HEART FAILURE

Classification of HF
New Onset

First presentation
Acute or slow onset

Transient

Recurrent or episodic

Chronic

Persistent
Stable, worsening or
decompensated
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Killip classification

Stage 1: No Heart Failure

no clinical sign of cardiac decompensation

Stage 2: Heart Failure

S3 gallop, pulmonary venous hypertension, wet rales in the
lower half of the lung field

Stage 3: Severe Heart Failure

rales throughout the lung field

Stage 4: Cardiogenic Shock

hypotension (SBP < 90 mmHg), peripheral vasoconstriction
(oliguria, cyanosis, sweating)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Aetiology

Coronary Artery Disease

Valvular Heart Disease
Hypertension
Cardiomyopathies (HCM, DCM, RCM)
Drugs ( blockers, CCB, Antiarrhythmic)
Toxins (Alcohol, Cocaine, Mercury, Cobalt)
Endocrine (DM, Hypo/hyperthyroid, Cushing)
Nutritional (Def. thiamine, selenium, obesity)
Infiltrative (Sarcoidosis, amyloidosis)
Others (Chagas, HIV, Peripartum, ESRD)

Contractility

Heart Rate

Preload

Stroke Volume

Cardiac
Output

Afterload

Preload: the ventricular wall tension at the end of

diastole.
Afterload: the ventricular wall tension during contraction.
Contractility: property of heart muscle that accounts for
changes in the strength of contraction, independent of
preload and afterload.
Stroke volume: volume of blood ejected from ventricle
during systole. (SV = EDV ESV)
Ejection fraction (EF) = SV : EDV
Cardiac output: volume of blood ejected from ventricle
per minute. (CO = SV x HR)

Symptoms
Major symptoms
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Ankle edema
Pulmonary edema
Fatigue
Exercise intolerance
Cachexia

Minor symptoms
Weight loss
Cough
Nocturia
Palpitations
Peripheral cyanosis
Depression

Physical Findings
Major symptoms
Tachycardia
Elevated venous pressure
Positive hepatojugular reflux
Pulmonary rales
Tachypnea
Third heart sound
Hepatomegaly
Ankle edema
Ascites
Pleural effusion

Minor symptoms
Mitral regurgitation
Cardiomegaly
Splenomegaly
Hypotension
Pulsus alternans
Extrasystole
Atrial fibrillation
Weight loss

Diagnostic Studies

ECG

Heart rate
Rhythm
Conduction
Ischaemic
Infarction
Hypertrophy
BBB
Prolonged QT interval
Perimyocarditis

Chest X-ray

Should be perform as soon as possible

Cardiomegaly
Congestion
Effusion
Infiltrates
Limitations of a supine film should be noted

Laboratory test

Blood count
Electrolyte (Na, K)
Urea, creatinine
Glucose
Albumin
Hepatic enzymes
INR
Cardiac markers
Natriuretic peptides (BNP & NT-pro BNP)

Arterial blood gas analysis

Assessment of oxygenation (pO2)

Respiratory function (pCO2)

Acid-base balance (pH)

Should be assessed in severe respiratory
distress

Echocardiography
General findings:
Size and shape of the ventricle
LV ejection fraction (LVEF)
Regional wall motion; synchronicity of ventricular
contraction

LV remodeling (concentric versus eccentric)

LV or RV hypertrophy (DDhypertension, COPD, valve

disease)
Morphology and severity of valve lesions
Mitral inflow and aortic outflow properties; RV pressure
gradient
Output state (low or high)

Echocardiography (cont.)
Systolic dysfunction:
Reduced LVEF (<45%)
Enlarged left ventricle
Thin LV wall
Eccentric LV remodeling
Mild or moderate mitral regurgitation
Pulmonary hypertension
Reduced mitral filling
Signs of increased filling pressure

Echocardiography (cont.)
Diastolic dysfunction:
Normal LVEF (45%-50%)
Normal LV size
Thick LV wall, dilated atria
Concentric LV remodeling
No or minimal mitral regurgitation
Pulmonary hypertension
Abnormal mitral filling pattern
Signs of increased filling pressure

Condition associated with a poor

prognosis in HF

Advanced age
Ischaemic aetiology
Resuscitated sudden death
Poor compliance
Renal dysfunction
Diabetes
Anaemia
COPD
Depression
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Management
Non Pharmacological:

Self care management

Symptom recognition
Weight monitoring
Diet and nutrition
Fluid intake (restriction of 1.5-2 L/d)
Alcohol (limited 10-20 g/d)
Smoking cessation
Immunization (pneumococcal and influenza)
Activity and exercise training
Sexual activity
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Pharmacological
Objective
Prognosis

Reduce mortality

Morbidity

Relieve symptom and sign

Improve quality of life
Eliminate oedema
Reduce fatigue and dyspnea
Reduce need hospitalization

Prevention

Occurrence myocardial damage

Progression myocardial damage
Remodelling myocardium
Reoccurence symptom
Hospitalization
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Treatment
Normal
Asymptomatic
LV dysfunction
EF <40%
Symptomatic CHF
ACEI
NYHA II Symptomatic CHF
NYHA - III
Diuretics mild
Neurohormonal inhibitors
Symptomatic CHF
Digoxin?
Loop diuretics
NYHA - IV
Inotropes
Specialized therapy
Transplant
Secondary prevention
Modification of physical activity

Acute Heart Failure

Rapid onset of symptoms and signs secondary to

abnormal cardiac function
Can present as new onset and without previously
known cardiac dysfunction or ADHF
Often life threatening and requires urgent treatment

AHF may present with one or several clinical

conditions:
1.
2.
3.
4.
5.
6.

Worsening or Decompensated Chronic Heart Failure

Hypertensive Heart Failure
Pulmonary Oedema
Cardiogenic Shock
Isolated Right HF
ACS and HF

Causes and precipitating factors

Ischaemic heart disease

Acute coronary syndrome

Mechanical complications of acute MI
RV infarction

Valvular

Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection

Myopathies

Postpartum cardiomyopathy
Acute myocarditis

Hypertension/arrhythmias
Circulatory failure

Septicaemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism

Decompensation of pre-existing CHF

Volume overload
Infection
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug and alcohol abuse

Diagnostic of Acute Heart Failure

Based on presenting symptoms and clinical

findings
History
Physical examination
ECG
Chest X-ray
Echocardiography
Laboratory (BGA, etc)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Monitoring
Non invasive:

Vital Sign
Oxygenation
Urine output
ECG

Invasive:

Arterial line (haemodynamic unstable)

Central venous lines
Pulmonary artery catheter
Coronary angiography

Goals of treatment
Immediate (ED/ICU/ICCU)
Improved symptom
Restore oxygenation and improve organ perfusion
Limit cardiac/renal damage
Minimize ICU length of stay
Intermediate (hospital)
Stabilize patient & optimize treatment strategy
Initiate appropriate pharmacology therapy
Consider device therapy
Minimize hospital length of stay
Long term and pre discharge management
Plan follow up strategy
Education
Prevention
Quality of life

Management

Immediate symptomatic treatment

Patient distressed or in pain >> analgesia,
sedation
Pulmonary congestion >> diuretic, vasodilator
Arterial oxygen saturation < 95% >> increase
FiO2, consider CPAP, NIPPV, mechanical
ventilation
Heart rate and rhythm disorder >> pacing,
antiarrhythmics, electroversion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Oxygen

As early as possible in hypoxaemic patients to achieve

O2 saturation 95% (> 90% in COPD).

Class I, level C
NIV with PEEP as soon as possible in every patient with
acute cardiogenic pulmonary oedema
Contraindication:
- unconscious patients
- anxiety
- immediate need ET intubation
- severe obstructive airway disease
- severe Right HF

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Morphine

Morphine should be considered in the early stage of

severe AHF with restlessness, dyspnoea, anxiety, chest
pain.
Respiration should be monitored
Caution: hypotension, bradycardia, advanced AV block,
CO2 retention

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Loop diuretics

Diuretics are recommended in AHF patients with

congestion and volume overload.
Class I, level B
Adverse effect:
- hypokalaemia, hyponatraemia
- hyperuricaemia
- hypovolaemia and dehydration
- neurohormonal activation
- may increase hypotension following ACEI/ARB therapy
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Vasodilators

Vasodilators are recommended at an early stage for AHF

without hypotension or serious obstructive valvular
disease.
Class I, level B
Adverse effect:
- headache (nitrat)
- tachyphylaxis (nitrat)
- hypotension (NTG or nesiritide infusion)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Inotropic agents

Inotropic agents should be considered in low output

states, in the presence of hypoperfusion or congestion.
Dobutamine (class IIa, level B)
Dopamine (class IIb, level C)
Milrinone and enoximone (class IIb,level B)
Levosimendan (class IIa, level B)
Norepinephrine (class IIb, level C)
Cardiac glycoside (class IIb, level C)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008