Cardiac

Failure
A presentation by:
Dr. Urwa Afzal
Dr. Zarqa Safdar
 Table of Contents:
● Definition and types of Heart Failure
● Pathophysiology and mechanism
● Scenario and approach to heart failure
● Signs and symptoms
● Classification of heart failure
● Investigations of heart failure
● Treatment of Heart Failure
● Complications of Heart Failure
● Acute Decompensated Heart Failire causing Pulmonary Edema.
●
Definition:
Heart failure is the clinical
syndrome that develops
when the heart cannot
maintain adequate output,
or can do so only at the
expense of elevated
ventricular pressure.
Types of Heart Failure:

1. Left Heart Failure vs Right Heart Failure

2. Systolic vs Diastolic Heart Failure
3. EFrHF vs EFpHF
Mechanisms of Heart Failure:
1. Reduced Ventricular Contractility(e.g. MI, cardiomyopathy)
2. Ventricular outflow obstruction(HTN, AS, Pul HTN, PS)
3. Ventricular inflow obstruction(MS, TS)
4. Ventricular Volume overload(MR, AR, VSD, ASD)
5. Arrythmias( Afib, tachycardia, complete heart block)
6. Diastolic Dysfunction( Constrictive pericarditis, restrictive
cardiomyopathy, cardiac temponade)
 Scenario
Pt. Azra, a 60 year old female, known case of diabetes mellitus type II,
and hypertension for the last 5 years(non compliant to medication),
presented to ER with shortness of breath for the last 2 days, with
orthopnea and PND. She is unable to climb stairs, as she complains of
worsening shortness of breath. What is your differential diagnosis and
how would you approach the patient?
 Symptoms of Heart Failure:
● Left Heart:
● Exertional Dyspnea
● Right Heart:
● Edema
● Orthopnea
● RHQ heaviness
● PND ● Loss of apetite
● Non productive nocturnal
cough
● Confusion and memory
impairment
● Diaphoresis and cool
extremities at rest
 Signs of Heart Failure:
● Left Heart: ● Right Heart:
● Displaced PMI ● Peripheral pitting edema
● Pathologic S3 and S4 ● JVD
● Crackles at bases of ● Hepatomegaly
lungs ● Ascites
● Dullness to percussion ● Right ventricular heave
and decreased tactile
fremitus of lower lung
fields
● Increased intensity of
pulmonic component of
S2
Diagnostic Criteria
of Heart Failure:
Boston Criteria:
● Upto 4 points can be counted from each of the
three categories.
● Added together, they create a composite score
with a maximum of 12 points
● Unlikely: 4 or less points
● Possible: 5 to 7 points
● Definitive: 8 to 12 points
 Framingham Criteria:
To make a diagnosis of Heart Failure, a person must have 2 or more major
criteria, or 1 major or 2 minor criteria.

Major Criteria: Minor Criteria:

● Acute Pulmonary Edema ● Ankle Edema
● Cardiomegaly ● Dyspnea on exertion
● Hepatojugular Reflex ● Hepatomegaly
● JVD ● Nocturnal cough
● Oryhopnea ● Pleural effusion
● Pulmonary Rales
● Tachycardia>120
● S3
● Weight loss >4.5kg in 5
days.in response to
treatment.
 Investigations:
● Baselines( CBC, RFTs, Serum electrolytes, ABGs)
● TFTs
● Iron studies
● ECG(for presence of IHD or previous MI, low voltage qrs, non
specific ST-T)
● Trop I
● Chest Xray( cardiomegaly, kerley B lines, prominent interstitial
markings, pleural effusion)
● BNP levels > 100
● NT-Pro BNP> 300
● Echocardiogram(EF, wall motion abnormalities, septal and
valvular defects, chamber dilation or hypertrophy)
● MUGA Scan(Radionuclide ventriculography)
● Coronary angiogram or stress testing
● Cardiac MRI
● CT Angiography
● Cardiac catheterization
 Treatment of Systolic Dysfunction(EFrHF):
● Lifestyle modifications
● Diuretics
● ACE Inhibitors
● ARBs ARNIs
● Beta Blockers
● Digitalis
● Hydralazine and Isosorbide dinitrates
● Anticoagulation
● Antiarrythmic therapy
● Statin therapy
 Non pharmacological Interventions:
● Fluid and free water restriction especially if
hyponatremic
● Minimize medications known to have deleterious effects
on heart failure e.g. negative inotropes, NSAIDS.
● Oxygen
● Physical Exercise
● Reduce salt intake
● Smoking cessation
● Restrict alcohol intake
 Treatment of Diastolic Dysfuction(EFpHF):

● Beta Blockers
● Diuretics
● ACE inhibitors and ARBs
● SGLT2i
 Drugs contraindicated in Heart Failure:
● Metformin
● Thiazolidinediones
● NSAIDs
● Class I Antiarrhythmic agents(quinidine, lidocaine, flecainide)
● COX 2 inhibitors
● CCBs except amlodipine
● Steroids
 Invasive options for management:
● Implantable cardiac defibrillator(ICD)
● Cardiac Resynchronization therapy(CRT)
● Cardiac transplant
● Coronary Revascularization
● Ventricular assist devices
 Acute Decompensated Heart Failure
(Leading to Acute Pulmonary Edema):
● It is the new onset or reoccurence of signs and symptoms of
heart failure requiring emergency therapy
● Causes: MI, cardiomyopathy, PE, myocarditis, Arrythmias,
valvular heart diseases, infections.
● Investigations: ECG, CXR, BNP, Echo
● First line treatment: Oxygen+ Morphine+ Nitrates+ Diuretics
+Intravenous nesiritide+ low salt diet + Beta Blocker + ACE
inhibitors.
A 68-year-old woman with cardiomyopathy and an ejection fraction
of 30% presents to your office for a routine follow-up after a recent
hospitalization for decompensated heart failure. She reports mild
dyspnea after 3 blocks during her daily walk. She says she rests
and then continues.

She is maintained on guideline-directed medical therapy for heart

failure including sacubitril/valsartan 97 mg/103 mg bid, carvedilol
12.5 mg bid, pravastatin 40 mg/d, and aspirin 81 mg/d.

Her physical examination reveals a blood pressure of 118/70 mm Hg,

a heart rate of 68 bpm and regular, a respiratory rate of 18
breaths/min, and a room air oxygen saturation of 96% with a
decrease to 92% with hallway ambulation. She has no JVD and her
lungs are clear. Her heart examination reveals a regular rhythm
with an S3 at the apex. She has no peripheral edema.
A basic metabolic profile obtained prior to her visit reveals the following serum
levels: sodium 138 mEq/L, potassium 4.3 mEq/L, chloride 99 mEq/L, bicarbonate 26
mEq/L, blood urea nitrogen 18 mg/dL, creatinine 1.6 mg/dL, and an estimated
glomerular filtration rate of 52 mL/min/1.73 m2.

The next, most appropriate, step in this patient’s management would be to:

CHOOSE ONE
A) Discontinue her sacubitril/valsartan and start lisinopril.

B) Discontinue carvedilol and starting metoprolol.

C) Add spironolactone to her regimen.

D) Start supplemental oxygen.

Thankyou for
your patience!