Pathophysiology and Physic Diagnostic of Heart Failure

Dhani Tri Wahyu Nugroho, MD

DEFINITION
Heart failure is a clinical syndrome characterized by decreased systemic
perfusion, inadequate to meet the body's metabolic demands as a result of
impaired cardiac pump function. Eugiene Braunwald defition of heart failure is
pathophysiologic state in which an abnormality of cardiac function is responsible
for failure of the heart to pump blood at a rate commensurate with metabolic
requirements of the tissues.
Heart failure is complex clinical syndrome that can result from any
struktural or functional cardiac disorder that impairs the ability ventricle to fill
with or eject blood and also impairs the ability of function as a pump to support a
physiological circulation.
Congestive heart failure similar to the above definitions but with features
of circulatory congestion (fluid retention) such as jugular venous distention,
rales, peripheral edema, and ascites.
HFpEF referred to as heart failure with preserved systolic function, and
this condition may also be referred to as diastolic heart failure. In diastolic heart
failure left ventricle loses its ability to relax normally (because the muscle has
become stiff). The heart can't properly fill with blood during the resting period
between each beat. HFrEF may also be called heart failure with low ejection
fraction, or heart failure with reduce systolic function, other similar terms
meaning systolic heart failure. The left ventricle loses its ability to contract
normally. The heart can't pump with enough force to push enough blood into
circulation. Between this two definition is HFmEF (moderate ejection fraction)
which echocardiography is useful method for separation three definition above.

ETIOLOGY AND PREVENTION POLICY

Preventing heart failure is of paramount importance. Once established,
the deterioration in the heart’s condition can often be treated, but typically
cannot be reversed. Policy-maker should highlight the need for healthcare
profesionals across all clinical diciplines to identify patient with illnesses that
increase the risk of heart failure and prescribe preventive medications. Equity of
access to preventive medications should be provided for those at greatest risj of
developing heart failure, regardless of age or income.
The clinical picture of heart failure is complex because there are many
posible causes of heart failure, and some are illnesses in their own right. Many
cases of heart failure can be regarded as the end stage of other underlying illness
and could be prevented if patients with these illnesses were identified and
treated appropriately at an early stage.
CHD and prior myocardial infarction (MI) account for approximately two
thirds of systolic heart failure cases. Ischaemic heart disease is present in over
50% of new cases. Essential hypertension may contribute to heart failure via
increased afterload and acceleration of CHD. Non-ischaemic idiopathic dilated
cardiomyopathy— patients tend to be younger, and at least 30% of cases appear
to be familial.15 Idiopathic dilated cardiomyopathy is present in approximately
5–10% of new cases. Uncommon cause systolic heart failure valvular heart
disease, especially mitral and aortic incompetence.
 Heart failure with preserved ejection fraction majority common cause is
hypertension (especially systolic hypertension). Patients tend to be female and
elderly. This cause now represents 40–50% of all hospital admissions for HF.
CHD, which may lead to impaired myocardial relaxation. men with diabetes are
twice as likely to develop heart failure than men without diabetes, and women
with diabetes are at a fivefold greater risk than women without diabetes.
Diabetes is additionally associated (independent of ischaemia) with interstitial
fibrosis, myocyte hypertrophy and apoptosis, as well as both autonomic and
endothelial dysfunction, all of which may contribute to the diabetic
cardiomyopathic state.
Across the globe, 17-45% of patient admitted to hospital with heart
failure die within 1 year of admission and the majority die within 5 years of
admission. In recent years, survival rates for patient with heart failure have
improved parallel with the introduction of modern evidence-based therapies and
patient-management systems. Population-based studies have found that about 1-
2% of people have heart failure. Another contributing factor to these increasing
numbers is improvement in treating heart attacks and other cardiovascular
disease with high risk of going on the develop heart failure.
Heart failure cause large numbers of deaths and widespread ill health,
and exacts huge economic and social costs-and the problem is become worse.

PHYSIC DIAGNOSTIC OF HEART FAILURE

Compliance with clinical practice guidelines is ofteb associated with
improved outcomes for patients with heart failure. It is important to encorage
heart failure education programmes that raise awareness of guidelines among all
appropriate healthcare professionals. Secondly, improvements in care should be
encouraged through the use of performance measures and incentives appropiate
to the locality.
The published guidelines therefore make different specific
recommendations, but all agree that there are three essential stages of care for
patients with heart failure :
 Diagnosis – should be timely and accurate
 Treatment – should be appropiate to each patient and available urgently,
if necessary
 Long-term management – should include follow up, monitoring and
support.

Diagnosis heart failure can be chalenging, even for trained profesionals.

Not all patients with heart failure have typical symptoms, and the same symptom
can be experienced by patients who do not have heart failure. Making an
accurate diagnosis requires a range of diagnostic tool and information, in
conjunction with clinical judgemnet and expert knowledge.
Full medical history is important, both in determining the cause/s of HF
(including past history of CHD, hypertension, or rheumatic fever; alcohol
consumption; family history of HF or cardiomyopathy), and assessing the
severity of the disease.
The following symptoms may occur in patients with HF :
 Exertional dyspnoea is present in most patients, initially with more
strenuous exertion, but later progresses to occur on level walking and
 eventually at rest. It also occurs in many other conditions.
 Orthopnoea—patients may prop themselves up on a number of pillows to
sleep. This indicates that the symptoms are more likely to be due to HF,
but occur at a later stage.
 Paroxysmal nocturnal dyspnoea (PND) also indicates that the symptoms
are more likely to be due to HF; but most patients with HF do not have
PND.
 Dry irritating cough may occur, particularly at night. Patients may be
mistakenly treated for asthma, bronchitis or ACEI-induced cough.
 Fatigue and weakness may be prominent, but are common in other
conditions.
 Dizzy spells or palpitations which may indicate an arrhythmia
Clinical diagnosis of HF is often unreliable, especially in obese patients, those
with pulmonary disease and the elderly. Therefore, it is important to perform
investigations to confirm the diagnosis.
A careful physical examination is important for initial diagnosis of HF,
identification of potential causes or aggravating factors, and ongoing evaluation
of disease status. It is very important to appreciate that patients with CHF may
show no detectable abnormal physical signs, because they are typically a late
manifestation. Furthermore, many of the signs may occur in other conditions. It
may also be difficult to detect physical signs that are present unless the doctor is
experienced in examining CHF patients. Consequently, investigations for
suspected CHF should often be initiated on the basis of symptoms alone, most
commonly unexplained breathlessness.
The following sign may be present :
 Signs of underlying cardiac disease, including a displaced apex beat, or a
murmur which may indicate underlying valve disease
 signs of fluid retention, including soft basal inspiratory crepitations which
do not clear with coughing, resting tachypnoea (requiring the patient to
sit up to obtain relief), raised jugular venous pressure, ankle and sacral
oedema, ascites or tender hepatomegaly
 signs of cardiac strain, including tachycardia or a third heart sound
 other abnormal vital signs