Congestive Heart Failure

 An imbalance in pump function in

which the heart fails to maintain the
circulation of blood adequately.
DIAGNOSIS
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
Mechanisms
 Coronary artery disease-  Alcohol--chronic
-chronic  MI--acute
 HTN--both  Diabetes—chronic
 Valvular heart disease
(especially aorta and
mitral disease)--chronic
 Infections--acute
 Dysrhythmias--acute
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
Pulmonary Edema due to Heart Failure
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
SUGAR LAND

Congestive Heart Failure CHF

HEART CENTER
Echocardiogram

Function of both ventricles

Wall motion abnormality that may
signify CAD
Valvular abnormality
Intra-cardiac shunts
Pericardial effusion
Restrictive pericarditis
Pulmonary hypertension
Types of Rhythms Associated with
CHF
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
Algorithm for the diagnosis of heart failure
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)
 Treatment

 Lifestyle changes

 Monitoring for changes

 Medications

 Surgery
 TREATMENT: Lifestyle choices

 Exercise,  Avoid alcohol

physical activity  Modify fluid
 Nutrition intake
 low saturated  Monitoring
fat, disease
 low salt diet  weights
 Lose weight  swelling
 Quit smoking  medications
 signs and
symptoms
Exercise

 General recommendation: 30
minutes most days of the week
 Specifics may be different for
different people (check with doctor
about what type and how much)
 Always want to start slow
and build up gradually
/www.fi.edu/biosci2/healthy/inline/options.gif
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)
Treatment - Surgery

 Angioplasty
 Coronary artery bypass graft
 Heart pump
 Transplant
Meds to AVOID in heart failure

 NSAIDS
 Can cause worsening of preexisting HF

 Thiazolidinediones
 Include rosiglitazone (Avandia), and
pioglitazone (Actos)
 Cause fluid retention that can exacerbate HF

 Metformin
 People with HF who take it are at increased
risk of potentially lethic lactic acidosis
 Implantable Cardioverter-Defibrillators
for HF
 Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
 About one-third of mortality in
HF is due to sudden cardiac
death.
 Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF ≤ 35% have a significant
survival benefit from an
implantable cardioverter-
defibrillator (ICD) for the
primary prevention of SCD.
Prognostication

NYHA Class 1 Year Mortality

I 5-10%

II-III 15-30%

IV 50-60%
Summary

 CHF has a very poor prognosis

 Often need multiple medications for
symptom control
 Palliative care can be of help in CHF
 Need multidisciplinary team