HEART FAILURE

by DR. Ahmed Abdali

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Heart failure: is inability of the heart to pump enough blood meets the body requirements due to MI
(myocardial infarction), cardiomyopathy, increase blood demands like in severe anemia,
hyperthyroidism, pregnancy, liver cell failure and etc.

Classification
1. According to the duration
A. Acute HF: recent problems as MI, arrhythmias and etc.
B. Chronic HF: gradual problems as Hypertension.
2. According to the side of the heart
A. Left sided HF
@systolic or HFrEF (Heart failure with reduced ejection fraction)
@Diastolic or HFpEF (heart failure with preserved ejection fraction)
B. Right sided heart failure
Usually the causes from left heart

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 Adaptive mechanisms

1. Alteration of myocyte regeneration and death

2. Left ventricular remodeling
3. Increased sympthetic activity
4. Increased RAAS activity (Renin-Angiotensin-Aldosterone System)

Sytolic HF (HFrEF)

Causes

A. Coronary artery disease (CAD)

B. HTN (hypertension), Valvular heart disease
C. Inflammation or infections as myocarditis
D. Paeripartum cardiomyopathy
E. Congenital Heart disease as TOF or TGA (Tetralogy of Fallo or Transposition of the great
arteries)
F. Drugs
G. Idiopathic
H. Rate cause endocrine abnormaities
I. Rheumatolic diseases and neurologic conditions

Diastolic HF

Causes

A. HTN, CAD, Valvular diseases

B. Hypertrophic cardiomyopathy (common in athletes)
C. Restritive cardiomyopathy ( amyloidosis, sarcoidosis)
D. Constritive pericarditis (post surgery)

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 RIGHT SIDED HF

CAUSES
A. Left sided HF (common)
B. CAD
C. Pulmonary hypertension
D. Pu,monary valve stenosis
E. Pulmonary embolism
F. Chronic pulmonary disease

ACUTE HF
A. Acute valve regurgitation in enfective endocarditis
B. MI
C. Arrhythmia (Atrial fibrilation AF , ventricular tachycardia VT, Supraventricular tachycardia
SVT)
D. Drugs as cacaine
E. Sepsis
F. Iatrogenic
G. Pregnancy
H. Sometimes after operation doctors give a lot of fluids can also cause Acute HF

Symptoms
 Exertional dyspnea- even at rest(severe)
 Othopnea- patoxysmal nocturnal dyspnea
 Chest pain – palpitation
 Acute pulmonary oedema
 Cough and wheeze
 Lower limb edema
 Ascites – weight gain
 Anorexia- nausea- cardiac cachexia
 Fatigue – bleeding- oligurea- nacturia
 CNS symproms (decreased memory, confusions)
 Headache. Insomnia, pschosis, hallucinations

SIGNS
A. ORTHOPNEA J. ascites
B. Central cyanosis K. maybe fever if a cause is imfection
C. Tachycardia L. malar flush

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 D. Jaundice M. S3 gallop, murmur
E. Rales on lung bases N. signs of liver cell failure
F. Acute pulmonary edema O. hepatosplenomegaly
G. Hepatojugular reflex
H. Bilateral leg edema
I. Congested neck veins

DIAGNOSIS OF HF

PND= paroxysmal nicturnal dyspnea

INVESTIGATIONS
Investigations are essential to determine the etiology, complications associated
with heart failure and modifiable risk factors.
 Observations

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  Blood pressure
 ECG
 Urinalysis

A. BNP OR NTpro BNP ( IF BNP <100 so it is heart failure)

B. CBC – look for anemia, infective causes
C. Creatinine+urea -- exclude renal failure as a cause of edema

D. LFT - exclude liver failure as a cause of edema.

E. TFT - exclude thyroid disease.
F. Lipid profile
G. Electrolytes levels

ECG

 Evidence of previous MI
 Left ventricular strain / hypertrophy
 Conduction abnormalities / AF or other arrhythmias

CHEST X-RAY

 Cardiomegaly (Cardiothoracic ratio > 50% on PA film)

 Alveolar shadowing edema
 Kerley B lines (fluid in septae of secondary lobules)
 Pleural effusion
 Upper lobe diversion

ECHO

 Abnormal heart valves.

 Congenital heart disease (abnormalities present at birth)
 Damage to the heart muscle from a heart attack.
 Heart murmurs.
 Inflammation (pericarditis) or fluid in the sac around the heart (pericardial effusion)
 Low or preserved Ejection fraction
 Thrombus
 Etc.

 Coronary angiogram: used for diagnostic and therapeutic purposes to diagnose/treat

coronary artery disease
 Right heart catheterization: reserved for the investigation of right-sided heart failure
 24 hr ECG: if an arrhythmia is suspected
 Lung function tests: to exclude alternative pathology impacting on symptoms
(breathlessness)

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 Heart failure on CXR demonstrating cardiomegaly, upper lobe diversion and Kerley-B lines.
MANAGEMENT

 Lifestyle modification and patient education are paramount in treating heart failure.
 Patients personal needs and values must be taken into account.
 Offer annual flu and a one-off pneumococcal vaccination.
 Smoking, alcohol, travel, driving and sexual advice may be needed.

1. Diuretics
(loop diuretics) as Furosemide 20 mg OD or torsemide
Thiazides as hydrochlorothiazide

 K sparing diuretics as spironolactone, Eplerenone 25 mg (Contra-indicated in

hyperkalaemia, hyponatremia, acute kidney injury.)

2. ACEI
Such as enalapril, Lisinopril, Ramipril
Ramipril 1.25 mg OD

3. ARBs
such as valsartan

4. Beta blockers
As bisoprolol, carvedilol
Selective Beta 1 blocker (bisoprolol and metaprolol)

5. SLGT2 Inhibitors
Such as dapagliflozin, empagliflozin, they really decrease cardiac death
used in patients with chronic kidney disease and heart failure with reduced ejection
fraction who meet specific criteria

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 6. Ivabradine
7. Sacubitril/valsartan: ARB with new neprilysin inhibitor, which prevents breakdown of
natriuretic peptides.
8. Hydralazine in combination with nitrate (nitroglycerin)

Nitroprusside sodium

9. Digoxin
10. Dopamine for 24 hr in patients HF and moderate hypotension (systolic BP 70-
90mmmhg)
11. soluble guanylate cyclase stimulator such as vericiguat (in patients with heart failure and
reduced ejection fraction)
12. Anticoagulation

if INR less than 2-3, (LV) Left ventricle thrombus, thromboembolic event, +/- evidence
of LV thrombus and paroxysmal or chronic atrial arrhythmias.

IMVASIVE STRATEGIES

A. Pacemaker-ICD (Implantable cardioverter defibrillator)

B. CABG –PCI (Coronary artery bypass graft surgery- Percutaneous Coronary
Intervention)
C. Valvular surgery
D. Ventricular restoration
E. ECMO (Extracorporeal membrane oxygenation)
F. Ventricular assist device
G. Heart transplant
H. Artificial heart
I. Stem cell and genetic therapy