HEART FAILURE

Definition:

• A clinical syndrome that develops when heart cannot

maintain an adequate cardiac out put or can do it only at
the expense of an elevated filling pressure.

• Results from any structural or functional abnormality that

impairs the ability of the ventricle to eject blood or to fill
with blood
Epidemiology

• About one third of all patients with congestive heart failure have diastolic heart
failure

• Prevalence is highest in patients older than 75 years old

• Mortality rate is about 5-8 % annually as compared to 10-15% among patients

with systolic heart failure

• Mortality rate is directly related to age and the presence/absence of coronary

disease.
Types of Heart failure

* Left, Right ,Biventricular

* Diastolic and systolic dysfunction

* High output and Low output failure

* Acute and Chronic failure

 Types of Heart failure…

•Low-Output Heart Failure:

•Systolic Heart Failure:

•Decreased cardiac output
•Decreased Left ventricular ejection fraction

•Diastolic Heart Failure:

•Elevated Left and Right ventricular end-diastolic pressures
•May have normal LVEF
• High-Output Heart Failure:

• Seen with peripheral shunting, low-systemic vascular

resistance, hyperthryoidism, beri-beri, carcinoid, anemia

• Often have normal cardiac output

• Right-Ventricular Failure

• Seen with pulmonary hypertension, large RV infarctions,

fluid overload
Causes

• Systolic Dysfunction

• Coronary Artery Disease

• Idiopathic dilated cardio-myopathy (DCMP)

• 50% idiopathic (at least 25% familial)
• 9 % mycoarditis (viral)
• Ischemic heart disease, prepartum, hypertension, HIV, connective tissue diseases,
substance abuse, drugs - doxorubicin

• Hypertension

• Valvular Heart Disease

• Diastolic dysfunction

• Hypertension

• Coronary artery disease (CAD)

• Hypertrophic obstructive cardio-myopathy (HOCM)

• Restrictive cardio-myopathy
Left sided failure

Signs:
• Tachypnea
• 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 hypoxemia, is a late sign of
extremely severe pulmonary edema.
Right sided heart failure- Signs

• Peripheral edema
• Ascites
• Hepatomegaly
• Jugular venous pressure is frequently assessed as a marker of fluid
status, which can be accentuated by the hepatojugular reflux.
• If the right ventricular pressure is increased, a parasternal heave
may be present, signifying the compensatory increase in
contraction strength.
Biventricular failure

• Most common cause of right-sided heart failure is left-

sided heart failure, therefore, patients present with both
sets of signs and symptoms.

• Dullness of the lung fields to finger percussion and

reduced breath sounds at the bases of the lung may
suggest the development of a pleural effusion and a
more common sign of biventricular failure
Precipitating factors

• Uncontrolled hypertension
• Atrial Fibrillation (AF), Infective endocarditis, Hyperthyroidism.
Hypothyroidism
• Non-compliance with or inappropriate discontinuation of
medications for heart failure
• Myocardial ischemia
• Anemia, fever, pulmonary infections
• Renal insufficiency
NYHA Classification

Class Description

No limitation of physical activity - ordinary physical activity doesn't cause tiredness,

I (Mild) heart palpitations, or shortness of breath

Slight limitation of physical activity, comfortable at rest, but ordinary physical activity
II (Mild) results in tiredness, heart palpitations, or shortness of breath

Marked or noticeable limitations of physical activity, comfortable at rest, but less

III (Moderate) than ordinary physical activity causes tiredness, heart palpitations, or shortness of
breath
Severe limitation of physical activity, unable to carry out any physical activity without
IV discomfort. Symptoms also present at rest. If any physical activity is undertaken,
(Severe) discomfort increases.
Investigations

• In all patients- total count, hemoglobin, ectrolytes, creatinine ,

liver function studies, urine analysis.

• Chest X-ray: PA lateral view-detects increased transverse

diameter of the heart, pulmonary venous congestion, pulmonary
edema, Kerley B lines, pleural effusion.

• ECG: for evidence of underlying LVH; sinus tachycardia,

intraventricular conduction defects, non specific STT changes.
• ECHOCARDIOGRAPHY : most useful diagnostic test, distinguishes
systolic and diastolic dysfunction , detects regional wall motion
abnormalities, gives prognostic information.

• Can dignose valvular, congenital disease or cardiomyopathy.

• BNP LEVELS: useful diagnostically; levels correlates with severity of HF,

falls as patient reaches compensatory phase.

• IN SELECTED PATIENTS: blood culture(inf endocarditis)

• Exercise test(coronary ds)

• Metabolic exercise test( diff cardiac exertional dyspnea from ventilatory defect
causing dyspnea)

• Lung scan(pulmonary embolism)

• Cardiac catheterisation

• Pulmonary angiography

• Thyroid function tests

• Liver function may be abnormal due to congestion

Complications

• Pleural effusion

• Atrial fibrillation (most common dysrhythmia)

• Loss of atrial contraction (kick) -reduce CO by 10% to 20%
• Promotes thrombus/embolus formation inc. risk for stroke
• Treatment may include cardioversion, antidysrhythmics,
and/or anticoagulants
• **High risk of fatal dysrhythmias (e.g., sudden cardiac
death, ventricular tachycardia) with HF and an EF <35%

• HF lead to severe hepatomegaly, especially with RV

failure
• Fibrosis and cirrhosis - develop over time
• Renal insufficiency or failure
• Cardiac cirrhosis
8 D’s of Heart failure treatment

• Decubitus
• Diet
• Digoxin
• Deriphylline
• Diuretics
• Diazepam
• Dilators
• Dopamine
AIM of the treatment

• Decrease in symptoms (e.g., shortness of breath, fatigue)

• Decrease in peripheral edema

• Increase in exercise tolerance

• Compliance with the medical regimen

• No complications related to HF
Treatment

• Decrease preload
• Decrease intravascular volume
• Decrease venous return i.e.
• Fowlers
• MSO4 and Ntg

• Decrease afterload

• Increase cardiac performance(contractility)

• CRT (cardiac resynchronization therapy)
• Balance supply and demand of oxygen
• Increase O2:

- O2, intubate, mechaanical ventilation with PEEP (if ADHF/PE)

• Decrease demand- use beta blockers, rest, decrease B/P
Drug therapy

▪ Vasodilators
• Diuretics ▪ ACE inhibitors- pril or ril
*first line heart failure
• Thiazide ▪ Angiotensin II receptor
blockers
• Loop ▪ Nitrates
▪ b-Adrenergic blockers- al
• Spironolactone or ol
▪ Nesiritide- Natrecor
(BNP)
• Drug therapy (cont’d)
• Positive inotropic agents
• Digitalis
• Calcium sensitizers- (Levosimendan) new under research;
cardioprotective, inc. cardiac contractility

• BiDil (combination drug containing isosorbide dinitrate

and hydralazine) approved only for the treatment of HF
in African Americans
• Nutritional therapy
• Diet/weight reduction recommendations-individualized
and culturally sensitive
• Dietary Approaches to Stop Hypertension (DASH) diet
recommended
• Sodium- usually restricted to 2.5 g per day
• Potassium encouraged unless on K sparing diuretics
(Aldactone)
Non pharmacological therapy

• Nonpharmacologic therapies
• Intraaortic balloon pump (IABP) therapy
• Used for cardiogenic shock
• Allows heart to rest
• Ventricular assist devices (VADs)
• Takes over pumping for the ventricles
• Used as a bridge to transplant
• Destination therapy-permanent, implantable VAD
• Cardiomyoplasty- wrap latissimus dorsi around heart
• Ventricular reduction -ventricular wall resected
• Transplant/Artificial Heart