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Heart Failure Internal Medicine Workshop Series Laos September /October 2009 Definition • Heart cannot pump enough blood to meet body’s needs • Heart is too weak or too stiff to fill and pump properly How does it affect our patients? • Decreases quality of life • Decreases activity level • Decreases survival – Annual mortality of 5% -50% Types of heart failure • Chronic – A long term condition with signs and symptoms that persist • Acute – An emergency situation that occurs when something affects your heart’s ability to function • acute myocardial infarction • acute arrhythmia Types of heart failure • Left sided – Fluid backs up into lungs • Right sided – Often occurs with left sided heart failure – Fluid backs up into abdomen, legs and feet • Systolic – Ventricle cannot contract properly, poor pumping • Diastolic – Ventricle cannot relax properly, poor filling Systolic Diastolic heart failure Causes of heart failure • Develops after other diseases damage or weaken the heart • The ventricles become weak, dilated and do not pump blood efficiently through the body (systolic failure) • The ventricles become stiff and do not fill well between heartbeats (diastolic failure) Causes of heart failure • Coronary artery disease and myocardial infarction – Ischemia to heart muscle • Hypertension – Heart muscle must work harder • Valvular heart disease – Damaged valves causes heart to work harder Causes of heart failure • Cardiomyopathy – Damage to heart muscle from infection, alcohol, drugs, thyrotoxicosis, lupus, or idiopathic (no cause found) • Myocarditis – Inflammation to heart muscle from viral infection or autoimmune disease • Congenital heart defects – Healthy parts work harder Causes of heart failure • Arrhythmia – Heart muscle must work harder • Other diseases – e.g. diabetes, thyroid disease, severe anemia, emphysema cause chronic heart failure – e.g. severe sepsis, pulmonary embolism, allergic reactions cause acute heart failure Clinical presentation left sided • All related to pulmonary congestion – Dyspnea – Orthopnea – Paroxysmal nocturnal dyspnea – Cough – Fatigue – Weakness Clinical presentation right sided • • • • Peripheral edema Abdominal distention Weight gain Nocturia Cardiac findings Systolic dysfunction • Tachycardia • Hypotension • S3 • Apical impulse is more lateral, and lasts longer • Left ventricular lift • Elevated jugular venous pulse Diastolic dysfunction • Tachycardia • Hypertension • S4 • Apical impulse is in proper position, but lasts longer • Left ventricular lift • Elevated jugular venous pulse New York Heart Association functional classification Class I II III IV Definition No symptoms Symptoms with ordinary activity Symptoms with less than ordinary activity Symptoms at rest or with any minimal activity Drugs DRUG Mechanism of action For patient Angiotensin Dilates blood vessels converting enzyme Decreases blood pressure (ACE) inhibitors Improves blood flow Decreases work of heart Live longer Feel better Angiotension II receptor blockers (ARBs) Same as ACE inhibitor Live longer Feel better Beta Blockers Slows heart rate Decreases blood pressure Live longer Feel better Drugs DRUG Mechanism of action For patient Digoxin Increase heart muscle contraction Feel better Slows heartbeat Diuretics Increases urination Prevents fluid accumulation Feel better Hydralazine Dilates blood vessels and nitrates Feel better Aldosterone Reverses scarring of heart antagonist Prevents fluid accumulation Feel better Live longer Treatment all patients • • • • • • • • Educate patient Cardiovascular risk reduction Lifestyle modification (exercise, decrease stress) Limit salt (1-3 gms daily) Limit fluid (1.5-2 litres daily) Limit alcohol Treat cause (ie hypertension, ischemia) Diuretic therapy Treatment if NYHA II • Add angiotensin converting enzyme (ACE) inhibitor • Add beta blocker Treatment if NYHA III-IV • • • • Add ARB (angiotension receptor blocker) Add digoxin Add hydralazine and nitrates Add spironolactone 3 cases • • • • • • Is the heart failure chronic or acute? Is it mostly right sided or left sided? Is it systolic or diastolic? What is the cause? What is the NYHA classification? How should we treat now? Case number 1 • 55 year old male with known coronary artery disease, previous myocardial infarction and previous admission for heart failure • Discharged from hospital two weeks ago on angiotension converting enzyme inhibitor and furosemide • Returns with mild dyspnea when walking, and orthopnea • Exam shows S3, tachycardia, elevated JVP Case number 2 • 45 year old woman with no known heart disease • Had hypertension during both pregnancies • Has symptoms of dyspnea for 3 months when doing housework • Has BP 170/70, heart rate of 100, elevated JVP, S4, few crackles in lungs, and mild peripheral edema Case number 3 • 40 year old male with no heart disease previous • Drinks a lot of alcohol and has poor nutrition • Presents to hospital severely short of breath and cyanotic • Has crackles in lungs, elevated JVP, S3, abdominal distention and peripheral edema • Treated in ED with furosemide and nitrates, now better