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

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

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

4. 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

5. 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

6. Systolic

7. Diastolic heart failure

9. 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)

10. 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

11. 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

12. 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

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

14. Clinical presentation right sided
Peripheral edema
Abdominal distention
Weight gain
Nocturia

15. 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

17. 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

18. 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

19. 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

20. 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

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

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

24. 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?

25. 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

26. 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)

27. 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