CARDIOVASCULAR

DISEASES
Dr Raveendra K.R
Assistant professor
Department of Medicine
BMC
Bangalore

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HEART FAILURE
(CCF/CHF)

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INTRODUCTION

Expected outcome of all cardiac diseases

Commonest cause is IHD and hypertension
Prevalence (UK) is 1% between 50-59 years
and 5-10% between 80-89 years
Both myocardial and extra-myocardial
causes contribute
HF with LV dysfunction mortality is very
high upto 50%

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DEFINITION

Inability of heart (LV) to pump a satisfactory

cardiac output to meet the demands of the
body or perfuse the vital organs

Failure of the HEART as a pump

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ETIOLOGY

Inflow tract obstruction MS ,TS

Outflow tract obstruction HTN ,AS ,PS PH
Problem in myocardium MI ,myocarditis
Problem in the blood (volume overload)
MR,AR,VSD,ASD,Anemia
Arrhythmias SVT ,VT ,CHB
Miscellaneous (diastolic dysfunction)
Constrictive pericarditis

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PREDISPOSING FACTORS
Infection
Anemia
Pregnancy
Infective endocarditis
MI
Hypertension
Physical\emotional stress
Rheumatic fever
Thyrotoxicosis
Pulmonary embolism
Arrhythmias
Drugs Beta blockers ,NSAIDS ,Steroids

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Compensatory mechanism of heart
failure
Dilatation of ventricles ( to increase stroke
volume)
Retention of sodium and water by kidneys
Increased sympathetic activity (increased HR
)
Increased Renin-angiotensin Increased
aldosterone leading to Sodium and water
retention
Myocardial hypertrophy
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Forms of heart failure

Acute vs Chronic heart failure

Right vs left
Forward vs backward
Systolic vs diastolic
High output vs low output

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Clinical features

Progressive fatigue \ Generalised weakness

Breathlessness exertional
Orthopnea and PND
Cheyne Stokes respiration
Edema Sacral \ Pedal
Syncope \Altered sensorium \Nocturia

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Clinical examination

Cyanosis
Pulsus alternans
Sinus tachycardia
S3/S4
Pulmonary rales
Increased JVP
Tender hepatomegaly
Pedal edema
Ascites
Jaundice
Cardiac cachexia
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Features of Right heart failure

Increased JVP
Tender hepatomegaly
Pedal edema
Systemic venous distension
S3

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Features of left heart failure

Dyspnea
Orthopnea
PND
Bilateral basal rales
S3

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Features of acute heart failure

Acute breathlessness
Progressive breathlessness ( At rest )
Acute causes MI / Arrhythmia /IE /Aortic
dissection /rupture mechanical valve
Increased JVP ,Triple gallop rhythm
Acute respiratory distress /orthopnea

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DDs for heart failure

Pulmonary embolism
ARDS
Ankle edema causes Renal disease
Cirrhosis liver
Hypoprotenemia

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Investigations

ECG
Chest X ray
2D Echo
Coronary angiogram
Hemogram
FBS ,PPBS ,
TFT ,Serum electrolytes

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Chest X-ray in LHF

Distension of upper lobe pulmonary veins

Prominent vascularity (lung)
Right to left pulmonary arteries dilatation
Interstitial edema /dilated lymphatics
Kerley B lines horizontal lines in
costophrenic angle /interlobular effusion
Hazy opacities alveolar edema
Pleural effusion

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Treatment of heart failure

Removal of precipitating cause

Treatment of cause
Control of congestive heart failure state

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Principles in management

Reduction of cardiac load (pre /post load )

Control of sodium and water intake
Enhancement of myocardial contraction

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Diet and exercise

Sodium ,water and fat restricted diet

Easily digestible food /vitamin rich
Reducing physical activity
Bed rest in severe heart failure
Advised emotional rest

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Drug therapy in Chronic Heart
failure
Diuretics
Digoxin
Vasodilators
ACE inhibitors
ARBS
Beta blockers

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Diuretics in heart failure

Low potency Spironolactone ,Amiloride

,Triamterene
Mid potency Thiazide
High potency Furosemide ,Torsemide
Increased Sodium and water excretion
Decreases preload ,decreases Systemic
/Pulmonary venous congestion

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Digoxin

Positive inotropic ,negative chronotropic

Half life 1.6 days ,85% excreted in urine
Acts on AV node and vagus
Increases refractory period of AV node
Acts through Na+ - K+ ATPase ( Na+ - Ca +)
Dosage 0.25 mg od (5/7)

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Digitalis intoxication

Common ,serious ,potentially fatal

Predisposition Hypokalemia
/hypomagnesemia/hypothyroid,Cardioversio
n ,IHD ,Renal dysfunction ,Old age
GIT symptoms Anorexia ,nausea and
vomiting
Arrhythmias PVC ,bigeminy ,AV blocks ,SA
block , Junctional /multifocal VT
Chronic gynaecomastia ,neuralgia ,cachexia
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Treatment of digoxin
toxicity
Withdraw digoxin
Lethal dose is 5 times minimmum effective
dose
Supplement Potassium in Hypokalemia
Lidocaine /Phenytoin for digoxin induced VT
Pacemaker for AV blocks
Digoxin Fab-Abs

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ACEI \ARBS in heart failure

Prevent \block angiotensin pathway

Decreases afterload
Used in the prevention of HF
Helps in remodelling of myocardium
Decreases cardiovascular events ( decrease
mortality )

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Beta blockers in HF

Decrease sympathetic stimulation

Decreases chances of arrhythmias /SCDS
Bisoprolol 1.25 mg od ,Metoprolol 2.5 mg od
They increase EF ,Decrease symptoms
,Decrease mortality and morbidity

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Amrinone /milrinone

Bipyridine ,non catecholamine ,non glycoside

+ve inotropic and vasodilator
Inhibit specific phosphodiesterase
Amrinone for IV use
Milrinone for oral use

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Complications of HF

Cardiogenic shock
Prerenal renal failure
Thromboembolism
Arrhythmias
Refractory HF
Death

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Refractory Heart failure

Inadequate response for treatment ( 6 months)

Reevaluate history ,examination
,investigations
Wrong diagnosis /improper treatment
/precipitating factor
Underlying /overlooked case (surgical )
Finally IV sodium nitroprusside /Dobutamine
/Amrinone
Last option Heart transplantation
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