Download Congestive Cardiac Failure Pathophysiology Precipitating Causes

Congestive Cardiac Failure
Pathophysiology
Failure of heart to
pump blood at
sufficient rate/volume
to meet metabolic
demands of peripheral
tissues, or the ability to
do so only at
abnormally high cardiac
filling pressures
SV = EDV – ESV
EF = SV/EDV x 100
HFrEF
(Heart Failure with
reduced EF)
- ↑EDV (ventricular
dilatation)
- ↓SV (poor
contractility/high
afterload)
HFpEF
(Heart Failure with
preserved EF)
- ↓ EDV (ventricular
hypertrophy)
- ↓ SV (due to
impaired filling)
- ↓SV/↓EDV = EF
does not change
appreciably
Diagnosis of HF
based on ESC
guidelines
- HF-REF – 3
conditions to be
satisfied
- HF-PEF – 4
conditions to be
satisfied
Precipitating Causes
Pre-existing heart failure:
- Non-compliance to medical
therapy
- Non-compliance to fluid
restriction
Cardiac causes:
- Myocardial ischemia/infarction
(Most common cause of new-onset
AHF; AHF occurs in 15% of patients with
ACS)
- Worsening Aortic Stenosis
(increased L-sided afterload)
- Others: Valvular heart disease
(AR/MR), Arrhythmias,
Myopathies, Myocarditis
Hypertensive Crisis
- Increase L-sided afterload
Respi causes (cor pulmonale –
increased R-sided afterload):
- Pulmonary embolism
- COPD
Renal cause
- Renal failure  Increased
preload
- Renal artery stenosis
High Output (systemic) causes:
- Systemic infection (Sepsis)
- Severe Anemia
- Thyrotoxicosis
- Pregnancy
Drugs/Toxins:
- CCB, Beta-blockers
- NSAIDs
(use of NSAIDs can unmask CCF)
Framingham
Diagnostic criteria
- 2 major, or 1
major + 2 minor
- Cocaine, Amphetamine
- Heavy Alcohol consumption
History
Acute History
Presenting Complaint
Shortness of Breath
- Severity/Exercise tolerance
o SOB at Rest (NYHA IV)
o Activities causing SOB
 Less than ordinary activity (NYHA III) – walking
for short distance
 Ordinary physical activity (NYHA II) – e.g.
climbing stairs, doing housework
 Ordinary activity does not cause SOB (NYHA I)
o Walking/Climbing distance before onset of SOB
o Premorbid baseline function
- Orthopnea
o Breathlessness worse on lying down
- Paroxysmal Nocturnal Dyspnea
o Wake up in middle of night with SOB
o Number of pillows used
- Relievers
o Sublingual nitrates
o Bronchodilators
Fluid Overload
- Facial swelling
- Abdominal distension (ascites)
- Scrotal edema
- Bilateral leg swelling
Systemic Review
(Causes/precipitating factors of CCF/Causes of SOB)
Think of 8 Major IM Departments (4 organs, 2 limbs, 2 systemic)
-
Cardio: CVS disease + CVS risk
Respi: Pulmonary disease + PE
Nephro: Renal
Gastro: Liver
Neuro: Neuro
Rheum: Autoimmune
Endo: Thyroid
Hemato: Anemia
Heart Disease
- Myocardial Infarction
o Symptoms: Chest pain, Diaphoresis
Physical examination
Determine Congestion
JVP Distension
Positive hepato-jugular reflux
3rd Heart Sound
Bibasal fine inspiratory crepitations
Bilateral wheeze (cardiac asthma)
Peripheral edema
Determine Perfusion
(warm vs cold)
Pulse pressure (PP)
- PP = SBP – DBP
- Narrow Pulse pressure (i.e. <25% of SBP)  indicates
inadequate cardiac output (hypoperfusion), predicts Cardiac
Index <2.2 (91% sensitivity)
o PMH: Previous AMI
- Arrhythmia
o Symptoms: Palpitations, Syncope, Pre-syncope
o PMH: Irregular heart beat
- Valvular Heart Disease
o PMH: Heart valve problems
- Cardiomyopathy
o PMH: Heart muscle problems
o Fam Hx: Heart muscle problems
Cardiovascular Risk Factors
- PMH Hypertension, Hypercholesterolemia, Diabetes
- Control & management of conditions
- Family history of conditions
Pulmonary Disease
- Symptoms: Cough, Sputum production, Wheezing,
Hemoptysis, Fever
- PMH: COPD, ILD
- Notes:
o Advanced COPD/ILD  Pulmonary HTN  CCF
o Pneumonia  SOB, Exacerbate CCF
Pulmonary Embolism
- Hemoptysis, Unilateral leg swelling, Recent period of
immobilization, Malignancy, Hemoptysis
- PMH: Previous DVT, PE
Renal Disease
- Symptoms: Pruritus, Proteinuria, Reduction in urine
output (Oliguria)
- PMH: Renal disease
Liver Disease
- Symptoms: RHC discomfort, Jaundice
- PMH: Liver disease
Neuromuscular Disease
- Symptoms: Muscle weakness, Daytime somnolence,
OSA, Fatigability at end of day (MG)
- PMH: Myasthenia Gravis, Myotonic Dystrophy
- Family history of neuromuscular disease
Thyroid Disease (both Hypo & Hyperthyroidism)
- Symptoms:
o Weight Loss, Weight Gain
o Heat intolerance, Cold intolerance
o Diarrhea, Constipation
o Tremors, Anxiety, Lethargy, Fatigue
- PMH: Thyroid Disease, Thyroid surgery, Thyroid
medications
- Family history of thyroid problem
Anemia
- Symptoms: Postural giddiness, Lethargy, Fatigue
- Menorrhagia, BGIT
Autoimmune
- Symptoms: Rashes, Hair loss, Ulcers
Drugs
- Precipitants of CCF:
o NSAIDs (Over-the-counter pain relief)
o Thiazolidinediones (e.g. Rosiglitazone)
o Non-dihydropyridine CCB (e.g. Verapamil,
Diltiazem)
- Compliance to Heart Failure Medications
Social
- Compliance to Diet and Fluid restrictions
- Smoking, Alcohol use
Chronic History
Course of Disease
Control
Complications of Disease
Cause (elicited in acute history)
Management History
Follow-up & Monitoring
Lifestyle Management
Medical Management
Compliance, Knowledge, Complications
Psychosocial History
ADLs, Ambulation
Caregiver, Home environment
Occupation, Finances
Psychological, Sexual
Symptomology of CCF:
- Low-output symptoms: Weakness, Fatigue, Exercise
intolerance, Altered mental state, Anorexia
- Left Heart Congestive Symptoms: Dyspnea,
Orthopnea, Paroxysmal nocturnal dyspnea (can
present as insomnia)
- Right Heart Congestive Symptoms: Edema/swelling,
RUQ discomfort, Bloating, Satiety
Investigations
Management (Acute)
CXR (ABCDE)
- Alveolar edema
General aims of management:
- ↓ Preload (↓ R-side filling) - Diuresis, Venodilator, Position
- ↑ Contractility (↑ L-side emptying) - Inotropes
- ↓ Afterload (↑ L-side emptying) - Vasodilator
- Relieve symptoms - Oxygen, Morphine
(causing peri-hilar shadow)
-
Kerley B lines
(due to interstitial edema)
- Cardiomegaly
(Cardiothoracic ratio >0.5)
-
Upper lobe Diversion
(dilated prominent upper lobe vessels –
“cephalization” of pulmonary
vascularture)
- Pleural Effusion
2D Echocardiogram
- ↓ Ejection Fraction
- ↑ Chamber Size
- Ventricular Hypertrophy
- Valvular Abnormalities
(e.g. abnormal Mitral Valve inflow)
- Pulmonary Artery Systolic
Pressure (PASP)
(Normal – 12-16mmHg, Pulmonary
hypertension if >25mmHg)
Electrocardiogram
- Evaluate cause of heart failure:
o Coronary Artery Disease
(e.g. Q waves of previous MI, ST & Twave changes indicative of
ischemia/infarction)
2 Questions to “Triage” every patient
Assess Degree of Congestion and Adequacy of Perfusion
1. Degree of Congestion (Dry vs Wet)
2. Degree of Perfusion (Warm vs Cold)
Warm
Cold
Dry
Outpatient
management
Inotropes
CCU admission
Wet
Diuresis
Venodilator
Diuresis
Vasodilators
Inotropes
CCU admission
Mgx of Congestive Acute Decompensated Heart failure (LMNOP) –
Management of Congestion
Lasix (Diuretics) – 3rd line in black book
- IV Furosemide
o IV Lasix 40-80mg bolus x1, followed by 40mg BD
- Potassium replacement
o SpanK 0.6mg OM
Management of Heart Failure with Reduced EF (LV Systolic
dysfunction)
Non-Pharmacological Management
Smoking Cessation
Dietary Modifications
- Fluid Restriction (1L/day)
- Sodium Restriction (<2g/day)
Exercise Training
- Regular low-level exercise for ambulatory patients
- Stamina training to improve walking distance
Daily Weight Monitoring
Advanced Medical Directive
Pharmacological Management
3 Aims:
- Disease modification (Mortality benefits, ↑ Expectancy)
- Symptom Palliation (Morbidity benefits, ↓ Readmissions)
- Cardiovascular Risk Factors Control & Prevention
Disease Modification (Mortality Benefits)
ACE Inhibitors/Angiotensin Receptor Blockers
- Indicated in all patients with LV systolic dysfunction regardless of
functional status (NYHA I-IV)
- Decrease in mortality in all NYHA
- Watch for raised creatinine, potassium, cough, angioedema
o Left Ventricular Hypertrophy
(indicating chronic hypertension 
hypertensive heart disease)
o Arrhythmia, Heart Blocks
o Low Voltage
(QRS amplitude <5mm in all limb
leads; <10mm in all precordial leads
 Indicative of infiltrative or
restrictive cardiomyopathy)
NT-proBNP
- Useful for distinguishing between cardiac
& non-cardiac causes of dyspnea
- Strong negative predictive value: negative
value can exclude AHF
- NT-proBNP > 1000pg/ml is diagnostic for
Acute Heart Failure, but value is generally
higher in:
o Advancing age
o Female sex
- NT-proBNP is also raised in respiratory,
renal & hepatic diseases:
o Cor Pulmonale
o Acute Pulmonary Embolism
o Primary Pulmonary Hypertension
o Renal failure
o Liver cirrhosis
- Strict I/O monitoring
o with Fluid restriction 1L/day
o and with Daily weighing
o Urinary catheterization to monitor urine output if needed
- Note: Diuretic Strategies (NEJM 2011 364 797)
o Dosage:
 IV 1x usual daily PO dose, or
 IV 2.5x usual daily PO dose: a/w greater diuresis but transient worsening of
renal function
o Administration:
 Bolus q12h(BD), or Continuous infusion (no significance difference)
- Note: Disadvantage acc to blackbook
o Indirect preload reduction via diuresis is delayed (45-120mins) as AHF patients
have diminished renal perfusion
o Administer GTN +/- ACE-Inhibitor before diuretics to ↓ adverse effects
Morphine
- Decrease symptoms
- Venodilation  Decrease afterload
Nitrates – 1st line in black book
- ↓Preload, ↓Afterload
- Advantages:
o Rapid onset of action (5mins for S/L GTN)
o Short half-life – effects can be easily reversed if AHF is misdiagnosed (BP
returns to normal 5-10mins after discontinuing IV GTN)
- Mode of Administration:
o Sublingual GTN for rapid initiation of treatment, followed by:
o Patch GTN for mild-moderate AHF
o IV GTN for severe AHF (20-50µg/min)
- Use in caution in:
o RV infraction
o Acute MR
o Aortic stenosis (cannot tolerate ↓ preload)
o Pulmonary hypertension (cannot tolerate ↓ preload)
o Hypotension
o Concurrent vasodilators (e.g. Sildenafil) - ↓↓BP
Oxygen +/- NIV
- ↓ symptoms, ↑ PaO2
- Indications for NIV
o Moderate-to-severe AHF
o Evidence of Pulmonary edema
o Intact mental state
o No evidence of STEMI
- Advantages of NIV:
o Decrease symptoms, Improve PaO2
o Decrease need for intubation, No change in mortality
Position
- Sit up with legs hanging on side of bed
- Ameliorate by low potassium diet and diuretics
- Accept rise of creatinine by up to 20%, discontinue if ↑Cr >20%
- Note: Presence of hypotension (asymptomatic) is not a contraindication to start
ACE-I
Beta-Blockers (Only 3: Bisoprolol, Cardvedilol, Metoprolol)
- Indicated in hemodynamically stable heart failure patients:
o NYHA I-II: Initiate beta-blockers
o NYHA III-IV: Use with caution
- Contraindicated in acute decompensated heart failure
- Carvedilol may be superior to the rest
- Aim for decrease in HR, mortality benefits and decrease
hospitalization rates in NYHA II-IV
Spironolactone (Aldosterone Antagonist)
- Indicated in NYHA III-IV patients
- Monitor renal function for hyperkalemia (esp. since pts are alr on
ACE-I/ARB)
Hydralazine & Nitrates
- Consider in patients who cannot tolerate ACEi/ARBs
- Inferior to ACEi, but still have 25% decrease in mortality
- Greatest benefit in black patients (40% mortality decrease)
Symptom Palliation
Diuretics (Loop +/- Thiazide diuretics)
- Relief of congestive symptoms
- No mortality benefits
Digoxin
- Indicated for heart failure patients with Atrial Fibrillation, NYHA
III-IV
- Utility: Symptomatic relief, reduce hospitalization, but no
mortality benefits
Cardiovascular Risk Factor control & prevention
Adjuncts – Intracardiac Devices
Cardiac Resynchronization Therapy (CRT)
- Synchronizes contraction of heart muscle via electrical impulses
to RV and LV in order to pump blood more effectively
- Indications (all 3):
o Symptomatic heart failure (NYHA III-IV), LVEF ≤35% on
o Maximal medical therapy (ACE-I + BB + Spironolactone +
Digoxin), with
o Evidence of intraventricular conduction delay (LBBB;
Other medications:
ACE Inhibitors (2nd Line acc. to EMD blackbook)
- ↓Preload, ↓Afterload
- Do not give if hypotension
- Advantages:
o Rapid onset of action (6-12 mins)
o Alternative for patients with contraindications for GTN
o Synergistic effect when ACE-I used with GTN
- Mode of Administration:
o Sublingual Captopril for mild-to-moderate AHF (dip regular captopril tablet
into water)
o IV Enalapril for moderate-to-severe AHF
Beta-blocker
- Reduce dose by ½ or more in moderate heart failure
- Discontinue if severe heart failure/need for inotropes
Treatment of Advanced Heart failure – Management of Perfusion
Pulmonary Artery Catheterization
- Consider PAC to guide treatment when:
o Not responding to initial management  Require inotropes
o Hypotensive/uncertain of volume status
o Renal dysfunction (↑ Creatinine)
- Goals of treatment with PAC:
o Cardiac index > 2.2 L/min/m2
 Note: CI = Cardiac output/Body surface area
QRS>120mm)
- Utility
o Mortality benefit (~30%)
o Increase Ejection Fraction
o Decrease symptoms and hospitalizations
Automatic Implantable Cardioverter Defibrillator (AICD)
- Detects abnormal heart rhythm – provides defibrillation to
restore regular heartbeat
- Indications:
o Primary prevention:
(Patients at increased risk of developing VF/VT  Sudden Cardiac Death)
 Prior AMI (>40 days ago) with LVEF ≤30%
 NYHA II/III CCF with LVEF ≤35%
o Secondary prevention:
 Previous spontaneous sustained VT (even if asymptomatic)
 Previous VF (survivor of VF arrest)
 Resuscitated Sudden Cardiac Death (thought to be due to
VT/VF)
o Note: Patient must have expected survival of at least 1 year
- Utility: Decrease mortality from sudden cardiac deaths
- Risk: Inappropriate shocks (due to misclassified SVT), Infection
- Following a discharge of ICD – check device to see if discharge
was appropriate, rule out ischemia
o Mean Arterial Pressure >60mmHg
Inotropes
- Indicated for patients who are hypotensive at onset to increase cardiac
contractility
- IV Dobutamine/Dopamine titrated according to response (similar to cardiogenic
shock management)
IV Vasodilators
Intubation
- Indicated for patients with Altered Mental State or worsening respiratory distress
- Purpose: Protect airway, improve breathing & ventilation
- For RSI, pretreat with IV fentanyl to reduce catecholamine release
Note: Combined CRT & AICD device (CRT-D – Cardiac
Resynchronization therapy – Defibrillator) often given to heart
failure patients who satisfy criteria for both devices
Permanent Pacemaker
- Indications:
o Symptomatic Sinus Bradycardia
o Symptomatic Chronotropic Incompetence (impaired HR
response to exercise)
o Symptomatic 3rd degree (complete) or 2nd degree (Mobitz Type
II) Heart Block
 If asymptomatic; HR<40 or asystole >3sec are also indications!
 Patients with AV blockage & Neuromuscular diseases – e.g. Myotonic
dystrophy – with or without symptoms, as they may progress unpredictably
o Carotid sinus hypersensitivity with asystole >3 seconds
o Symptomatic recurrent Supraventricular Tachycardia which
can be terminated by pacing (after failure of ablation & pacing)
Avoid offending Medications:
- NSAIDs (Over-the-counter pain relief)
- Thiazolidinediones (e.g. Rosiglitazone)
- Non-dihydropyridine CCB (e.g. Verapamil, Diltiazem)
Acute Management
-
ABC
o
o
o
Establish airway
 KIV Intubate if worsening respiratory distress or altered mental state
Start Patient on Oxygen therapy to keep SpO2 >95%
 NRM may be required if serious; Venturi mask (controlled oxygen therapy) for COPD patients with cor pulmonale
 KIV Non-Invasive Ventilation if moderate-to-severe heart failure (& evidence of pulmonary edema) with intact mental
state and no evidence of STEMI
Set 2 large bore IV cannula for administration of medications
 Judicious fluid resuscitation if patient in cardiogenic shock
(RV failure may be pre-load dependent and require fluid boluses, whereas excessive fluid in LV failure will result in worsening of pulmonary edema)
-
-
-
-
Monitor & Evaluation
o Evaluate Degree of Congestion & Adequacy of Perfusion
o Vitals Q4hrly + SpO2
 Narrowed pulse pressure <25% SBP – indicative of patient being “Cold”
o Daily Weight
o Strict Input-Output Monitoring
Input
o Fluid Restriction 1L per day
o Low Salt Diet
Output
o Urinary Catheterization to monitor fluid status
Up
o Inform senior, Transfer patient to high dependency
o Refer cardio if: STEMI, NSTEMI, Cardiogenic shock, Suspected Pericardial Tamponade
Investigation
o STAT
 ABG
 Rule out differential diagnosis of Pulmonary Embolism
 Performed if patient is dyspneic, hypoxic
 CBG
 Serial ECG
 Look for cause of heart failure (e.g. Arrhythmias, AMI – previous or current, LVH from chronic hypertension,
Dilated CMP)
 Markers of poor ejection fraction: Anterior Q waves, Poor R wave progression (seen in LVH and post-anterior
MI), Small limb leads

o
Labs






o
-
KIV Telemetry if ACS/Arrhythmias suspected
Full Blood Count
 Look for anemia
Renal Panel
 To be done daily as long as patient is on diuretics
Liver Function Test
 Look for hepatic congestion, hypoalbuminemia
Serial Cardiac Enzymes
Urine Dipstick
Others:
 Fasting Glucose, Fasting Lipids
 Thyroid Function Test (if thyroid dysfunction suspected)
 BNP (if diagnosis of heart failure in doubt)
 Digoxin levels (if patient was on digoxin)
Imaging
 Chest X-ray
 Alveolar edema with perihilar shadow (bat wing), Kerly B lines (due to interstitial edema), Cardiomegaly
(cardiothoracic ratio >0.5), Upper Lobe Diversion, Pleural Effusion
 Transthoracic Echocardiogram
 Required for all new heart failures to assess heart function and evidence of cardiac ischemia
 Look for Ejection Fraction, LVH, Valvular Heart Disease
Medications
o Initial Medications for Congestion
 Lasix + Potassium replacement
 PO/IV Lasix 40-80mg BD
 + PO Span K 600mg (Potassium Chloride)
o Replace 600mg Span K for every 40mg Lasix
o Give lower dose if renal impairment
 Morphine
 Low-dose IV Morphine 2mg STAT
 Nitrates
 Sublingual GTN can be given for rapid initiation of treatment (onset of action within 5 minutes)
 IV GTN for severe AHF given in ICU (if not hypotensive)
 Oxygen
 Position patient at 45 degrees or upright with legs hanging on side of bed
Stop Triggers:
 NSAIDs
 Non-dihydropyridine Calcium Channel Blockers – Verapamil, Diltiazem
 Thiazolidinediones – Rosiglitazone
 +/- Beta blockers
 +/- ACE Inhibitors
Disposition
o ICU if:
 Indications:
 Intubation
 PaO2 <60mmHg, PCO2>45mmHg, SBP <90mmHg
 ACS (ST depression), Altered mental status
 For closer Monitoring:
 Pulmonary Artery Catheterization
o Given if not responsive to treatment, uncertain of volume status, need to start inotropes
 For management of Perfusion:
 Inotropic support
o Dopamine (if SBP <70)
o Dobutamine (if SBP 70-100)
 Mechanical circulatory support
o Intra-aortic balloon pump
 Inflates in diastole to increase coronary perfusion
 Deflates in systole to decrease left ventricular afterload and hence decrease myocardial oxygen
demand
o Ventricular Assist Device
 For aggressive management of Congestion:
 IV Vasodilators (e.g. IV Nitroprusside)
o Evaluate for causes of acute heart failure
 Dietary indiscretion, Medical non-adherence
 Drugs (beta blockers, calcium channel blockers, NSAIDs, Thiazolidinediones)
 Hypertensive Crisis
 CVS: Worsening Aortic Stenosis
 Respi: COPD/PE  Cor pulmonale
 Renal: Renal Failure
o Discharge
o
-


Educate patient on medication and fluid compliance
Stress test for evidence of cardiac ischemia (if new onset heart failure)
Heart Failure with Preserved Ejection Fraction
Epidemiology
Approximately 50% of heart failure
patients have normal/preserved LV
Ejection Fraction:
- Normal EF > 55%
- Preserved EF 40-55%
Etiology/Risk factors
Risk Factors
- ↑ Age
- Female sex
- Diabetes Mellitus
- Atrial fibrillation
HFpEF is predominant in older adults
Etiology
- Ischemia, Previous MI
- Left Ventricular Hypertrophy
- Cardiomyopathy
o Hypertrophic
o Infiltrative
o Restrictive
- Hypothyroidism
- Increasing prevalence worldwide due to
aging population  overtaking HFrEF as
most common form of HF
Comparable morbidity & mortality
rates with HFrEF
Pathophysiology
- Impaired relaxation
- ↑ in passive stiffness
LV dysfunction
-
1st exclude LV dysfunction
2nd exclude thyroid issues (e.g. hypothyroidism), electrolyte derangements, infection
Diagnosis of exclusion: Non-ischemic dilated CMP
o Significant family history
No therapies have been shown to
improve the outcome of HFpEF
No mortality/hospitalization benefit
to ACE-I/ARB
Congestive Cardiac Failure
Heart Failure is a clinical diagnosis that is based upon a careful history and physical examination
Modified Framingham clinical criteria for the diagnosis of heart failure
Major Criteria
Minor Criteria
(only considered if they cannot be attributed to another
medical condition, e.g. pulmonary hypertension, chronic
lung disease, cirrhosis, ascites, or nephrotic syndrome)
Symptoms
(History)
Signs
(Physical
Examination)
Chest X-Ray
- Paroxysmal Nocturnal Dyspnea
- Orthopnea
- Weight loss >4.5kg in 5 days in response to
treatment
- Third Heart Sound
- Elevated JVP
- Pulmonary crepitation/rales
- Exertional Dyspnea
-
Tachycardia (>120/min)
Nocturnal cough
Pleural effusion
Hepatomegaly
Bilateral Ankle Edema
- Cardiomegaly on CXR
- Pulmonary Edema on CXR
Diagnosis of CCF requires the presence of at least 2 major criteria, or 1 major + 2minor criteria
European Society of Cardiology Guidelines
NYHA Classification:
-
Class I: Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, dyspnea, or anginal pain
Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical
activity results in fatigue, palpitation, dyspnea, or anginal pain
Class III: Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary
physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac
insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.