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 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

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.
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 one
• Acute pulmonary edema third from maximum recorded
• S3 gallop • Tachycardia (heart rate>120
• Increased central venous pressure beats/min.)
(>16 cm H2O at right atrium)
• Hepatojugular reflux
• Weight loss >4.5 kg in 5 days in
response to treatment
A normal heart pumps blood in a smooth and synchronized way.
Heart Failure Heart

A heart failure heart has a reduced ability to pump blood.

 Systolic (or squeezing) heart failure
◦ Decreased pumping function of the heart, which
results in fluid back up in the lungs and heart

 Diastolic (or relaxation) heart failure

◦ Involves a thickened and stiff heart muscle
◦ As a result, the heart does not fill with blood
◦ This results in fluid backup in the lungs and heart
 Signs and Symptoms
◦ fatigue, weakness,
◦ wt. gain, inc. abd.
girth, anorexia
◦ elevated neck veins
◦ Hepatomegaly +HJR
◦ may not see signs of
What does this
 What is this called?
 Coronary artery
disease  Diabetes
 Congenital heart defects
 Hypertension (LVH)
 Other:
 Valvular heart
disease ◦ Obesity
 Alcoholism ◦ Age
 Infection (viral) ◦ Smoking
◦ High or low hematocrit leve
◦ Obstructive Sleep Apnea

CAD=coronary artery disease; LVH=left ventricular hypertrophy.

10 More deaths from heart
Heart Failure Patients in US

10 
failure than from all forms
8 of cancer combined

 550,000 new cases/year

 4.7 million symptomatic
4 3.5 patients; estimated 10
million in 2037

1991 2000 2037*

*Rich M. J Am Geriatric Soc. 1997;45:968–974.

American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.
 Pleural effusion
 Atrial fibrillation (most common
◦ 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
 **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
Ejection Fraction (EF)
 Ejection Fraction (EF) is the percentage of
blood that is pumped out of your heart
during each beat
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
I Asymptomatic
B Structural heart disease but without
symptoms of heart failure

II Symptomatic with moderate exertion

C Structural heart disease with prior or
current symptoms of heart failure
III Symptomatic with minimal exertion

D Refractory heart failure requiring IV Symptomatic at rest

specialized interventions

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
 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)
 Heart rate
 Rhythm
 Conduction
 Ischaemic
 Infarction
 Hypertrophy
 Prolonged QT interval
 Perimyocarditis
 Should be perform as soon as possible
 Cardiomegaly
 Congestion
 Effusion
 Infiltrates
 Limitations of a supine film should be noted
 Blood count
 Electrolyte (Na, K)
 Urea, creatinine
 Glucose
 Albumin
 Hepatic enzymes
 Cardiac markers
 Natriuretic peptides (BNP & NT-pro BNP)
 Assessment of oxygenation (pO2)
 Respiratory function (pCO2)
 Acid-base balance (pH)
 Should be assessed in severe respiratory
General findings:
 Size and shape of the ventricle

 LV ejection fraction (LVEF)

 Regional wall motion; synchronicity of ventricular

 LV remodeling (concentric versus eccentric)

 LV or RV hypertrophy (DD—hypertension, COPD,

valve disease)
 Morphology and severity of valve lesions

 Mitral inflow and aortic outflow properties; RV

pressure gradient
 Output state (low or high)
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

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

Dark blood imaging Wall thickness, morphology of the
myocardium, tumor masses

Bright blood imaging Wall thickness, geometry of the

Myocardial tagging Cardiac rotation, shear motion,
torsion, myocardial twist

Phase contrast imaging Blood flow velocity, cardiac output,

pressure gradients
Contrast enhancement Myocardial fibrosis, ischemic zone,
infarct size
MR coronary angiography Coronary anatomy, coronary
Stress imaging Wall motion abnormalities,
recruitable stroke work, ischemic
Perfusion and diffusion imaging Perfusion abnormalities, territory,
ischemic zone
Spectroscopy Viability, energy-rich
 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
Coronary artery Death

Hypertension Myocardial Pathologic Low ejection

injury remodeling fraction Death

Valvular disease failure

•Neurohormonal Chronic
stimulation Fatigue
•Myocardial Edema

Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.

Beta Renin + Angiotensinogen
• CO Angiotensin I
• Na+ ACE
Angiotensin II
Aldosterone Secretion Fibrosis
Salt & Water Retention

 Afterload  Plasma Volume Edema

 Preload
 Cardiac Output
 Cardiac Workload

Heart Failure
Type What it does
•ACE inhibitor •Expands blood vessels which lowers
(angiotensin-converting blood pressure, neurohormonal
enzyme) blockade

•ARB (angiotensin receptor •Similar to ACE inhibitor—lowers

blockers) blood pressure

•Beta-blocker •Reduces the action of stress

hormones and slows the heart rate
•Digoxin •Slows the heart rate and improves the
heart’s pumping function (EF)

•Diuretic •Filters sodium and excess fluid from the

blood to reduce the heart’s workload

•Aldosterone •Blocks neurohormal activation and controls

blockade volume
 Improve Symptoms  Improve Survival
◦ Diuretics (water pills) ◦ Betablockers
◦ digoxin ◦ ACE-inhibitors
◦ Aldosterone blockers
◦ Angiotensin receptor
blockers (ARB’s)
What Why
•Eat a low-sodium, low-fat •Sodium is bad for high blood pressure,
diet causes fluid retention

•Lose weight •Extra weight can put a strain on

the heart

•Stay physically active •Exercise can help reduce stress

and blood pressure

•Reduce or eliminate alcohol •Alcohol and caffeine can weaken an

and caffeine already damaged heart

•Quit Smoking •Smoking can damage blood vessels and

make the heart beat faster
 Transplant
 Artificial hearts
 New “gadgets” to help doctors manage heart
 A good solution to the failing heart– get a
new heart
 Unfortunately we are limited by supply, not
 Approximately 2200 transplants are
performed yearly in the US, and this number
has been stable for the past 20 years.
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

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
Dry and Wet and
Tissue perfusion

warm warm

Dry and cold Wet and cold

Pulmonary congestion

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Ischaemic heart disease
 Acute coronary syndrome
 Mechanical complications of acute MI
 RV infarction
 Valve stenosis
 Valvular regurgitation
 Endocarditis
 Aortic dissection
 Postpartum cardiomyopathy
 Acute myocarditis
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
 Based on presenting symptoms and clinical
 History
 Physical examination
 Chest X-ray
 Echocardiography
 Laboratory (BGA, etc)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Non invasive:
 Vital Sign
 Oxygenation
 Urine output
 Arterial line (haemodynamic unstable)
 Central venous lines
 Pulmonary artery catheter
 Coronary angiography
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
 Immediate symptomatic treatment
 Patient distressed or in pain >> analgesia,
 Pulmonary congestion >> diuretic,
 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
 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 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
 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

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
 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 should be considered in low
output states, in the presence of hypoperfusion or
 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
 Heart failure is common and has high
 Drug therapy improves survival
◦ Betablockers, ACE-I, aldosterone antagonists
 Newer device therapies are showing
promise for symptom relief and improved
◦ Biventricular pacing, ICD’s
 Transplants remain rare, but technology for
mechanical assist devices continues to
improve- stay tuned!