Heart Failure

Heart Failure
Heart (or cardiac) failure is the state in which
the heart is unable to pump blood at a rate
commensurate with the requirements of the
tissues or can do so only from high pressures

Braunwald 8th Edition, 2001

Types of Heart Failure
Systolic Dysfunction
Coronary Artery Disease
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive
cardiomyopathy (HCM)
Restrictive cardiomyopathy
Mechanisms and Causes of HF

Impaired Contractility Increased Afterload

Myocardial infarction AS
Transient ischemia Uncontrolled HTN
Chronic volume overload Systolic Dysfunction
MR/AR
Dilated cardiomyopathy
Left Sided HF

Diastolic Dysfunction

Obstruction of LV filling Impaired ventricular relaxation

MS LVH
Pericardial constriction or Hypertrophic cardiomyopathy
tamponade Restrictive cardiomyopathy
Transient ischemia
Mechanisms and Causes of HF
Cardiac Causes
Left sided HF
Pulmonary stenosis
Right ventricular infarction

Right Sided HF

Parenchymal pulmonary disease

Pulmonary Vascular Disease COPD
Pulmonary emobolism
Interstitial lung disease
Pulmonary HTN
Chronic infections
Right ventricular infarction
Adult respiratory distress syndrome
Pathophysiology
Pathophysiology of Heart
Failure
Increased contractility
Stroke volume (cardiac

Normal

A
Heart Failure
output)
Hypotension

B C

Pulmonary congestion

Left ventricular end diastolic pressure (volume)

Compensatory Mechanisms:
Renin-Angiotensin-Aldosterone System
Beta Renin + Angiotensinogen
Stimulation
CO Angiotensin I
Na+ ACE
Angiotensin II
Kaliuresis
Aldosterone Secretion Fibrosis
Peripheral
Vasoconstrictio
n Salt & Water Retention

Afterload Plasma Volume Edema

Preload
Cardiac Output
Cardiac Workload

Heart Failure
Congestive Heart Failure
Framingham Criteria for Congestive Heart
Failure

Diagnosis of CHF requires the simultaneous

presence of at least 2 major criteria or 1
major criterion in conjunction with 2 minor
criteria.

The Framingham Heart Study criteria are 100%

sensitive and 78% specific for identifying
persons with definite congestive heart failure.
 Symptoms

Major symptoms Minor symptoms

Paroxysmal nocturnal dyspnea Bilateral ankle edema
Neck vein distention Nocturnal cough
Rales Dyspnea on ordinary exertion
Radiographic cardiomegaly Hepatomegaly
(increasing heart size on chest Pleural effusion
radiography) Decrease in vital capacity by
Acute pulmonary edema one third from maximum
S3 gallop recorded
Increased central venous Tachycardia (heart rate>120
pressure (>16 cm H2O at right beats/min.)
atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in
response to treatment
 Signs and symptoms of CHF
Shortness of breath often with activities or while
lying flat
Weakness and fatigue
Awakening short of breath at night
Need for increased pillows at night helps lungs
drain of excess fluid
Coughing or wheezing
Swelling of feet and legs or other dependent areas
Anorexia/loss of appetite
Weight gain
Symptoms of HF

Fatigue
Activity decrease
Cough (especially supine)
Edema
Shortness of breath
 Right Heart Failure

Signs and Symptoms

fatigue, weakness,
lethargy
wt. gain, inc. abd.
girth, anorexia
elevated neck veins
Hepatomegaly +HJR
may not see signs of
LVF
Classifying Heart Failure:
Terminology and Staging
A Key Indicator for Diagnosing Heart
Failure
Ejection Fraction (EF)
Ejection Fraction (EF) is the percentage of
blood that is pumped out of your heart
during each beat
Heart Failure
Etiology and Pathophysiology

Systolic failure- most common cause

Hallmark finding: Dec. in *left ventricular
ejection fraction (EF)
Due to
Impaired contractile function (e.g., MI)
Increased afterload (e.g., hypertension)
Cardiomyopathy
Mechanical abnormalities (e.g., valve
disease)
Heart Failure
Etiology and Pathophysiology
Diastolic failure
Impaired ability of ventricles to relax and fill
during diastole > dec. stroke volume and CO
Diagnosis based on presence of pulmonary
congestion, pulmonary hypertension, ventricular
hypertrophy
*normal ejection fraction (EF)- Know why!
 Heart Failure
Etiology and Pathophysiology

Mixed systolic and diastolic failure

Seen in disease states such as dilated
cardiomyopathy (DCM)
Poor EFs (<35%)
High pulmonary pressures
Biventricular failure (both ventricles may be
dilated and have poor filling and emptying
capacity)
 Factors effecting heart
pump effectiveness
Preload
Volume of blood in ventricles at end diastole
Depends on venous return
Depends on compliance

Afterload
Force needed to eject blood into circulation

Arterial B/P, pulmonary artery pressure

Valvular disease increases afterload

ACC/AHA Stages

NY ASSN Funct Class

How Heart Failure Is Diagnosed
Medical history is taken to reveal symptoms
Physical exam is done
Tests
Chest X-ray
Blood tests
Electrical tracing of heart (Electrocardiogram or
ECG)
Ultrasound of heart (Echocardiogram or Echo)
X-ray of the inside of blood vessels (Angiogram)
Pulmonary vessel congestion
 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
 Indications for Coronary
Angiography

Heart failure patients with angina

Patients with prior myocardial infarction or known
coronary artery disease
Patients (younger than 65 yr) with unexplained
heart failure
Positive exercise test in patients with
cardiovascular risk factors
Heart failure patients with positive scintigraphy,
stress echocardiography, or positron emission
tomography results
Heart failure patients with severely dyskinetic
myocardium
DIET Approach With Heart
Failure
Educate
Diagnose Diet
Etiology Exercise
Severity (LV dysfunction)
Lifestyle
Initiate
CV Risk
Diuretic/ACE inhibitor
-blocker Titrate
Spirololactone Optimize ACE
Digoxin inhibitor
Optimize -
blocker
 Treating Congestive Heart
failure
Upright position
Nitrates
Lasix
Oxygen
ACE inhibitors
Digoxin

Fluids(decrease)
After load (decrease)
Sodium retention
Test (Dig level, ABGs, Potassium level)
 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. Worsening or Decompensated Chronic Heart Failure
2. Hypertensive Heart Failure
3. Pulmonary Oedema
4. Cardiogenic Shock
5. Isolated Right HF
6. ACS and HF
 Clinical classifications

Dry and Wet and

Tissue perfusion

warm warm

Dry and Wet and

cold cold

Pulmonary
congestion

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
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
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
FLUID OVERLOAD > Acute
Decompensated Heart Failure
(ADHF)/Pulmonary Edema

>Medical
Emergency!
 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
Patient counseling

Lifestyle changes

Monitoring for changes

Medications

Surgery
Patient counseling

Lifestyle changes
Stop smoking
Loose weight
Avoid or limit alcohol
Avoid or limit caffeine
Eat a low-fat, low-sodium diet
Exercise
Patient counseling

Reduce stress
Keep track of symptoms and
weight and report any changes
or concern to the doctor
Limit fluid intake
See the doctor more frequently
Heart Failure
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
Heart Failure
Complications
**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
 Thank
you