HREAT FAILURE

What is heart failure ?

Heart failure (HF): a complex clinical syndrome in which there is structural or functional impairment of
ventricular filling and/or ejection of blood

Note ( The term “heart failure” is preferred over “congestive heart failure” because not all patients
present with symptoms of fluid overload.(

Etiology and underlining pathophysiology

1- Underlying causes of heart failure include structural abnormalities (congenital or acquired) that
affect the peripheral and coronary arterial circulation, pericardium, myocardium, or cardiac valves,
.thus leading to increased hemodynamic burden or myocardial or coronary insufficiency

-Coronary artery disease -congenital heart failure

-Idiopathic cardiomyopathy- -Valvular heart disease

-Peripartum cardiomyopathy -LV failure

2-Fundamental causes include biochemical and physiologic mechanisms, through which either an
increased hemodynamic burden or a reduction in oxygen delivery to the myocardium results in
impairment of myocardial contraction.

-Arrhythmia -Myocardial infarction (MI) - Anemia

- Beriberi heart disease -Paget disease of bone -Pregnancy
-Polycythemia vera

3-Precipitating causes Overt heart failure may be precipitated by progression of the underlying heart
disease (eg, valvular disease ) or various conditions (fever, anemia, infection) or medications
(chemotherapy, nonsteroidal anti-inflammatory drugs [NSAIDs]) that alter the homeostasis of heart
failure patients.

-Diabetes mellitus -Hypertension -Infections and inflammation

- Drugs - Sepsis -Obesity -Hyperthyroidism

Classification of heart failure

1-Acute versus Chronic heart failure

.Acute: develops suddenly within hours or days in a previously asymptomatic patient

Chronic: develops gradually, the heart has become weaker and has difficulty pumping enough blood
.through the body to supply it with oxygen progressively

2-Left versus Right and Biventricular heart failure

Left: characterized by a reduction in effective left ventricular output for a given pulmonary venous or
left atrial pressure

Right: characterized by a reduction in effective right ventricular output for any given right atrial
.pressure
Biventricular: involves both sides of the heart; reduced effective output at both ventricles, displaying
.features of right and left sided heart failure

3 -Forward versus Backward heart failure

Forward: caused by inadequate cardiac output that leads to diminished perfusion of vital organs
.leading to ischaemia and can progress to cardiogenic shock

Backward: damming of blood into venous system, excess accumulation of fluid in the body and
.edema, called anasarca

4 -Systolic versus Diastolic heart failure

Systolic: develops as a result of impaired myocardial contraction (systolic dysfunction)

Diastolic: develops as a result of weak ventricular filling caused by impaired ventricular relaxation
(diastolic dysfunction)

5 -Low-output versus High-output heart failure

Low output: heart cannot pump enough blood to meet your body’s needs, caused by conducting
conditions such as congenital, valvular, rheumatic, hypertensive, coronary and cardiomyopathic
.disease

High output: heart pumps a greater amount than usual, but it is still not enough to meet the demands

.of the body, caused by anemia, Paget's disease of bone, beriberi and thyrotoxicosis

Signs and symptoms of heart failure-:

1-Change in skin color or greyish pallor (episodes of change in skin color associated with
weakness), low cardiac output may cause peripheral vasoconstriction, resulting in coolness,
pallor, and cyanosis of the digits, with poor capillary refill.
2-Sweating, which may be very heavy-:In HF patients the overactive sympathetic nervous
system generates a signaling to the sweat glands to induce a dispersion of fluids with loss of
sodium and chlorine at the glandular ductal level.
3-Extreme anxiety.
4-Sudden loss of consciousness usually means that the blood supply to the brain is seriously
reduced blood flow to the brain may be reduced when the heart rate or rhythm is abnormal
(too slow or too fast) or when the heart cannot pump blood adequately because blood flow is
blocked, for example, by narrowing of a valve.
5-Lightheadedness or dizziness in people with heart failure is often caused by their medicines.
However, irregular heartbeats, which often happen with heart failure, or a temporary drop in
blood pressure, caused by rising from a sitting or lying position (postural hypotension), can
also cause dizziness
6-Poor Blood Supply to Extremities-:The heart can no longer pump enough blood to meet the
body's needs, which causes poor blood circulation. Heart failure due to diastolic dysfunction
develops because the heart muscle stiffens (particularly the left ventricle) and may thicken so
that the heart cannot fill normally with blood. Consequently, blood backs up in the left atrium
and lung (pulmonary) blood vessels and causes congestion.
7-Shortness of breath with activity or when lying down. Blood often backs up and causes fluid
to build up in the lungs and in the legs. The fluid buildup can cause shortness of breath and
swelling of the legs and feet
8-Fatigue and weakness- :The origins of fatigue in HF are unclear and are likely to be
multifactorial. Pathophysiologic causes of fatigue in HF include low cardiac output and poor
tissue perfusion, muscle metabolic abnormalities, autonomic nervous system abnormalities,
deconditioning effects, and endothelial dysfunction.
9-Swelling in the legs, ankles and feet-:The heart lacks the necessary force to propel the blood
through the arteries and back through the veins, leading to increased pressure in the blood
vessels. This elevation in pressure forces fluid out of the blood vessels and into the
surrounding tissues, resulting in swelling, or edema.
10-Rapid or irregular heartbeat-: If the heart and its chambers or valves haven't formed
correctly, the other parts of the heart have to work harder to pump blood. This may lead to
heart failure. Irregular heart rhythms, called arrhythmias
11-Reduced ability to exercise, due to dut to inadequate blood flow to active skeletal muscle
secondary to impaired cardiac output.
12-Wheezing-:Heart failure can cause fluid to build up in the lungs, a condition called
pulmonary edema. It also can cause fluid buildup in and around the airways. This can cause
shortness of breath, coughing and wheezing similar to the symptoms of asthma
13-A cough that doesn't go away or a cough that brings up white or pink mucus with spots of
blood-:The coughing is due to the fluid accumulation or congestion, in the lungs, which
increases the effort of breathing.
14-Swelling of the belly area ,due to fluid retention and congestion in the liver and gut.
15-Very rapid weight gain from fluid buildup.
16-Nausea and lack of appetite-:The heart can't pump enough blood to meet the needs of
body tissues. The body diverts blood away from less vital organs, particularly muscles in the
limbs, and sends it to the heart and brain. ... a feeling of being full or sick to your stomach. The
digestive system receives less blood, causing problems with digestion.
17-Difficulty concentrating or decreased alertness-:Heart failure may lead to cognitive
impairment by creating a tiny calcium leak inside the brain's neurons.
18-Chest pain if heart failure is caused by a heart attack.
19-Elevated jugular venous pressure: This happens when blood is unable to flow as it should.
The blood backs up in the vein, increasing jugular vein pressure.
20-pulsas alternans
21-Displaced apex beat
22-Right ventricular heave
23-Third heart sound-:The sound happens as a result of blood striking the left ventricle during
early diastole.
24-Hepatomegaly-:Congestive hepatomegaly is a backup of blood in the liver, resulting from
heart failure. Severe heart failure causes blood to back up from the heart into the inferior vena
cava..
25-Cachexia

Precipitating factors
Common precipitating factors of heart failure include:

-Ischemic heart diseases. -Cardiomyopathy

-Uncontrolled high blood pressure(HTN) -Heart attacks.

- Infections (such as pneumonia, myocarditis) -Arrhythmias.

-Congenital heart diseases(ASD,VSD) -Non-adherence to medications.

-Certain medications like NSAIDs or antiarrhythmics.

Investigation
Echocardiography. ECG

Electrocardiogram for ischaemia, hypertension or arrhythmia .Cardiac chamber dimension ,systolic

and diastolic function, regional wall motion abnormalities, valvular heart disease, cardiomyopathies.

*Right or left ventricular hypertrophy

*Myocardial ischemia or infarction

* Arrhythmia

Chest X-ray.CXR

Look for cardiomegaly, pulmonary congestion with upper lobe diversion, fluid in fissures, pulmonary
oedema

*Evidence of pulmonary hypertension *Pleural effusion *Cardiomegaly

CBC: Anemia

Blood urea nitrogen (BUN) and serum creatinine (Cr): Abnormal when there

decreased renal perfusion

Myocardial biopsy: Check for cardiomyopathy

Thyroid function test : Rule out thyroid disease

Serum beta natriuretic peptide (BNP): Elevated when ventricular filling pressures are high
Coronary angiography: If ischemia is likely the cause of HF

CMR (cardiac MRI). Assessment of viability in dysfunctional myocardium with the use of dobutamine

for contractile reserve or with gadolinium for delayed enhancement (‘infarct imaging’).

Cardiopulmonary exercise testing. Peak oxygen consumption (VO2) is predictive of hospital

admission and death in heart failure. A 6-minute exercise walk is an alternative

Management

A) Lifestyle changes: e. g (eating a balanced diet, doing exercise and not smoking) .
B) Medications: A combination of medicines may be used to treat heart failure :
1- Angiotensin-converting enzyme (ACE) inhibitors: reducing salt and water retention,
vasoconstriction, and sympathetic activation.
2- Angiotensin II receptor blockers (ARBs):For patients intolerant of ACE inhibitors
3- Beta blockers: Counteract adverse effects of sympathetic stimulation, reduce arrhythmia risk
4- Diuretics: Reduce plasma volume, preload, and venous congestion.
5- Digoxin: For rate control in heart failure with atrial fibrillation (AF)
6- Positive inotropes: help the heart pump blood better and maintain blood pressure
C) Surgery or other procedures *:
1- .Coronary Bypass Surgery: This procedure improves blood flow to the heart by creating a new
path for blood to travel around blocked arteries.
2- Heart Valve Repair or Replacement: If heart failure is caused by a damaged heart valve, surgery
may be necessary to repair or replace it.
3- Implantable Cardioverter-Defibrillator (ICD): Although an ICD doesn't treat heart failure directly,
it helps prevent complications by correcting life-threatening heart rhythms.
4- .Cardiac Resynchronization Therapy (CRT): is used to ensure that the lower chambers of the
heart beat in sync, improving the heart's efficiency.
5- Ventricular Assist Device (VAD): A VAD is a mechanical pump that supports the heart in pumping
blood from its lower chambers to the rest of the body.
6- .Heart Transplant: In cases of severe heart failure where other treatments are ineffective, a heart
transplant may be necessary, involving the replacement of the failing heart with a healthy donor
heart.

Drugs that may worsen HF :

The following drugs should be avoided or used with caution in patients with HF:

1- Nondihydropyridine calcium channel blockers: associated with higher HF rate of recurrence

2- NSAIDS: can worsen HF symptoms Thiazolidinediones (e.g., pioglitazone): increased risk of
congestion and hospitalization
3- Antidepressants: Consider interactions with HF pharmacotherapy.
4- Inhalation anesthetics: may induce myocardial depression and peripheral vasodilation, and
decrease sympathetic activity
5- Class IC and class III antiarrhythmic drugs: increased mortality
6- DPP-4 (e.g., saxagliptin, alogliptin): increased risk of hospitalization for HF
According to ACC /AHA Guidelines for the management of Heart failure , treatment depends on
the stage of progress:

Stage Definition Treatment

A At high risk for HF but -Quit smoking -Exercise regularly

without structural Risk
-Discontinue alcohol or illegal drug use
factors for heart disease or
symptoms of HF -If you have coronary artery disease, diabetes, high
blood pressure, lipids disorders, or other vascular or
*Hypertension.
cardiac conditions, taking medications as prescribed

B Structural heart disease but -take an ACE inhibitor or ARB(Heart disease,

without LV dysfunction, LV
without signs of heart failure)
hypertrophy
-Beta-blockers should be prescribed for patients after
signs or symptoms of HF
a heart attack

-Surgery options should be discussed for coronary

artery or valve disease

C Structural heart disease -African-American patients may be prescribed a

with prior or Most forms of hydralazine/nitrate combination if symptoms persist.
chronic HF
-Diuretics (water pills) and digoxin may be prescribed
if symptoms persist

-An aldosterone inhibitor may be prescribed when

symptoms remain severe with other therapies

-Restrict dietary sodium (salt) -Monitor weight

-Restrict fluids (as appropriate) -Pacemaker or

ICD.

D Refractory HF requiring -Patient should be evaluated to determine if the

specialized Advanced/ end following
stage HF
treatments are available options:
* Not responding to
-Ventricular assist devices
treatment .
-Surgery options -Research therapies

-Continuous infusion of intravenous inotropic drugs

-End-of-life (palliative or hospice) care