HEART FAILURE

definition DEF : inability of the heart to maintain adequate cardiac output to meet the body demands. a decrease in pumping ability of the heart with a consequent decrease in the cardiac reserve and the adaptive mechanisms that serve to maintain the cardiac output while also contributing to the progression of heart failure. cardiac reserve : The ability to increase cardiac output during increased activity.

ETIOLOGY

Left sided heart failure Volume overload : 1.Aortic regurgitation. 2.Mitral regurgitation. 3.Patent ductus arteriosus. Pressure overload : 1.Systemic hypertension. 2.Aortic stenosis. myocardial diseases : 1.Ischemic heart disease. 2.Dilated cardiomyopathy.

Right sided heart failure Volume overload : 1.Atrial septal defect. 2.Tricuspid regurgitation. Pressure overload : 1.Pulmonary hypertension. 2.Pulmonary stenosis. Myocardial diseases : 1.Cardiomyopathy secondary to left ventricular failure.

FEATURE OF LEFT HEART FAILURE

SYMPTOMS

Features of left heart failure Symptoms :- 1.Dyspnea. 2. Symptoms due to reduced cardiac output. 3.Nocturia. 4.Chronic cough.

dyspnea Patient initially presents with EXERTIONAL DYSPNEA ORTHOPNEA PAROXYSMAL NOCTURNAL DYSPNEA DYSPNEA AT REST

Pathophysiology

EXERTIONAL DYSPNEA Exertion lead to increased venous return and relative normal right heart transmits this in pulmonary circulation. In the presence of LHF blood is not properly pumped to the systemic circulation, resulting in damming of blood in pulmonary veins, producing pulmonary venous congestion. This congestion stimulate fine nerve endings around the terminal alveoli which produce a sensation of breathlessness. When exercise is stopped, venous return is diminished, congestion subsides and dyspnea is relieved.

ORTHOPNEA It means breathlessness on lying flat. Approximately ½ liter of blood pooled in the leg veins during standing is returned to effective circulation. In this way venous return is increased. The workload on the heart becomes increased which already has poor function, therefore lung congestion and dyspnea develop. The effect of hydrostatic pressure is lost on lying flat.

PAROXYSMAL NOCTURNAL DYSPNEA It means episode of breathlessness at night during sleep. Redistribution of fluid. The effect of hydrostatic pressure is lost. Depression of nervous system during sleep leads to reduced awareness of pulmonary congestion. The patient awake up with intense breathlessness, which often produces feeling of suffocation. The patient sits upright and opens window in the hope that the cool fresh air will ease his breathing.

Symptoms due to reduced cardiac out put Fatigue. Weakness. It is due to reduced blood flow to skeletal muscles and the CNS.

OTHER SYMPTOMS Nocturia. Chronic cough.

On examination

INSPECTION :- Bulging precordium if there is left venticular hypertrophy. PALPATION :- Apex beat is displaced and heaving in character. AUSCULTATION :- Gallop rhythm : tachycardia with S₃ or S₄. Basal crepitations are heard and rhonchi. Loud P₂ may be heard : pulmonary hypertension.

FEATURES OF RIGHT HEART FAILURE

SYMPTOMS

TISSUE CONGESTION : it results from inability of the heart to empty properly, showing the following features. CEREBRAL :headache, insomnia, restlessness. PULMONARY : cough, dyspnea. PORTAL : anorexia, nausea and vomiting. PAIN IN RIGHT HYPOCHONDRIUM. RENAL : oliguria and nocturia. PERIPHERAL : edema of feet and sacrum.

ON EXAMINATION

1.Tachycardia. 2.Raised JVP. 3.Pitting peripheral edema. 4.Tender smooth hepatomegaly. 5.Ascites and signs of pleural effusion.

INVESTIGATION

1.ECG : R and L ventricular hypertrophy. Myocardial ischemia or infarction. Arrhythmia. 2.X-ray chest : bat’s wings appearance in acute pulmonary edema. Cardiomegaly. Pleural effussion. 3.ECHOCARDIOGRAPHY : To detect the cause.

bat’s wings appearance in acute pulmonary edema

TREATMENT

TREATMENT STRATEGY Correction of underlying cause as valvular heart disease. Removal of precipitating cause such as pneumonia. Control of congestive heart failure.

Control of heart failure GENERAL MEATURES : 1.Rest. 2.Diet : low salt, good general nutrition, weight reduction. 3.Stop smoking. 4.Exercise. 5.Vaccination : influenza and pneumococcal.

DRUG MANAGEMENT Diuretics. Dilators. Digitalis.

DIURETICS Loop diuretics : frusemide ( lasix). Potassium sparing diuretics : spironolactone. Thiazide diuretics : metalazone.

VASODILATORS ACE inhibitors. Angiotensin II receptor antagonists. Hydralazine. Nitrates. Nesiritide.

DIGITALIS Digoxin.

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