By:Dawit Ayele(MD,Internist)

 “Heart (or cardiac) failure is the pathophysiological state in which  the heart is unable to pump blood at a rate commensurate with  the requirements of the metabolizing tissues or can do so only  from an elevated filling pressure.”  - Eugene Braunwald  “Congestive heart failure (CHF) represents a complex clinical  syndrome characterized by abnormalities of left ventricular  function and neurohormonal regulation, which are accompanied  by effort intolerance, fluid retention, and reduced longevity”  - Milton Packer

Burden of CHF is staggering 5 million in US (1.5% of all adults) 500,000 cases annually In the elderly 6-10% prevalence 80% hospitalized with HF 250,000 death/year attributable to CHF $38 billion (5.4% of healthcare cost)

◦ Coronary artery disease- ◦ HTN--both ◦ Valvular heart disease (especially aorta and mitral disease)--chronic ◦ Congenital ◦ Alcohol-- ◦ Diabetes— ◦ Cardiomyopathies

 Infection  Arrhythmia  Physical,Fluid,Dietary,Env’tal,Emotional excess  MI  Anemia  Pulmonary embolism  Worsening of HTN  Thyrotoxicosis  Infective endocarditis  Rheumatic,viral or other myocarditis..

 SYSTOLIC VERSUS DIASTOLIC FAILURE  LOW-OUTPUT VERSUS HIGH-OUTPUT HEART FAILURE  ACUTE VERSUS CHRONIC HEART FAILURE  RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE  BACKWARD VERSUS FORWARD HEART FAILURE

 1. Syndrome of decrease exercise tolerance  2. Syndrome of fluid retention  3. No symptoms but incidental discovery of LV  dysfunction

 Major Criteria  Orthopnea/PND  Venous distension  Rales  Cardiomegaly  Acute pulm edema  Elevated JVP  HJR  Circ time >25s  Minor Criteria  Ankle edema  Night cough  Exertional dyspnea  Hepatomegaly  Pleural effusion  Tachycardia (>120)  Decrease VC  Weight loss with CHF tx  Framingham Criteria

 Class I: Symptoms with more than ordinary activity  Class II: Symptoms with ordinary activity  Class III: Symptoms with minimal activity  Class IIIa: No dyspnea at rest  Class IIIb: Recent dyspnea at rest  Class IV: Symptoms at rest

At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of HF STAGE D End-stage HF

Designed to emphasize preventability of HF Designed to recognize the progressive nature of LV dysfunction

◦ COMPLEMENT, DO NOT REPLACE NYHA CLASSES NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) Stages - progress in one direction due to cardiac remodeling

◦ Occurs when the left ventricle fails as an effective forward pump ◦  back pressure of blood into the pulmonary circulation ◦  pulmonary edema ◦ Cannot eject all of the blood delivered from the right heart. ◦ Left atrial pressure rises  increased pressure in the pulmonary veins and capillaries ◦ When pressure becomes too high, the fluid portion of the blood is forced into the alveoli. ◦  decreased oxygenation capacity of the lungs ◦ AMI common with LVF, suspect

◦ Severe resp. distress–  Evidenced by orthopnea, dyspnea  Hx of paroxysmal nocturnal dyspnea. ◦ Severe apprehension, agitation, confusion—  Resulting from hypoxia  Feels like he/she is smothering ◦ Cyanosis— ◦ Diaphoresis—  Results from sympathetic stimulation ◦ Pulmonary congestion  Often present  Rales—especially at the bases.  Rhonchi—associated with fluid in the larger airways indicative of severe failure  Wheezes—response to airway spasm

◦ Jugular Venous Distention— not directly related to LVF.  Comes from back pressure building from right heart into venous circulation ◦ Vital Signs—  Significant increase in sympathetic discharge to compensate.  BP—elevated  Pulse rate—elevated to compensate for decreased stroke volume.  Respirations—rapid and labored

◦ Neurohormonal system ◦ Renin-angiotensin-aldosterone system ◦ Ventricular hypertrophy

Myocardial Disease LV DysfunctionImpedance VasoconstrictionNeurohormonal Activation LV Remodeling Vascular Remodeling Preload Renal Blood Flow Na Retention

◦ Decreased renal blood flow secondary to low cardiac output triggers renin secretion by the kidneys  Aldosterone is released  increase in Na+ retention  water retention  Preload increases  Worsening failure

◦ Long term compensatory mechanism ◦ Increases in size due to increase in work load ie skeletal muscle

 Principles:thorough Hx & P/E  Supplemental investigations especially:BNP,ECG,Echocardiography,CXR  Management:(1) general measures; (2) correction of the underlying cause; (3) removal of the precipitating cause; (4) prevention of deterioration of cardiac function; and (5) control of the congestive HF state

Control Volume Slow Disease Progression Diuretic RAAS Inhibition RAAS Inhibition Beta-Blockade Treat residual symptoms Treat residual symptoms DIGOXIN + SPIRONOLACTONE Am J Cardiol 1999;83(suppl 2A):9A-38A