Congestive Heart Failure (CHF)

2. Congestive Heart Failure(CHF)

3. Presented To: Presented By:

5. Overview of CHF • Review cardiac physiology and pathophysiology • Etiology • Classification of CHF • Stages of CHF • Early recognition of CHF • Diagnosis of CHF • Early and aggressive management of CHF

6. Heart Failure The term “ cardiac failure” or “heart failure” means simply failure of heart to pump enough blood to satisfy the needs of body.

7. CONGESTIVE HEART FAILURE Definition: “Congestive heart failure (CHF) occurs when the heart can't meet the metabolic demands of the body (failure of the heart to supply the tissue with their needs of blood”.

8. Heart Physiology

9. Physiology Systole: The contraction of the cardiac muscle tissue in the ventricles is called systole. When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The increased pressure due to the contraction of the ventricles is called systolic pressure.

10. Physiology Cont… Diastole: The relaxation of the cardiac muscle tissue in the ventricles is called diastole. When the ventricles relax, they make room to accept the blood from the atria. The decreased pressure due to the relaxation of the ventricles is called diastolic pressure.

11. Physiology Cont… Electrical Conduction System: The heart is composed primarily of muscle tissue. A network of nerve fibers coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an efficient, wave-like pumping action of the heart.

12. Conduction System

13. PATHOPHYSIOLOGY • Abnormal changes occur to right ventricle, left ventricle or both. • Cardiac output in heart failure is below the normal range. • The myocardium becomes very weak because of low blood and oxygen supply and myocardium contractility is reduced. • The ejection fraction falls from its normal values of about 0.6to 0.2.

14. PATHOPHYSIOLOGY • The falling myocardium decreases myosin ATPase. • Abnormal Actin and Tropomyosinis formed. • Relaxation is slowed, possibly because of slowed uptake of ca+2 by sarcoplasmic reticulum. • Venous return is reduced because of lack of proper cardiac pump and edemais caused.

15. PATHOPHYSIOLOGY • Compensatory mechanism causes the increased secretion of aldosteron and arginine vasopressin and makes this CHF situation mor aggressive

16. Etiology • Ischemic heart diseases • Systemic Hypertension • Cardiomyopathy • Coronary artery disease MAIN CAUSES

17. ETIOLOGY • congenital heart disease • Valvular heart disease • Hyperthyroidism • Anemia • Alcohol • Miscellaneous OTHER CAUSES

18. People Live with Atherosclerosis – But Die of Thrombosis! The formation, progression and rupture of an atherosclerotic plaque

19. Hypertension • Hypertrophic Cardiomyopathy

20. CATEGORIES FOR CLASSIFICATION

21. CLASSIFICATION OF CHF There are many different ways to categorize CHF: • Left heart failure Vs Right heart failure • Diastolic dysfunction Vs Systolic dysfunction • Backward Vs Forward failure • Low output heart failure Vs High output heart failure

22. New York Heart Association Functional classification • Class 1: Asymptomatic • Class 2: Symptomatic with mild activity • Class 3: Symptomatic with moderate activity • Class 4: symptomatic at rest

23. STAGES OF CHF STAGE A: Includes pts at risk for developing heart failure STAGE B: Includes pts with structural heart disease but no recognized symptom of heart failure STAGE D: Includes relatively small group of pts that have become refractory to usual therapies STAGE Structural heart disease with current or prior symptoms of heat failure.

24. Diagnosis • Clinical findings (Signs and symptoms) • Laboratory findings

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26. Symptoms • Tachycardia • Shortness of breath • Exertionaldyspnea at first,orthopnea, proximal nocturnal dyspnea and rest dyspnea. • Non-productive cough • Nocturia • fatigue & exercise intolerance

27. Symptoms • Edema • Hepatic congestion • occasionally loss of appetite and nausea • impaired GI perfusion or ascites • Pulmonary edema

28. Acute Pulmonary Edema is a true Life Threatening Emergency for which the clinical picture is hard to forget!

29. SYMPTOMS

30. SIGNS • Vital signs may be normal but: • Tacchycardia, hypotension & reduced pulse pressure • increased sympathetic nervous system activity: • cold extremities &diaphoresis • Physical exam shows following signs:

31. Physical Exam • Anxious • Pale • Clammy • Dyspnea • Tachypnea • Confusion • Edema Tachycardia • Pink Frothy Sputum • Cyanosis • Diaphoretic • Hypertension

32. Diagnosis(II-Laboratory findings)

33. Lab Analysis cont… • BLOOD COUNT: Low blood cell count may cause symptoms like CHF or contribute to the condition.

34. Lab Analysis cont… • . B-TYPENATRIURETIC PEPTIDE(BNP): • This is a hormone produced at higher levels by the failing heart muscle. This is a good screening test; the levels of this hormone generally increase as the severity of heart failure worsens. • SERUM ELECTROLYTE: Sodium, potassium, and other electrolyte levels, especially if the person has been treated with diuretics and/or has kidney disease

35. Lab Analysis cont… • MUGA -SCAN TEST: • A small amount of a mildly radioactive dye is injected into a vein and travels to the heart. • STRESS TEST: • A treadmill or medication (nonwalking) stress test is used to help evaluate the cause or causes of heart failure, in particular, regarding coronary artery disease. This test is frequently combined with nuclear imaging or echocardiography to improve accuracy.

36. Echocardiogram • An echocardiogram is a noninvasive test that uses reflected sound waves off the heart to determine its size,structure, and function.

37. Chest X-ray: • This is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually enlarges in CHF, and this may be visible on the x-ray film. • Cardiomegaly • Pulmonary Edema • Pulmonary vessel congestion

38. Cardiomegaly

39. Pulmonary Edema

40. Pulmonary vessel congestion

41. Electrocardiogram • This painless test measures the electrical activity (rhythm) of the heart. • Rhythm disorders…

42. Angiography • coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery.

43. Precipitating Causes • Non Compliance with Meds and Diet • Acute MI • Arrhythmia • Pneumonia • Increased Sodium Diet (Holiday Failure) • Anxiety • Pregnancy

44. Emergency Dept. Management Sit upright High flow O2 Ventilatory support Diuretics Morphine Dopamine Dobutrex Antihypertensives Digitalis

45. The Management of CHF I) General measures • Improving oxygen delivery: Administration of oxygen (40-50% ) with humidity. • Sedation :morphine sulfate

46. The Management of CHF • Salt restriction: low salt consumption in diets, less than 3g/day and avoidance of salty snacks. • Healthy life style • Treatment of the cause as hypertension

47. The Management of CHF • Elimination and correction of predisposing factors as anemia, infection. • Nutrition:CHF increases the metabolic demands while making food intake itself more difficult. • Enhanced Caloric Content DIET , nasogastric orgastrostomy feedings.

48. PHARMACOLOGICAL TREATMENT DIURETIC THERAPY INHIBITORS OF RENIN ANGIOTENSIN ALDO SYSTEM STATIN THERAPY GROUPS OF DRUGS B-BLOCKERS ANTICOAGULATION DIGITALIS GLYCOSIDE ANTIARRHYTHMIC THERAPY VASODILATORS CALCIUM CHANNEL BLOCKER COMBINATION OF MEDICAL THERAPIES

49. The Management of CHF II) Drug therapy A- Diuretics: • Diuretics are the most effective means of providing the symptomatic relief to pts with moderate to severe CHF. “A COMBINATION OF DIURETIC AND ACE INHIBITOR SHOULD BE THE INITIAL TREATMENT IN MOST SYMPTOMATIC PATIENTS”

50. A- Diuretics I) Thiazide diuretic as • Hydrochlorothiazide(25-100mg) • Metolazone(2.5-5mg) • Chlorthalidone (25-50mg) Onset: 1-2 hours Duration of action: 12-24 hour. Metolazne has relatively higher efficacy.