CONGESTIVE HEART FAILURE

Heart Failure
Results from any structural or functional
abnormality that impairs the ability of the
ventricle to eject blood (Systolic Heart Failure)
or to fill with blood (Diastolic Heart Failure).
The Vicious Cycle of Congestive Heart
Failure

LV Dysfunction causes Decreased Blood Pressure and

Decreased cardiac output Decreased Renal perfusion

Stimulates the Release

of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure
 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.
 Causes of Low-Output Heart Failure

Systolic Dysfunction
Coronary Artery Disease
Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial)
9 % mycoarditis (viral)
Ischemic heart disease, perpartum, hypertension, HIV, connective tissue
disease, substance abuse, doxorubicin
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
 Clinical Presentation of Heart Failure

Due to excess fluid accumulation:

Dyspnea (most sensitive symptom)
Edema
Hepatic congestion
Ascites
Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)
Due to reduction in cardiac ouput:
Fatigue (especially with exertion(
Weakness
 Physical Examination in Heart Failure

S3 gallop
Low sensitivity, but highly specific
Cool, pale, cyanotic extremities
Have sinus tachycardia, diaphoresis and peripheral vasoconstriction
Crackles or decreased breath sounds at bases (effusions) on lung exam
Elevated jugular venous pressure
Lower extremity edema
Ascites
Hepatomegaly
Splenomegaly
Displaced PMI
Apical impulse that is laterally displaced past the midclavicular line is usually indicative of
left ventricular enlargement>
Measuring Jugular Venous Pressure
 Lab Analysis in Heart Failure
CBC
Since anemia can exacerbate heart failure
Serum electrolytes and creatinine
before starting high dose diuretics
Fasting Blood glucose
To evaluate for possible diabetes mellitus
Thyroid function tests
Since thyrotoxicosis can result in A. Fib,
and hypothyroidism can results in HF.
Iron studies
To screen for hereditary hemochromatosis as cause of heart failure.
ANA
To evaluate for possible lupus
Viral studies
If viral mycocarditis suspected
 Chest X-ray in Heart Failure
Cardiomegaly
Cephalization of the pulmonary vessels
Kerley B-lines
Pleural effusions
Cardiomegaly
Pulmonary vessel congestion
Kerley B lines
 Cardiac Testing in Heart Failure

Electrocardiogram:
May show specific cause of heart failure:
Ischemic heart disease
Dilated cardiomyopathy: first degree AV block, LBBB, Left
anterior fascicular block
Amyloidosis: pseudo-infarction pattern
Idiopathic dilated cardiomyopathy: LVH
Echocardiogram:
Left ventricular ejection fraction
Structural/valvular abnormalities
 Further Cardiac Testing in Heart Failure

Exercise Testing
Should be part of initial evaluation of all patients with CHF.
Coronary arteriography
Should be performed in patients presenting with heart failure who have
angina or significant ischemia
Reasonable in patients who have chest pain that may or may not be
cardiac in origin, in whom cardiac anatomy is not known, and in patients
with known or suspected coronary artery disease who do not have angina.
Measure cardiac output, degree of left ventricular dysfunction, and left
ventricular end-diastolic pressure.
 Further testing in Heart Failure
Endomyocardial biopsy
Not frequently used
Really only useful in cases such as viral-induced
cardiomyopathy
 Classification of Heart Failure

New York Heart Association (NYHA)

Class I symptoms of HF only at levels that would
limit normal individuals.
Class II symptoms of HF with ordinary exertion
Class III symptoms of HF on less than ordinary
exertion
Class IV symptoms of HF at rest
 Classification of Heart Failure (cont.)

ACC/AHA Guidelines
Stage A High risk of HF, without structural heart
disease or symptoms
Stage B Heart disease with asymptomatic left
ventricular dysfunction
Stage C Prior or current symptoms of HF
Stage D Advanced heart disease and severely
symptomatic or refractory HF
 Chronic Treatment of Systolic Heart Failure

Correction of systemic factors

Thyroid dysfunction
Infections
Uncontrolled diabetes
Hypertension
Lifestyle modification
Lower salt intake
Alcohol cessation
Medication compliance
Maximize medications
Discontinue drugs that may contribute to heart failure (NSAIDS,
antiarrhythmics, calcium channel blockers)
 Order of Therapy
1. Loop diuretics
2. ACE inhibitor (or ARB if not tolerated)
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs
 Diuretics
Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve symptoms
Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Shown to improve survival in CHF
 ACE Inhibitor
Improve survival in patients with all severities
of heart failure.
Begin therapy low and titrate up as possible:
Enalapril 2.5 mg po BID
Captopril 6.25 mg po TID
Lisinopril 5 mg po QDaily
If cannot tolerate, may try ARB
 Beta Blocker therapy
Certain Beta blockers (carvedilol, metoprolol, bisoprolol)
can improve overall and event free survival in NYHA class II
to III HF, probably in class IV.
Contraindicated:
Heart rate <60 bpm
Symptomatic bradycardia
Signs of peripheral hypoperfusion
COPD, asthma
PR interval > 0.24 sec, 2nd or 3rd degree block
 Hydralazine plus Nitrates
Dosing:
Hydralazine
Started at 25 mg po TID, titrated up to 100 mg po TID
Isosorbide dinitrate
Started at 40 mg po TID/QID

Decreased mortality, lower rates of

hospitalization, and improvement in quality of
life.
 Digoxin
Given to patients with HF to control symptoms
such as fatigue, dyspnea, exercise intolerance
Shown to significantly reduce hospitalization
for heart failure, but no benefit in terms of
overall mortality.
 Other important medication in Heart Failure --
Statins
Statin therapy is recommended in CHF for the
secondary prevention of cardiovascular
disease.
Some studies have shown a possible benefit
specifically in HF with statin therapy
Improved LVEF
Reversal of ventricular remodeling
Reduction in inflammatory markers (CRP, IL-6, TNF-
alphaII)