Group

C2
Physiology Laboratory
Small Group Discussion
Output

November 7, 2015

[CONGESTIVE HEART FAILURE]

By: ASUBARIO, Olufunmilola Omonike; BALADAD, Alvin Byron; DE JESUS, Chrislou; GURUNG, Man
Bahadur; KALANYEG, Kristie; MAHALEE, Naphitcharak; MONTHATHONG, Thanapol; PANLASIGUI,
Rikkimae Maria; SAMSON, Chino Paolo; SOLONIO, Natalie Keith; VALDEZ, Gregorio
 CONGESTIVE HEART FAILURE

Heart failure is a physiological state in which cardiac output is insufficient to meet

the needs of the body and lungs. The term "congestive heart failure" is often used as
one of the common symptoms is swelling or water retention. Heart failure is divided into
two different types: heart failure due to reduced ejection fraction (also known as heart
failure due to left ventricular systolic dysfunction or systolic heart failure) and heart
failure with preserved ejection fraction (HFpEF) also known as diastolic heart failure or
heart failure with normal ejection fraction. Heart failure with reduced ejection fraction
occurs when the ejection fraction is less than 40%. In diastolic heart failure, the heart
muscle contracts well but the ventricle does not fill with blood well in the relaxation
phase. Ejection fraction is the proportion of blood pumped out of the heart during a
single contraction. It is given as a percentage with the normal range being between 50
and 75%.

The term "acute" is used to mean rapid onset, and "chronic" refers to long
duration. Chronic heart failure is a long term condition, usually kept stable by the
treatment of symptoms. Acute decompensated heart failure is a worsening of chronic
heart failure symptoms which can result in acute respiratory distress. High-output heart
failure can occur when there is an increased cardiac output. The circulatory overload
caused, can result in an increased left ventricular diastolic pressure which can develop
into pulmonary edema.

Heart failure (HF), often referred to as congestive heart failure (CHF), occurs
when the heart is unable to pump sufficiently to maintain blood flow to meet the body's
needs. The terms chronic heart failure (CHF) or congestive cardiac failure (CCF) are
often used interchangeably with congestive heart failure. Signs and symptoms
commonly include shortness of breath, excessive tiredness, and leg swelling. The
shortness of breath is usually worse with exercise, while lying down, and may wake the
person at night. A limited ability to exercise is also a common feature.

Common causes of heart failure include coronary artery disease including a

previous myocardial infarction (heart attack), high blood pressure, atrial fibrillation,
valvular heart disease, excess alcohol use, infection, and cardiomyopathy of an
unknown cause. These cause heart failure by changing either the structure or the
functioning of the heart. There are two main types of heart failure: heart failure due to
left ventricular dysfunction and heart failure with normal ejection fraction depending if
the ability of the left ventricle to contract is affected, or the heart's ability to relax is
otherwise affected. The severity of disease is usually graded by the degree of problems
with exercise. Heart failure is not the same as myocardial infarction (in which part of the
heart muscle dies) or cardiac arrest (in which blood flow stops altogether). Other
diseases that may have symptoms similar to heart failure include obesity, kidney failure,
liver problems, anemia and thyroid disease.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 2

EPIDEMIOLOGY:

Heart failure (HF) is a major public health issue with a current prevalence of over
5.8 million in the USA and over 23 million worldwide. Every year in the USA, more than
550,000 individuals are diagnosed with HF for the first time, and there is a lifetime risk
of one in five of developing this syndrome. A diagnosis of HF carries substantial risk of
morbidity and mortality, despite advances in management. Over 2.4 million patients who
are hospitalized have HF as a primary or secondary diagnosis, and nearly 300,000
deaths annually are directly attributable to HF.

Despite advances in therapy and management, HF remains a deadly clinical

syndrome. In the USA, one in eight deaths has HF mentioned on the certificate, 20% of
which have HF as the primary cause of death. Mortality risk steadily increases after a
new diagnosis of HF. Based on the Framingham Heart Study, 30-day mortality is
around 10%, 1-year mortality is 20–30%, and 5-year mortality is 45–60%. After
hospitalization, the prognosis worsens.

SIGNS & SYMPTOMS

Left Sided Heart Failure

Common respiratory signs are increased rate of breathing and increased work of
breathing (non-specific signs of respiratory distress). Rales or crackles, heard initially in
the lung bases, and when severe, throughout the lung fields suggest the development
of pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe low blood
oxygen, is a late sign of extremely severe pulmonary edema.

Additional signs indicating left ventricular failure include a laterally displaced apex
beat (which occurs if the heart is enlarged) and a gallop rhythm (additional heart
sounds) may be heard as a marker of increased blood flow, or increased intra-cardiac
pressure. Heart murmurs may indicate the presence of valvular heart disease, either as
a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.
The patient will have dyspnea (shortness of breath) on exertion and in severe cases,
dyspnea at rest. Increasing breathlessness on lying flat, called orthopnea, occurs. It is
often measured in the number of pillows required to lie comfortably, and in orthopnea,
the patient may resort to sleeping while sitting up. Another symptom of heart failure is
paroxysmal nocturnal dyspnea: a sudden nighttime attack of severe breathlessness,
usually several hours after going to sleep. Easy fatigability and exercise intolerance are
also common complaints related to respiratory compromise.

"Cardiac asthma" or wheezing may occur. Compromise of left ventricular forward

function may result in symptoms of poor systemic circulation such as dizziness,
confusion and cool extremities at rest.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 3

 Right-sided failure

Physical examination may reveal pitting

peripheral edema, ascites, and liver enlargement.
Jugular venous pressure is frequently assessed as a
marker of fluid status, which can be accentuated by
eliciting hepatojugular reflux. If the right ventricular
pressure is increased, a parasternal heave may be
present, signifying the compensatory increase in
contraction strength.

Backward failure of the right ventricle leads to

A man with congestive heart failure and marked congestion of systemic capillaries. This generates
jugular venous distension. External jugular vein
excess fluid accumulation in the body. This causes
marked by an arrow.
swelling under the skin (termed peripheral edema or
anasarca) and usually affects the dependent parts of
the body first (causing foot and ankle swelling in people who are standing up, and sacral
edema in people who are predominantly lying down). Nocturia (frequent nighttime
urination) may occur when fluid from the legs is returned to the bloodstream while lying
down at night. In progressively severe cases, ascites (fluid accumulation in the
abdominal cavity causing swelling) and liver enlargement may develop. Significant liver
congestion may result in impaired liver function, and jaundice and even coagulopathy
(problems of decreased blood clotting) may occur.

Acute pulmonary edema (Left). Note enlarged heart size, apical vascular redistribution (circle),and small bilateral
pleural effusions (arrow). Severe peripheral edema (Right).

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 4

CAUSES

The following are the most common causes of congestive heart failure:

 Coronary artery disease and heart attack (which may be "silent")

 Cardiomyopathy
 High blood pressure (hypertension)
 Heart valve disease
 Congenital heart disease
 alcoholism and drug abuse

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

Predisposing factors: Precipitating factors:

-Hypercholesterolemia - Coronary Artery Disease
- Age (>55 y/o) - Myocardial Infarction
- Smoking, Alcoholism - Hypertension
- Increase Sodium intake - Obesity
- Heredity - Heart valve disease
- Cardiomyopathy

Decrease stroke
volume

Decrease cardiac
output

COMPENSATORY MECHANISM (Body activates neurohormonal pathways to

increase circulating blood volume)

Activation of sympathetic nervous

system

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 5

 Release of Stimulation of kidneys
catecholamines to release Renin

Binds to alpha-1 Renin will be acted upon by Angiotensinogen

receptors from the liver to become Angiotensin I

Angiotensin I will be acted upon by Angiotensin Converting

Vasoconstriction
enzyme from the lungs to become Angiotensin II

Increase total peripheral Aldosterone Stimulation of

resistance secretion pituitary gland

Increase cardiac Increase Sodium & water

workload blood retention
pressure
Release of Anti-
diuretic hormone
Increase
heart rate Fluid retention

Increase
contractility
Increase preload

Left ventricular
Right ventricular
hypertrophy
hypertrophy Edema

Backflow of Decrease Backflow of

blood to the oxygenated blood blood in the
aorta in the body lungs

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 6

 Blood Fatigue Accumulation of
backflows to fluid in the lungs
the body (CONGESTION)

Peripheral
edema
Pulmonary Edema
Jugular vein
distention
Ascites

Crackles, Dyspnea,
Increase RR, Frothy
sputum

DIAGNOSIS

 Chest X-ray-This is very helpful in identifying the buildup of fluid in the lungs. Also,
the heart usually enlarges in congestive heart failure, and this may be visible on the
X-ray film. In addition, other disorders may be diagnosed.

 Electrocardiogram (ECG)- is a painless test that measures the electrical activity

(rhythm) of the heart. For this test, which takes just a few minutes, one lies on a
table with electrodes attached to the skin of the chest, arms, and legs. The ECG
can reveal several different heart problems that can cause heart failure, including
heart attacks, rhythm disorders, long-standing strain on the heart from high blood
pressure, and certain valve problems. However, the ECG result may be normal in
heart failure.

 Echocardiogram (EKG): This is a type of ultrasound that shows the beating of the
heart and the various cardiac structures. It is safe, painless, and one of the most
important tests for diagnosing and following patients with heart failure over time.
- An echocardiogram can be useful in determining the cause of heart failure (such
as problems with the muscle, valves, or pericardium) and it provides an accurate
measurement of the left ventricle's ejection fraction, an important measure of the
heart's pumping function.
Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 7
- In multiple-gated acquisition scanning (MUGA scan), a small amount of a mildly
radioactive dye is injected into a vein and travels to the heart. As the heart
pumps, pictures are taken. The pumping performance of the left and right
ventricles can then be determined from these pictures. This test is used far less
often than echocardiography.

 Blood tests- Low blood cell counts (anemia) may cause symptoms much like
congestive heart failure or contribute to the condition.

- Sodium, potassium, magnesium, and other electrolyte levels may be

abnormal, especially if the person has been treated with diuretics and/or has
kidney disease.
- Tests for kidney function.
- B-type natriuretic peptide (BNP) can be measured. This is a hormone
produced at higher levels by the failing heart muscle. This is a good screening
test; the levels of this hormone generally increase as the severity of heart
failure worsens.

 Stress testing: A treadmill or medication (nonwalking) stress test is used to help

evaluate the cause or causes of heart failure, in particular, regarding coronary
artery disease. This test is frequently combined with nuclear imaging or
echocardiography to improve accuracy. Stress testing is commonly performed
and is a cornerstone of diagnostic cardiology.

 MRI (Magnetic resonance imaging)-Magnetic fields are used to provide images

of the structure of the heart and its ability to pump blood to the body.If used with
a special MRI contrast agent (gadolinium), it can provide information about
inflammation, injury, and blood flow to the heart.

 Cardiac catheterization (cath)-During this procedure, a small tube is inserted

into and artery in the leg or arm. The catheter is moved to the heart to measure
pressures inside the heart and to put contrast into the coronary arteries to look
for blockages.Although this test is invasive, it is common and considered the
“gold standard” for diagnosing coronary artery disease as well as for measuring
various pressures in the heart and diagnosing certain disorders of the heart
valves.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 8

TREATMENT AND MANAGEMENT

Medications

 Diuretics (water pills): The buildup of fluid is usually treated with a diuretic.

- Diuretics cause the kidneys to remove excess salt and accompanying water
from the bloodstream, thereby reducing the amount of blood volume
incirculation. With a lower volume of blood, the heart does not have to work so
hard. The number of red and white blood cells is not changed.

- The end result is an improvement in the ability to breathe (clear out water in
the lungs) and a lessening of the swelling in the lower body.

- Diuretics commonly used in heart failure include furosemide

(Lasix),bumetanide (Bumex),hydrochlorothiazide (HCTZ), spironolactone
(Aldactone), eplerenone(Inspra), triamterene (Dyrenium),torsemide
(Demadex), or metolazone(Zaroxolyn), or a combination agent (for example,
Dyazide)

- Spironolactone and eplerenone are not only mild diuretics but can also be used
with stronger diuretics like furosemide (Lasix). They have been shown to
prolong life in certain types of heart failure patients when used in combination
with angiotensin-converting enzyme (ACE) inhibitors. The patient's physician
will know what medication or combinations should be best for each individual;
however, it is not uncommon for dosages and medications to be changed by
the physician as the disease changes or if better medication becomes
available.

 Cardiac Glycoside:

- Digoxin (Lanoxin): a mild inotrope and, in some cases, is beneficial as an

add-on therapy to ACE inhibitors and beta-blockers. It is the most common
form of digitalis.

- can reduce heart failure symptoms and hospitalizations, but it does not prolong
life.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 9

 - mainly used as an antiarrhythmic to control the rate of the heart in atrial
fibrillation and flutter. In contrast, excessive digoxin in the blood can cause life-
threatening arrhythmias.

- Although commonly used in the past, digoxin has moved far down the list of
recommended drugs for treatment of heart failure. It is still considered for
patients who are taking ACE inhibitors, ARBs, beta-blockers and/or diuretics
and are still experiencing heart failure symptoms.

 Vasodilators- These medications enlarge the small arteries or arterioles, which

relieve the systolic workload of the left ventricle. Therefore, the heart has to work
less to pump blood through the arteries. This also generally lowers blood
pressure. Just as importantly, they reduce the levels of certain deleterious
hormones and signals that can worsen heart failure.

 ACE inhibitors- most widely used vasodilators for congestive heart failure. They
block the production of angiotensin II, which is abnormally high in congestive
heart failure. Angiotensin II causes vasoconstriction with increased workload on
the left ventricle, and it is directly toxic to the left ventricle at excessive levels.
They are important because they not only improve symptoms, but they also
have been proven to significantly prolong the lives of people with heart failure.
They do this by slowing progression of the heart damage and in some cases
improving heart muscle function.

- Captopril(Capoten), Enalapril (Vasotec), Iisinopril (Zestril/Prinivil), Benazepril(L

otensin), Quinapril (Accupril), Fosinopril (Monopril), and Ramipril(Altace). Many
times the individual drugs are used together as part of a combination pill (for
example, Vaseretic, a combination pill containing enalapril and
hydrochlorothiazide).

 Angiotensin II receptor blockers (ARBs)- work by preventing the effect of

angiotensin II at the tissue level. Examples of ARB medications
includecandesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar),losarta
n (Cozaar), valsartan (Diovan), telmisartan (Micardis), andeprosartan (Teveten).
These medications are usually prescribed for people who cannot take ACE
inhibitors because of side effects. Both are effective, but ACE inhibitors have
been used longer with a greater number of clinical trial data and patient
information.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 10

 - ACE inhibitors and ARBs may cause the body to retain potassium, but this is
generally only a problem in people with significant kidney disease, or in people
who are also taking a potassium-sparing diuretic, such as triamterene or
spironolactone. Potassium levels can be monitored with lab testing.

 Calcium channel blockers (CCBs) are arterial vasodilators that are not used
for treatment of heart failure because clinical trials have proven no specific
benefit. However, calcium channel blockers are useful for lowering blood
pressure. If the cause of the congestive heart failure is high blood pressure and
the patient is not responding to ACE inhibitors or ARBs, a CCB may be
considered. Some CCBs include diltiazem (Cardizem), verapamil(Calan,
Isoptin), nifedipine (Procardia, Adalat), and amlodipine (Norvasc).

 Nitroglycerin is a nitrate preparation that is administered to treat acute chest

pain, or angina. Nitrates are venous vasodilators that include
isosorbidemononitrate (Imdur) andisosorbidedinitrate (Isordil). They are
commonly used in combination with an arterial vasodilator, such as hydralazine.

 Hydralazine (Apresoline) is a smooth muscle arterial vasodilator that may be

used for congestive heart failure. Clinical trial data has shown hydralazine plus
nitrates to be especially effective in African-Americans with heart failure, when
used in addition to ACE inhibitors or ARBs.

 Isosorbidedinitrate and hydralazine (BiDil) is a fixed dose combination of

isosorbidedinitrate (20 mg/tablet) and hydralazine (37.5 mg/tablet). This drug is
indicated for heart failure in African-Americans based in part on results of the
African American Heart Failure Trial (A-HeFT).

 Beta-blockers- These drugs slow down the heart rate, lower blood pressure,
and have a direct effect on the heart muscle to lessen the workload of the heart.
Specific beta-blockers, such as carvedilol (Coreg) and long-
acting metoprolol (Toprol XL), have been shown to decrease symptoms,
hospitalization due to congestive heart failure, and deaths. Other beta-blockers
include bispropolol (Zebeta), atenolol (Tenormin),propranolol (Inderal),
and bystolic (Nebivolol), but they are generally not used with significant
congestive heart failure.

- work in part by blocking the action of norepinephrine on the heart muscle. They
prevent norepinephrine from binding to beta-receptors in the heart muscle and
arterial walls. Norepinephrine may be toxic to the heart in prolonged, high

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 11

 doses. Clinical trials have proven that beta-blockers gradually improve the
systolic function of the left ventricle, thereby improving symptoms and
prolonging life.

 Inotropes- IV inotropes are stimulants, such as dobutamine and milrinone, which

increase the pumping ability of the heart. These are used as a temporary support
of a very weak left ventricle that is not responding to standard congestive heart
failure therapy. Commonly used inotropes are dobutamine (Dobutex) and
milrinone (Primacor). Phenylephrine (Neo-Synephrine) may be used when a
patient is suffering with severe low blood pressure

Surgery

-is aimed at stopping further damage to the heart and improving the heart's function.
Procedures used include:

Bypass surgery: The most common surgery for heart failure is bypass surgery
to route blood around a blocked heart artery.

Left ventricular assist device (LVAD): The LVAD helps your heart pump blood
throughout your body. It allows you to be mobile, sometimes returning home to await
a heart transplant.

Heart valve surgery: As heart failure progresses, the heart valves that normally
help direct the flow of blood through the heart to the rest of the body may no longer
completely close, allowing blood to "leak" backward. The valves can be repaired or
replaced.

Infarct exclusion surgery (Modified Dor or Dor Procedure): When aheart

attack occurs in the left ventricle (left lower pumping chamber of the heart), a scar
forms. The scarred area is thin and can bulge out with each beat (an aneurysm). A
heart surgeon can remove the dead area of heart tissue or the aneurysm.

Heart transplant: A heart transplant is considered when heart failure is so

severe that it does not respond to all other therapies

Management:

 Treat swelling with the following measures:

 Elevate the feet and legs if they are swollen.
Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 12
  Eat a reduced-salt diet.
 Weigh in every morning before breakfast and record it in a diary that can
be shown to a health care provider.

 Avoid the following:

 Not taking prescribed medications
 Smoking (in all forms)
 Alcohol (up to one drink per day is usually fine, unless prone to excessive
intake/alcoholism)
 Excessive emotional stress and/ordepression (seek professional help)
 High altitude (breathing is more difficult because of the lower level of
oxygen in the atmosphere; pressurized cabin air travel is usually fine)
 Herbal or other complementary medicine without first consulting a doctor
to see if they are safe

 Patients with congestive heart failure should know the following information that
may apply to their disease

 Keep walking or doing some form of aerobic exercise. Join a cardiac

rehabilitation program (this program can monitor a person's exercise
capacity).
 People with diabetes must control their blood sugar level every day.
Patients should know their HbA1C level. It should be less than 7.0%, and
preferably less than 6.5%.
 People with high blood pressure should measure it regularly, and make
sure they know the value, (systolic pressure should be below 140 mm Hg
in everyone and even below 130 in many individuals).
 People with elevated lipid levels (cholesterol and triglycerides) can take
medications to get the bad cholesterol (LDL) below 70 optimally (or at
least below 100), good cholesterol (HDL) above 40 for men and 50 for
women, and the triglycerides below 150.

PROGNOSIS

Prognosis in heart failure can be assessed in multiple ways including clinical

prediction rules and cardiopulmonary exercise testing. Clinical prediction rules use a
composite of clinical factors such as lab tests and blood pressure to estimate prognosis.
Among several clinical prediction rules for prognosing acute heart failure, the 'EFFECT
rule' slightly outperformed other rules in stratifying patients and identifying those at low

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 13

risk of death during hospitalization or within 30 days. Easy methods for identifying low
risk patients are:

• ADHERE Tree rule indicates that patients with blood urea nitrogen < 43 mg/dl
and systolic blood pressure at least 115 mm Hg have less than 10% chance of
inpatient death or complications.

• BWH rule indicates that patients with systolic blood pressure over 90 mm Hg,
respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L,
no new ST-T wave changes have less than 10% chance of inpatient death or
complications.

A very important method for assessing prognosis in advanced heart failure

patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually
required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary
exercise testing involves measurement of exhaled oxygen and carbon dioxide during
exercise. The peak oxygen consumption (VO2 max) is used as an indicator of
prognosis. As a general rule, a VO2 max less than 12–14 cc/kg/min indicates a poor
survival and suggests that the patient may be a candidate for a heart transplant.
Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent
International Society for Heart and Lung Transplantation (ISHLT) guidelines also
suggest two other parameters that can be used for evaluation of prognosis in advanced
heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope
> 35 from the CPX test. The heart failure survival score is a score calculated using a
combination of clinical predictors and the VO2 max from the cardiopulmonary exercise
test.

Heart failure is associated with significantly reduced physical and mental health,
resulting in a markedly decreased quality of life. With the exception of heart failure
caused by reversible conditions, the condition usually worsens with time. Although
some people survive many years, progressive disease is associated with an overall
annual mortality rate of 10%.

Approximately 18 of every 1000 persons will experience an ischemic stroke

during the first year after diagnosis of HF. As the duration of follow-up increases, the
stroke rate rises to nearly 50 strokes per 1000 cases of HF by 5 years.

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 14

References:

1. Guyton, AC; Hall, JE: Textbook of Medical Physiology, 11th edition. Elsevier Inc.
2006.

2. Koeppen, BM; Stanton, BA: Berne and Levy Physiology, 6th edition. Elsevier Inc.
2010.

3. en.wikipedia.org

4. http://www.nhlbi.nih.gov/health/health-topics/topics/af

5. http://www.emedicinehealth.com/congestive_heart_failure/page8_em.htm

Physiology Laboratory Small Group Discussion Output | Congestive Heart Failure 15