Congestive heart failure Dr/Rehab Gwada

Objectives – Define Congestive Heart Failure. – Outlines the Factors Affecting Cardiac Output – Discuses the Causes and pathophysiology – differentiate between Types of heart failure – Identify Clinical manifestations – outlines Classification of heart failure – identify Diagnostic evaluation – Explain the management

What is the Congestive Heart Failure – Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs – Not a disease but a “syndrome” – Caused by long-standing HTN and CAD – The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and other changes that may further weaken the heart. – Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs – Not a disease but a “syndrome” – Caused by long-standing HTN and CAD – The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and other changes that may further weaken the heart.

Factors Affecting Cardiac Output Cardiac Output Preload AfterloadContractility Heart RateStroke Volume = X

Factors Affecting Cardiac Output 1)Heart Rate 2)Preload The volume of blood/amount of fiber stretch in the ventricles at the end of diastole (i.e., before the next contraction) It is affected by venous blood pressure and the rate of venous return. Preload increases as vasoconstriction, and fluid volume increase. 3)Afterload The resistance against which the ventricle must pump. Excessive afterload = difficult to pump blood → reduced CO/SV Factors that increase afterload include: aortic and pulumonary stenosis, systemic & pulmonary HTN, vasoconstriction. 4)Contractility – Ability of the heart muscle to contract; relates to the strength of contraction. – Infarctions, Ischemic tissue decreases contractility.

Pathophysiology of CHF Pump fails → decreased stroke volume /CO. Compensatory mechanisms kick in to increase CO 1. SNS stimulation → release of epinephrine/nor- epinephrine 1.Increase HR 2.Increase contractility 3.Peripheral vasoconstriction (increases afterload) 2.Myocardial hypertrophy: walls of heart thicken to provide more muscle mass → stronger contractions

Pathophysiology of CHF 3. Hormonal response: ↓ renal perfusion Thus: Kidneys release renin, which stimulates conversion of angiotensin I → angiotensin II, which causes: 1.Aldosterone release → Na and water retention 2.Peripheral vasoconstriction.

Pathophysiology of CHF Compensatory mechanisms may restore CO to near-normal. But, excessive the compensatory mechanisms can worsen heart failure. Why?.

Pathophysiology of CHF 1.Vasoconstriction: ↑ the resistance against which heart has to pump (i.e., ↑ afterload), and therefore ↓ CO 2.Na and water retention: ↑ fluid volume, which ↑ preload. If too much “stretch” (too much fluid) → ↓ strength of contraction and ↓ CO (Starling’s Law ) 3.Excessive tachycardia → ↓ diastolic filling time → ↓ ventricular filling → ↓ SV and CO

Causes of congestive heart failure Coronary artery disease High blood pressure vasoconstriction causes a higher pressure which causes CHF when hypertrophy from working too hard, because the heart tires out. Heart valves disorders The valves don't close properly allowing regurgitation. Inflammation of Heart muscle (myocarditis, cardiomyopathy) Heart attack(MI as it changes the functioning of the heart).

Causes of congestive heart failure (cont … ) Severe lung disease ( pulmonary hypertension) Severe anemia Overactive thyroid gland (hyperthyroidism) Underactive thyroid gland (hypothyroidism) Abnormal heart rhythms ( atrial fibrillation) Atrial fibrillation (usually an electrical problem) the blood is not going into the ventricles properly. Kidney failure

Congestive heart failure Types Left-sided heart failure There are two types of left-sided heart failure Systolic dysfunction Diastolic dysfunction Right-sided heart failure

Congestive Heart Failure Types of Congestive Heart Failure Left-sided failure – Most common form – Blood backs up through the left atrium into the pulmonary veins Pulmonary congestion and edema – Eventually leads to biventricular failure Left-sided failure – Most common form – Blood backs up through the left atrium into the pulmonary veins Pulmonary congestion and edema – Eventually leads to biventricular failure

Cont. Right-sided failure – Blood backs up into right atrium and venous circulation – Venous congestion Peripheral edema Hepatomegaly Splenomegaly Jugular venous distension Right-sided failure – Blood backs up into right atrium and venous circulation – Venous congestion Peripheral edema Hepatomegaly Splenomegaly Jugular venous distension

Chronic Congestive heart failure Clinical manifestations – Symptoms – Dyspnea – Paroxysmal nocturnal dyspnea (PND) – Orthopnea – Reduced exercise tolerance, lethargy, fatigue – Nocturnal cough – Ankle swelling – Anorexia

Chronic Congestive heart failure Clinical manifestations ( cont … ) – Signs – Cachexia and muscle wasting – Tachycardia – Pulsus alternans – Elevated jugular venous pressure – Crepitations – Third heart sound – Lower extremity edema – Hepatomegaly (tender) – Ascites

Congestive heart failure Diagnostic evaluation Patient history Physical examination Diagnostic tests 1.Electrocardiography 2.Echocardiography(ejection fraction) 3.Chest x-ray 4.Blood tests 5.Radionuclide 6. magnetic resonance 7.computed tomography imaging 8.cardiac catheterization with angiography 9.a biopsy of heart muscle is needed

Management Strategies for Congestive heart failure CHF Medication Cardiac rehabilitation Lifestyle changes exercises surgery

Congestive heart failure Treatment lifestyle change 1.Salt restriction 2.Exercises 3.Smoking and alcoholism cessation. 4.Body overweight (daily weight) 5.Elevate the feet and legs if they are swollen. 6.Avoid Excessive emotional stress and/or depression 7.Control HTN & cholesterol level 8.Control Diabetes. As,Diabetes deteriorates blood vessel walls because glucose causing the walls to be sticky.

Congestive heart failure Treatment Medication: Diuretics Inotropic drugs Vasodilators  -Adrenergic blockers Opioids ACE inhibitors Cardiac rehabilitation (this program can monitor a person's exercise capacity).

(surgical intervention) Percutaneous coronary intervention (Angioplasty) Coronary artery bypass grafting ( revascularization) Valve replacement Biventricular pacemaker Heart transplantation Congestive heart failure Treatment (cont … )

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