Heart failure
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Heart Failure. By:Dawit Ayele ( MD,Internist ). Definition. “ Heart (or cardiac) failure is the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirements of the metabolizing tissues or can do so only

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Heart failure

Heart Failure

By:DawitAyele(MD,Internist)


Definition

Definition

  • “Heart (or cardiac) failure is the pathophysiological state in which

  • the heart is unable to pump blood at a rate commensurate with

  • the requirements of the metabolizing tissues or can do so only

  • from an elevated filling pressure.”

  • - Eugene Braunwald

  • “Congestive heart failure (CHF) represents a complex clinical

  • syndrome characterized by abnormalities of left ventricular

  • function and neurohormonal regulation, which are accompanied

  • by effort intolerance, fluid retention, and reduced longevity”

  • - Milton Packer


Heart failure epidemiology

Heart Failure: Epidemiology

􀁺 Burden of CHF is staggering

􀁺 5 million in US (1.5% of all adults)

􀁺 500,000 cases annually

􀁺 In the elderly

􀁺 6-10% prevalence

􀁺 80% hospitalized with HF

􀁺 250,000 death/year attributable to CHF

􀁺 $38 billion (5.4% of healthcare cost)


Heart failure

Underlying Etiologies

  • Alcohol--

  • Diabetes—

  • Cardiomyopathies

  • Coronary artery disease-

  • HTN--both

  • Valvular heart disease (especially aorta and mitral disease)--chronic

  • Congenital


Precepitating factors

Precepitating factors

  • Infection

  • Arrhythmia

  • Physical,Fluid,Dietary,Env’tal,Emotional excess

  • MI

  • Anemia

  • Pulmonary embolism

  • Worsening of HTN

  • Thyrotoxicosis

  • Infective endocarditis

  • Rheumatic,viral or other myocarditis..


Forms of heart failure

Forms of Heart Failure

  • SYSTOLIC VERSUS DIASTOLIC FAILURE

  • LOW-OUTPUT VERSUS HIGH-OUTPUT HEART FAILURE

  • ACUTE VERSUS CHRONIC HEART FAILURE

  • RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE

  • BACKWARD VERSUS FORWARD HEART FAILURE


Typical presentations of heart failure

Typical presentations of heart failure

  • 1. Syndrome of decrease exercise tolerance

  • 2. Syndrome of fluid retention

  • 3. No symptoms but incidental discovery of LV

  • dysfunction


Heart failure is a clinical diagnosis

Heart Failure is a Clinical Diagnosis

  • 􀁺 Minor Criteria

  • 􀁺 Ankle edema

  • 􀁺 Night cough

  • 􀁺 Exertionaldyspnea

  • 􀁺 Hepatomegaly

  • 􀁺 Pleural effusion

  • 􀁺 Tachycardia (>120)

  • 􀁺 Decrease VC

  • 􀁺 Weight loss with CHF tx

  • Framingham Criteria

  • Major Criteria

  • 􀁺 Orthopnea/PND

  • 􀁺 Venous distension

  • 􀁺 Rales

  • 􀁺 Cardiomegaly

  • 􀁺 Acute pulm edema

  • 􀁺 Elevated JVP

  • 􀁺 HJR

  • 􀁺 Circ time >25s


Nyha class

NYHA Class

􀁺

  • Class I: Symptoms with more than ordinary activity

  • Class II: Symptoms with ordinary activity

  • Class III: Symptoms with minimal activity

  • Class IIIa: No dyspnea at rest

  • Class IIIb: Recent dyspnea at rest

  • Class IV: Symptoms at rest


Stages of heart failure

Stages of Heart Failure

At Risk for Heart Failure:

STAGE A High risk for developing HF

  • STAGE B Asymptomatic LV dysfunction

  • Heart Failure:

  • STAGE C Past or current symptoms of HF

  • STAGE D End-stage HF


Stages of heart failure1

Stages of Heart Failure

  • Designed to emphasize preventability of HF

  • Designed to recognize the progressive nature of LV dysfunction


Stages of heart failure2

Stages of Heart Failure

  • COMPLEMENT, DO NOT REPLACE NYHA CLASSES

  • NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)

  • Stages - progress in one direction due to cardiac remodeling


  • Heart failure

    Left Ventricular Failure with PE

    • When pressure becomes too high, the fluid portion of the blood is forced into the alveoli.

    • decreased oxygenation capacity of the lungs

    • AMI common with LVF, suspect

    • Occurs when the left ventricle fails as an effective forward pump

    • back pressure of blood into the pulmonary circulation

    •  pulmonary edema

    • Cannot eject all of the blood delivered from the right heart.

    • Left atrial pressure rises  increased pressure in the pulmonary veins and capillaries


    Heart failure

    Signs and Symptoms of LVF

    • Diaphoresis—

      • Results from sympathetic stimulation

    • Pulmonary congestion

      • Often present

      • Rales—especially at the bases.

      • Rhonchi—associated with fluid in the larger airways indicative of severe failure

      • Wheezes—response to airway spasm

    • Severe resp. distress–

      • Evidenced by orthopnea, dyspnea

      • Hx of paroxysmal nocturnal dyspnea.

    • Severe apprehension, agitation, confusion—

      • Resulting from hypoxia

      • Feels like he/she is smothering

    • Cyanosis—


    Heart failure

    • Jugular Venous Distention—not directly related to LVF.

      • Comes from back pressure building from right heart into venous circulation

    • Vital Signs—

      • Significant increase in sympathetic discharge to compensate.

      • BP—elevated

      • Pulse rate—elevated to compensate for decreased stroke volume.

      • Respirations—rapid and labored


    Heart failure

    Compensatory Mechanisms in CHF

    • Neurohormonalsystem

    • Renin-angiotensin-aldosteronesystem

    • Ventricular hypertrophy


    Neurohormonal activation contributes to the progression of chf

    Neurohormonal Activation Contributes to the Progression of CHF

    Myocardial Disease

    Impedance

    LV Dysfunction

    LV RemodelingVascular Remodeling

    Vasoconstriction

    Neurohormonal Activation

    Renal Blood Flow

    Preload

    Na Retention


    Heart failure

    Renin-Angiotensin Mechanism

    • Decreased renal blood flow secondary to low cardiac output triggers renin secretion by the kidneys

      • Aldosterone is released  increase in Na+ retention  water retention

      • Preload increases

      • Worsening failure


    Heart failure

    Ventricular Hypertrophy

    • Long term compensatory mechanism

    • Increases in size due to increase in work load ie skeletal muscle


    Patient approach mgt

    Patient approach & Mgt

    • Principles:thoroughHx & P/E

    • Supplemental investigations especially:BNP,ECG,Echocardiography,CXR

    • Management:(1) general measures;

      (2) correction of the underlying cause;

      (3) removal of the precipitating cause;

      (4) prevention of deterioration of cardiac function; and

      (5) control of the congestive HF state


    Heart failure disease management

    Heart Failure: Disease Management

    Control Volume Slow Disease Progression

    +

    Diuretic

    RAAS

    Inhibition

    Beta-Blockade

    Treat residual

    symptoms

    DIGOXIN

    SPIRONOLACTONE

    Am J Cardiol 1999;83(suppl 2A):9A-38A


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