHAT ARE THE DIFFENETIAL
DIAGNOSIS ?
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HOW WILL YOU MANAGE THIS CASE ?
CASE SCENARIO
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The patients presents with high output failure in
the setting of pagets disease. in addition to this
disorder, several other conditions have been
associated with high output states, including
anemia, arteriovenous
fistulas,pregnancy,hyperthyroidism and beriberi.
CASE SCENARIO
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In this case ,in light of lack of clinical risk
facors,ischemic cardiomyopathy is very unlikely.
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Patients with high output heart failure in general
respond well to treatment of underlying conditions,
with subsequent improvement of heart failure
symptoms. Diuretics are helpful for symptomatic relief.
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Although sinus tachycardia is common in this patient
population, ventricular tachycardia is rare.
Thanks