Internal Medicine Workshop Series Laos September /October 2009 Heart Failure Internal Medicine Workshop Series Laos September /October 2009

Definition Heart cannot pump enough blood to meet body’s needs Heart is too weak or too stiff to fill and pump properly

How does it affect our patients? Decreases quality of life Decreases activity level Decreases survival Annual mortality of 5% -50%

Types of heart failure Chronic Acute A long term condition with signs and symptoms that persist Acute An emergency situation that occurs when something affects your heart’s ability to function acute myocardial infarction acute arrhythmia

Types of heart failure Left sided Right sided Systolic Diastolic Fluid backs up into lungs Right sided Often occurs with left sided heart failure Fluid backs up into abdomen, legs and feet Systolic Ventricle cannot contract properly, poor pumping Diastolic Ventricle cannot relax properly, poor filling

Systolic

Diastolic heart failure

Causes of heart failure Develops after other diseases damage or weaken the heart The ventricles become weak, dilated and do not pump blood efficiently through the body (systolic failure) The ventricles become stiff and do not fill well between heartbeats (diastolic failure)

Causes of heart failure Coronary artery disease and myocardial infarction Ischemia to heart muscle Hypertension Heart muscle must work harder Valvular heart disease Damaged valves causes heart to work harder

Causes of heart failure Cardiomyopathy Damage to heart muscle from infection, alcohol, drugs, thyrotoxicosis, lupus, or idiopathic (no cause found) Myocarditis Inflammation to heart muscle from viral infection or autoimmune disease Congenital heart defects Healthy parts work harder

Causes of heart failure Arrhythmia Heart muscle must work harder Other diseases e.g. diabetes, thyroid disease, severe anemia, emphysema cause chronic heart failure e.g. severe sepsis, pulmonary embolism, allergic reactions cause acute heart failure

Clinical presentation left sided All related to pulmonary congestion Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Cough Fatigue Weakness

Clinical presentation right sided Peripheral edema Abdominal distention Weight gain Nocturia

Cardiac findings Systolic dysfunction Diastolic dysfunction Tachycardia Hypotension S3 Apical impulse is more lateral, and lasts longer Left ventricular lift Elevated jugular venous pulse Tachycardia Hypertension S4 Apical impulse is in proper position, but lasts longer Left ventricular lift Elevated jugular venous pulse

New York Heart Association functional classification Class Definition I No symptoms II Symptoms with ordinary activity III Symptoms with less than ordinary activity IV Symptoms at rest or with any minimal activity

Drugs DRUG Mechanism of action For patient Angiotensin converting enzyme (ACE) inhibitors Dilates blood vessels Decreases blood pressure Improves blood flow Decreases work of heart Live longer Feel better Angiotension II receptor blockers (ARBs) Same as ACE inhibitor Beta Blockers Slows heart rate

Drugs DRUG Mechanism of action For patient Digoxin Increase heart muscle contraction Slows heartbeat Feel better Diuretics Increases urination Prevents fluid accumulation Hydralazine and nitrates Dilates blood vessels Aldosterone antagonist Reverses scarring of heart Live longer

Treatment all patients Educate patient Cardiovascular risk reduction Lifestyle modification (exercise, decrease stress) Limit salt (1-3 gms daily) Limit fluid (1.5-2 litres daily) Limit alcohol Treat cause (ie hypertension, ischemia) Diuretic therapy

Treatment if NYHA II Add angiotensin converting enzyme (ACE) inhibitor Add beta blocker

Treatment if NYHA III-IV Add ARB (angiotension receptor blocker) Add digoxin Add hydralazine and nitrates Add spironolactone

3 cases Is the heart failure chronic or acute? Is it mostly right sided or left sided? Is it systolic or diastolic? What is the cause? What is the NYHA classification? How should we treat now?

Case number 1 55 year old male with known coronary artery disease, previous myocardial infarction and previous admission for heart failure Discharged from hospital two weeks ago on angiotension converting enzyme inhibitor and furosemide Returns with mild dyspnea when walking, and orthopnea Exam shows S3, tachycardia, elevated JVP Ischemic cardiomyopathy

Case number 2 45 year old woman with no known heart disease Had hypertension during both pregnancies Has symptoms of dyspnea for 3 months when doing housework Has BP 170/70, heart rate of 100, elevated JVP, S4, few crackles in lungs, and mild peripheral edema Hypertension causing PSF (diastolic ) CHF Possible hyperthyroidism (tachy, wide pulse pressure)

Case number 3 40 year old male with no heart disease previous Drinks a lot of alcohol and has poor nutrition Presents to hospital severely short of breath and cyanotic Has crackles in lungs, elevated JVP, S3, abdominal distention and peripheral edema Treated in ED with furosemide and nitrates, now better Alcoholic cardiomyopathy, beriberi