1. MBBS; FCPS ( Cardiology ) Cardiologist Holy Family Hospital
Dr Muhammad Saeed
MBBS; FCPS ( Cardiology )
Cardiologist Holy Family Hospital

2. Congestive Cardiac Failure
Heart failure is a clinical syndrome that develops when heart cannot maintain adequate output or can do so only at the expense of elevated ventricular filling pressure.

3. Pathophysiology
Cardiac out put depends upon preload( volume and pressure of blood in the ventricles at the end of diastole), afterload( volume and pressure of blood in ventricles during systole) and the myocardial contractility.

4. If the primary abnormality is impairment in ventricular myocardial function, leading to fall in cardiac out put. This can occur because of impaired systolic contraction, impaired diastolic relaxation or both. This activates counter regularly neurohumoral mechanisms that in normal physiological circumstances, would support cardiac function but in the setting of impaired ventricular function can lead to a harmful increase in both preload and after load. A vicious circle may be established because any additional fall in cardiac out put will cause further neurohumoral activation and increasing peripheral vascular resistance.

5. Stimulation of rennin angiotensin system leads to vasoconstriction, sodium and water retention and sympathetic nervous system activation. This is mediated by angiotensin II which is a potent vasoconstrictor of arterioles in both kidney and systemic circulation. Activation of the sympathetic nervous system may initially sustain cardiac output through increases myocardial contractility and heart rate. Prolonged sympathetic activation also caused negative effects including myocytes necrosis. Sympathetic activation also causes peripheral vasoconstriction and and arrhythmias.
Sodium and water retention is promoted by the release of aldosterone,endothelin-1( a potent vasoconstrictor).

6. Etiology of Heart failure
1) Coronary artery disease ( Acute MI, NTEMI, leading to systolic and diastolic dysfunction) --- Regional wall motion abnormality.
2) Myocarditis or Cardiomyopathy– Global systolic dysfunction.
3) Ventricular Outflow obstruction– Hypertension, aortic stenosis( Left sided heart failure). Pulmonary hypertension, pulmonary valve stenosis( Right heart failure).
4) Ventricular inflow obstruction --- Mitral stenosis, tricuspid stenosis.

7. 5) Ventricular volume overload– MR AR VSD( Left sided heart failure)
5) Ventricular volume overload– MR AR VSD( Left sided heart failure). TR, ASD ( Right sided heart failure).
6) Arrhythmia– AF, Tachycardia cadiomyopathy.
7) Diastolic dysfunction– Constrictive pericarditis,Restrictive cardiomyopathy,LVH due to AS, Hypertension.

8. Right and Left sided heart failure
Left sided heart failure: In left sided heart failure there is reduction in left ventricular output and increase in left atrial and pulmonary venous pressure. An acute increase increase in left atrial pressure cause pulmonary congestion or pulmonary edema. Right sided heart failure: There is reduction in right ventricular output and increase in right atrial and systemic venous pressure. Causes of isolated right sided heart failure are Chronic lung disease( Corpulmonale),Pulmonary embolism and pulmonary stenosis. Biventricular heart failure: Failure of both ventricles may develop in Dilated cardiomyopathy, Ischemic heart disease. Or because the disease of left heart leads to chronic elevation of the left atrial pressure pulmonary hypertension and right heart failure

9. Symptoms of CCF
Acute heart failure: Heart failure may develop suddenly eg in Acute MI, Acute infective valvular endocarditis, Acute MR or acute AR. Acute left ventricular failure presents with sudden onset of dyspnoea at rest, profuse sweating, palpitation Chronic heart failure: When there is gradual impairment of cardiac function, several compensatory changes may occur, it is called Compensatory heart failure , the condition with impaired cardiac function but adaptive changes have prevented the development of obvious heart failure, eg chronic MR, AR. In chronic heart failure patient may has dyspnoea on exertion, symptoms of low cardiac output in systolic dysfunction like fatigue or poor effort tolerance.

10. Signs of CCF Acute heart failure:
1)Patient may be agitated, pale and clammy.
2)Peripheries are cold
3)Pulse is rapid
4)BP is usually high because of sympathetic over activity but may be normal or low if the patient is in cardiogenic shock.
5) JVP may be raised with right heart failure
6) In acute heart failure apex is usually not displaced.
7) A gallop rhythm, with third heart sound
9) A 4th heart sound may be present
10) A new systolic murmur may be due to acute MR or Acute VSD.
10) Basal crepitation or throughout the lungs if pulmonary edema is severe.
11) Expiratory wheeze.

11. Chronic heart failure: 1) Chronic heart failure is sometimes associated with marked weight loss caused by combination of anorexia and impaired absorption due to gastrointestinal congestion. 2) Low cardiac output causes cold peripheries. 3) Pulse may be feeble and rapid. 4) Blood pressure may be low 5) Apex may be displaced in chronic heart failure. 6) Heart sounds intensity may change depending upon underlying disease. 7) In chronic MR pan systolic murmur, in chronic AR mid systolic and early diastolic murmur.

12. Right heart failure: 1) Pulse may be low volume. 2) BP may be low
Right heart failure: 1) Pulse may be low volume. 2) BP may be low. 3)Raised JVP with prominent a wave initially then v wave afterward. 4) Left parasternal heave. 5) Palpable pulmonary component of 2nd heart sound. 6) Pulmonary component of 2nd heart sound may be loud. 7) Right sided 4th heart sound initially latter on right sided 3rd heart sound. 8) Pan systolic murmur of TR, early diastolic murmur of PR.

13. Investigations
Blood tests: RFT with electrolytes,Hb,thyroid function. BNP is raised in heart failure.
ECG
X-Rays chest
Echocardiography

14. Treatment of CCF
Acute heart failure: 1) Sit the patient up to reduce the pulmonary congestion 2) Oxygen inhalation. Non invasive positive pressure ventilation( continuous positive airway pressure- CPAP)of 5-10 mmHg 3) IV morphine 4) IV nitrates 5) IV fur0semide

15. Chronic heart failure: 1) Oral furesemide 2) ACE inhibitors 3) Vasodilators like Nitrates, hydralazine 4) Beta- adrenoceptor blocker therapy 5) ICD ( implantable defibrillators) 6) Cardiac resynchronization therapy( CNRT) 7) Coronary revascularization with PCI or CABG 8) Ventricular assist devices 9) Heart transplantation

16. Life style modifications.
Blood pressure control.
Control of blood cholesterol.
Don't smoke
Eat a heart healthy diet
Low salt
Exercise regularly
Maintain a healthy weight

17. Pulmonary Edema
Definition: Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in numerous alveoli in the lungs, making it difficult to breathe.
With each breath alveoli take in oxygen and release carbon dioxide. Normally the exchange of gases take place without problem. But in pulmonary edema alveoli fill with fluid instead of air, preventing oxygen from being absorbed into bloodstream.

18. Heart-related (cardiogenic)pulmonary edema
Cardiogenic pulmonary edema is a type of pulmonary edema caused by increased pressures in the heart.
This condition usually occurs when the diseased or overworked left ventricle is not able to pump out enough of the blood it receives from lungs. As a result pressure increases inside of left atrium and then in pulmonary veins and pulmonary capillaries, causing fluid to be pushed through the capillary walls into the alveoli.

19. Causes of cardiogenic pulmonary edema
Coronary artery disease( Acute MI or severe ischemia).
Exacerbation of chronic heart failure
Cardiomyopathy
Valvular heart diseases because of increased volume overload of LV( Valvular regurgitation) and mitral stenosis.
Hypertension

20. Symptoms
1)Extreme shortness of breath at rest. 2)A feeling of suffocating or drowning 3)Wheezing or gasping for breath. 4)Anxiety, restlessness or a sense of apprehension 5)A cough with frothy sputum that may be tinged with blood. 6)Chest pain if pulmonary edema is caused by heart disease. 7)Palpitation because of irregular heart beat 8)Profuse sweating

21. Signs
Cyanosis
Pulse may be low volume or high volume, may be regular or irregular
Blood pressure may be low or high.
Rales are present in all lung fields and generalized wheezing or rhonchi.
Depending upon cause of pulmonary edema, systolic or diastolic murmurs.

22. Investigations Chest X-rays. Pulse oximetery
Blood Tests( ABGs, Increase level of B-type natriuretic peptide( BNP). Other blood tests are RFTs with electrolytes, Thyroid function tests, Blood CP
ECG
Echocardiography --- For valvular problems, wall motion abnormality etc
Pulmonary artery wedge pressure.
Cardiac catheterization. Including Coronary angiogram.

23. Differential Diagnosis
Bronchial asthma or COPD
Pneumonia
Pneumothorax
Pulmonary embolism

24. Treatment
In full blown pulmonary edema patient should be placed in a sitting position with legs dangling over side of bed, this facilitate respiration and reduces venous return.
Oxygen--- Oxygen inhalation through a face mask or nasal cannula is the first step in the treatment of pulmonary edema to obtain po2> 60 mmHg. Oxygen level is monitor by pulse oxymeter. Sometimes it may be necessary to assist breathing with a machine such as mechanical ventilator.
Preload reducers: Preload reducing medications decrease the pressure caused by fluid going into the heart and lungs. IV Nitrates and frusemide( Lasix) are usually used. Because of increase urination because of frusemide urinary catheters are usually used.
Morphine: This drug may be used to relieve shortness of breath and anxiety. In a dose of 2-8 mg iv or sc.

25. After load reducers: These medications such as nitroprusside dilate blood vessels and pressure load is being off from left ventricle.
Blood pressure medications: If blood pressure is high blood pressure reducing medications are used and if blood pressure is low medications which raise blood pressure are used.

26. Life style modifications
Blood pressure control.
Control of blood cholesterol.
Donot smoke
Eat a heart healthy diet
Low salt
Exercise regularly
Maintain a healthy weight