DIFFERENTIATE: 1. HIGH AND LOW OUTPUT FAILURE RIGHT AND LEFT SIDED HEART FAILURE SYSTOLIC FROM DIASTOLIC DYSFUNCTION Question 9

Output Failure Low Output Failure Due to high systemic vascular resistance – Coronary artery disease MI, Ischemia – Chronic pressure overload HPN, Obstructive Valvular Disease – Chronic volume overload Regurgitant Valvular Disease, L-R shunt, Extracardiac shunting – Non-ischemic dilated cardiomyopathy Viral disease – Disorders of rate and rhythm brady/ tachyarrhythmia High Output Failure Due to low systemic vascular resistance – Metabolic disorders Thyrotoxicosis, Nutritional Disorders (Beri-beri) – Excessive blood-flow requirements Anemia, Pregnancy, AV fistula

Symptoms based on Sided of Failure Right-Sided Edema (Feet and sacral area) Nocturia Ascites Hepatomegaly – Jaundice, coagulopathy Systemic venous distention Left-Sided Aortic regurgitation (ventricle hemodynamically overloaded) Dyspnea, orthopnea, PND, (pulmonary congestion)

Signs based on Side of Failure Right-Sided Pitting edema Ascites Hepatomegaly Increased JVP Parasternal heave Left-Sided Tachypnea or increase WOB Rales or crackles Pulmonary edema Cyanosis Laterally displaced apex beat Gallop rhythm Heart murmurs (AS or MR)

Dysfunction Systolic Impaired contraction – Inadequate cardiac output: weakness, fatigue, reduced exercise tolerance Diastolic Impaired relaxation (EF >50%) – Elevated filling pressure/ volume overload: elevated JVP – Increase in pulmonary capillary pressure : Dyspnea Index eventActivation of neuro- hormonal systems Sustained neuro- hormonal activation: impaired contraction IschemiaReduced ATP: Slowed myocardial relaxation LV filling is delayed because LV compliance is reduced