HEART FAILURE

Definition: A state in which the heart cannot provide sufficient cardiac output to satisfy the metabolic needs of the body 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 Volume over load: Regurgitate valve High output status High output status Pressure overload: Systemic hypertension Outflow obstruction Outflow obstruction Loss of muscles: Post MI, Chronic ischemia Loss of muscles: Post MI, Chronic ischemia Connective tissue diseases Connective tissue diseases Infection, Poisons (alcohol,cobalt,Doxorubicin) Infection, Poisons (alcohol,cobalt,Doxorubicin) Restricted Filling: Pericardial diseases, Restrictive cardiomyopathy, tachyarrhythmia cardiomyopathy, tachyarrhythmia

Classification of heart failure

Pathophysiology Hemodynamic changes Hemodynamic changes Neurohormonal changes Neurohormonal changes Cellular changes Cellular changes

Hemodynamic changes systolic dysfunction systolic dysfunction diastolic dysfunction diastolic dysfunction

Neurohormonal changes N/H changes Favorable effect Unfavor. effect  Sympathetic activity  Sympathetic activity  HR,  contractility, vasoconst.   V return, vasoconst.   V return,  filling  filling Arteriolar constriction  After load  workload  O 2 consumption  Renin-Angiotensin –  Renin-Angiotensin – Aldosterone Aldosterone Salt & water retention  VR Vasoconstriction   after load  Vasopressin  Vasopressin Same effect  interleukins &TNF   interleukins &TNF  May have roles in myocyte hypertrophy Apoptosis  Endothelin  Endothelin Vasoconstriction  VR  After load

Cellular changes  Changes in Ca +2 handling.  Changes in adrenergic receptors: Slight  in α 1 receptors Slight  in α 1 receptors β 1 receptors desensitization  followed by down regulation β 1 receptors desensitization  followed by down regulation  Changes in contractile proteins  Changes in contractile proteins  Program cell death ( Apoptosis )  Program cell death ( Apoptosis )  Increase amount of fibrous tissue  Increase amount of fibrous tissue

Symptoms SOB, Orthopnea, PND, cough with frothy sputum SOB, Orthopnea, PND, cough with frothy sputum Low cardiac output symptoms Low cardiac output symptoms Abdominal symptoms: Anorexia, nausea, Abdominal symptoms: Anorexia, nausea, abdominal fullness, abdominal fullness, Rt hypochondrial pain Rt hypochondrial pain

NYHA Classification of heart failure Class I: No limitation of physical activity Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class III: Marked limitation of physical activity Class IV: Unable to carry out physical activity without discomfort Class IV: Unable to carry out physical activity without discomfort

Physical Signs High diastolic BP & occasional decrease in systolic BP (decapitated BP) High diastolic BP & occasional decrease in systolic BP (decapitated BP) JVP JVP Rales (Inspiratory) Rales (Inspiratory) Displaced and sustained apical impulses Displaced and sustained apical impulses Third heart sound – low pitched sound that is heard Third heart sound – low pitched sound that is heard during rapid filling of ventricle. during rapid filling of ventricle. Fourth heart Sound (S 4 ) Usually at the end of diastole Fourth heart Sound (S 4 ) Usually at the end of diastole Pale, cold sweaty skin

Framingham Criteria for Dx of Heart Failure Major Criteria: Major Criteria: PND PND JVP JVP Rales Rales Cardiomegaly Cardiomegaly Acute Pulmonary Edema Acute Pulmonary Edema S 3 Gallop S 3 Gallop Positive hepatic Jugular reflex Positive hepatic Jugular reflex ↑ venous pressure > 16 cm H 2 O ↑ venous pressure > 16 cm H 2 O

Dx of Heart Failure (cont.) Minor Criteria Minor Criteria Lower Limb edema, Lower Limb edema, Night cough Night cough Dyspnea on exertion Dyspnea on exertion Hepatomegaly Hepatomegaly Pleural effusion Pleural effusion ↓ vital capacity by 1/3 of normal ↓ vital capacity by 1/3 of normal Tachycardia 120 bpm Tachycardia 120 bpm Weight loss 4.5 kg over 5 days management Weight loss 4.5 kg over 5 days management

Forms of Heart Failure Systolic & Diastolic Systolic & Diastolic High Output Failure High Output Failure Pregnancy, anemia, thyrotoxisis, A/V fistula, Beriberi, Pagets disease Pregnancy, anemia, thyrotoxisis, A/V fistula, Beriberi, Pagets disease Low Output Failure Low Output Failure Acute Acute large MI, aortic valve dysfunction--- large MI, aortic valve dysfunction--- Chronic Chronic

Forms of heart failure ( cont.) Right vs Left sided heart failure: Right vs Left sided heart failure: Right sided heart failure : Right sided heart failure : Most common cause is left sided failure Most common cause is left sided failure Other causes included : Pulmonary embolisms, pulmonary hen, Other causes included : Pulmonary embolisms, pulmonary hen, RV infarction's RV infarction's Usually presents with: LL edema, ascites, hepatic congestion cardiac cirrhosis (on the long run ) cardiac cirrhosis (on the long run )

Differential diagnosis Pericardial diseases Pericardial diseases Liver diseases Liver diseases Nephrotic syndrome Nephrotic syndrome Protein losing enteropathy Protein losing enteropathy

Laboratory Findings Anemia Anemia Hyperthyroid Hyperthyroid Chronic renal insuffiency, electrolytes abnormality Chronic renal insuffiency, electrolytes abnormality Pre-renal azotemia Pre-renal azotemia Hemochromatosis Hemochromatosis

Electrocardiogram Old MI or recent MI Old MI or recent MI Arrhythmia Arrhythmia Some forms of Cardiomyopathy are tachycardia related Some forms of Cardiomyopathy are tachycardia related LBBB→ may help in management LBBB→ may help in management

ECG showing Entopic

ECG showing LVH

Chest X-ray Size and shape of heart Size and shape of heart Evidence of pulmonary venous congestion (dilated or upper lobe veins → perivascular edema) Evidence of pulmonary venous congestion (dilated or upper lobe veins → perivascular edema) Pleural effusion Pleural effusion

Fluid in transverse fissure cardiomegaly B/L hilar congestion Upper lobe diversion Chest X-Ray

Echocardiogram Function of both ventricles Function of both ventricles Wall motion abnormality that may signify CAD Wall motion abnormality that may signify CAD Valvular abnormality Valvular abnormality Intra-cardiac shunts Intra-cardiac shunts

Cardiac Catheterization When CAD or valvular is suspected When CAD or valvular is suspected If heart transplant is indicated If heart transplant is indicated

TREATMENT Correction of reversible causes Correction of reversible causes Ischemia Ischemia Valvular heart disease Valvular heart disease Thyrotoxicosis and other high output status Thyrotoxicosis and other high output status Shunts Shunts Arrhythmia Arrhythmia A fib, flutter, PJRT A fib, flutter, PJRT Medications Medications Ca channel blockers, some antiarrhythmics Ca channel blockers, some antiarrhythmics

Diet and Activity Salt restriction Salt restriction Fluid restriction Fluid restriction Daily weight (tailor therapy) Daily weight (tailor therapy) Gradual exertion programs Gradual exertion programs

Diuretic Therapy The most effective symptomatic relief The most effective symptomatic relief Mild symptoms Mild symptoms HCTZ, Chlorthalidone, Metolazone HCTZ, Chlorthalidone, Metolazone More severe heart failure → loop diuretics More severe heart failure → loop diuretics Lasix (20 – 320 mg QD), Bumex (Bumetanide 1- 8mg),Torsemide (20-200mg) Lasix (20 – 320 mg QD), Bumex (Bumetanide 1- 8mg),Torsemide (20-200mg)

K + Sparing Agents Triamterene & amiloride – acts on distal tubules to ↓ K secretion Triamterene & amiloride – acts on distal tubules to ↓ K secretion Spironolactone (Aldosterone inhibitor) 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 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 They block the R-A-A system and ↓ Bradykinin degradation They block the R-A-A system and ↓ Bradykinin degradation Delay onset & progression of HF in pts with asymptomatic LV dysfunction Delay onset & progression of HF in pts with asymptomatic LV dysfunction ↓ cardiac remodeling ↓ cardiac remodeling Angiotensin II receptor blockers Angiotensin II receptor blockers Can be used in certain conditions when ACE I are contraindicated (angioneurotic edema, cough) Can be used in certain conditions when ACE I are contraindicated (angioneurotic edema, cough)

Side effects of ACE inhibitors Angioedema Angioedema Hypotension Hypotension Renal insuffiency Renal insuffiency Rash Rash cough cough

Digitalis (cont.) Mechanism of Action +ve inotropic effect +ve inotropic effect Vagotonic effect Vagotonic effect Arrhythmogenic effect Arrhythmogenic effect Digitalis Toxicity Digitalis Toxicity Anorexia,Nausea, vomiting, Headache, Xanthopsia scotoma, Disorientation Anorexia,Nausea, vomiting, Headache, Xanthopsia scotoma, Disorientation

Digitalis Toxicity Cardiac manifestations Cardiac manifestations Sinus bradycardia and arrest Sinus bradycardia and arrest A/V block (usually 2 nd degree) A/V block (usually 2 nd degree) Atrial tachycardia with A/V Block Atrial tachycardia with A/V Block Development of junctional rhythm in patients with a fib Development of junctional rhythm in patients with a fib PVC’s, VT/ V fib (bi-directional VT) PVC’s, VT/ V fib (bi-directional VT)

β Blockers Has been traditionally contraindicated in pts with CHF In addition to improved LV function multiple studies show improved survival The only contraindication is severe decompensated CHF

Vasodilators Reduction of afterload By arteriolar vasodilatation hydralazin Reduction of afterload By arteriolar vasodilatation hydralazin Reduction of preload By venous dilation Reduction of preload By venous dilation Nitrates Nitrates

Positive inotropic agents β adrenergic agonists, dopaminergic agents β adrenergic agonists, dopaminergic agents dopamine, dobutamine, milrinone, amrinone dopamine, dobutamine, milrinone, amrinone Several studies showed ↑ mortality with oral inotropic agents Several studies showed ↑ mortality with oral inotropic agents So the only use for them now is in acute sittings as cardiogenic shock So the only use for them now is in acute sittings as cardiogenic shock

New Methods Implantable ventricular assist devices Implantable ventricular assist devices Biventricular pacing (only in patient with LBBB & CHF) Biventricular pacing (only in patient with LBBB & CHF) Artificial Heart Artificial Heart

Cardiac Transplant It has become more widely used since the advances in immunosuppressive treatment It has become more widely used since the advances in immunosuppressive treatment Survival rate Survival rate 1 year 80% - 90% 1 year 80% - 90% 5 years 70% 5 years 70%

Prognosis Annual mortality rate depends on patients symptoms and LV function Annual mortality rate depends on patients symptoms and LV function 5% in patients with mild symptoms and mild ↓ in 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 30% to 50% in patient with advances LV dysfunction and severe symptoms 40% – 50% of death is due to SCD 40% – 50% of death is due to SCD

Learning strategies Student should be able to Student should be able to Differentiate b/w Rt and Lt sided heart failure Differentiate b/w Rt and Lt sided heart failure Identify the clinical features of heart failure Identify the clinical features of heart failure Pick up the abnormailities on investigations Pick up the abnormailities on investigations Know emergency and long term treatment plan Know emergency and long term treatment plan

Psychomotor skills Student should Student should Demonstrate method of looking at raised JVP Demonstrate method of looking at raised JVP Look for chest and CVS abnormalities Look for chest and CVS abnormalities Identify the risk factor by history taking and examining the patient Identify the risk factor by history taking and examining the patient

MCQ 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. 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 a, b, c, and e. a, b, c, and e.

CASE SCENARIO 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. 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. What is your clinical impression ? What is your clinical impression ?

CASE SCENARIO On physical exam she has elevated jugular venous pressure and peripheral edema as well as tachycardia without a third heart sound. On physical exam she has elevated jugular venous pressure and peripheral edema as well as tachycardia without a third heart sound. 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. 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 WHAT ARE THE DIFFENETIAL DIAGNOSIS ? WHAT ARE THE DIFFENETIAL DIAGNOSIS ? HOW WILL YOU MANAGE THIS CASE ? HOW WILL YOU MANAGE THIS CASE ?

CASE SCENARIO 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. 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 In this case,in light of lack of clinical risk facors,ischemic cardiomyopathy is very unlikely. In this case,in light of lack of clinical risk facors,ischemic cardiomyopathy is very unlikely. 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. 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. Although sinus tachycardia is common in this patient population, ventricular tachycardia is rare. Although sinus tachycardia is common in this patient population, ventricular tachycardia is rare.

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