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CARDIAC FAILURE. TOPICS. INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE. Return to Cardiovascular Pathology Index Page.

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CARDIAC FAILURE

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Cardiac failure l.jpg

CARDIAC FAILURE

TOPICS

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE

Return to Cardiovascular Pathology Index Page

Brian Angus Pathology Department University of Newcastle upon Tyne


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INTRODUCTION

  • very common clinical problem

  • due to many types cardiac disease

  • prognosis poor - median survival 3 yrs


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SIDE OF HEART AFFECTED

The heart works as a unit with both ventricles contracting in unison. Heart failure usually involves both the right and left sides, giving symptoms and signs related to both - congestive cardiac failure. Sometimes left or right heart failure predominates, for example RHF in chronic obstructive airways disease, and acute LVF in myocardial infarction. In the ensuing slides we will consider right and left heart failure separately.


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SIDE OF HEART AFFECTED

LEFT pulmonary congestion and oedema - breathlessness

RIGHTperipheral oedemahepatic congestionraised JVP

CONGESTIVE : R & L

Note: chronic LHF leads to RHF


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CAUSES OF CARDIAC FAILURE

  • ischaemic heart disease

  • systemic hypertension

  • valvular heart disease

  • congenital heart disease

  • lung disease COAD (cor pulmonale)

  • Rarities e.g. cardiomyopathy


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LEFT HEART FAILURE: EFFECTS

Acute LHF -Pulmonary oedema

Frothy blood stained sputum

ChronicLHF - Dyspnoea

on exertion

Poor renal perfusion -

Renin-angiotensin system activated


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LEFT HEART FAILURE: THE RENIN-ALDOSTERONE-ANGIOTENSIN SYSTEM

Poor renal perfusion is sensed by the juxtaglomerular apparatus, which secretes renin. Renin converts angiotensinogen in the blood to angiotensin1. This in turn is converted by ACE (angiotensin converting enzyme) to angiotensin2, which increases blood pressure directly by vasoconstriction and by increasing adrenal secretion of aldosterone. ACE inhibitors are used to treat heart failure as well. as hypertension. Diuretic drugs are another mainstay of treatment.


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THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM

JGA

RENIN

ANGIOTENSINOGEN ANGIOTENSIN 1

ANGIOTENSIN 2

ADRENAL

ACE

ALDOSTERONE

VASOCONSTRTICTS

ACE INHIBITORS

Na RETENTION

INCREASED BP


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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RIGHT HEART FAILURE: EFFECTS

Hepatic congestion: nutmeg appearance

Raised JVP

Oedema - Tissues: Ankles and sacrum

Pleural and peritoneal cavities


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RIGHT HEART FAILURE: EFFECTS 1

Hepatic congestion: nutmeg appearance

Raised JVP

Oedema - Tissues: Ankles and sacrum

Pleural and peritoneal cavities

The photograph shows the “nutmeg” liver of chronic venous congestion


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RIGHT HEART FAILURE: EFFECTS 2

Hepatic congestion: nutmeg appearance

Raised JVP

Oedema - Tissues: Ankles and sacrum

Pleural and peritoneal cavities

The photograph shows pitting oedema of the ankle. An indentation has been left by firm digital pressure


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RIGHT HEART FAILURE: EFFECTS 3

Hepatic congestion: nutmeg appearance

Raised JVP

Oedema - Tissues: Ankles and sacrum

Pleural and peritoneal cavities

The photograph shows bilateral pleural effusions.


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PLEURAL EFFUSIONS


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RIGHT HEART FAILURE: COR PULMONALE

Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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CONGESTIVE CARDIACFAILURE:EFFECTS

Congestive = Combined R & L

Most cases are congestive but sometimes features of R or L CF predominate


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CONGESTIVE CARDIACFAILURE:CLINICAL FEATURES

SUMMARY

dyspnoea

oedema

venous congestionraised JVP mild hepatomegaly


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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CARDIAC FAILURE

DIAGNOSIS

  • History

  • Examination

  • Chest X-RAY

  • ECG

  • Echocardiography

  • BNP

BNP = B type natriuretic peptide.

Hormone released into plasma by steressed myocytes in CF


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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DYSPNOEA

Dyspnoea (breathlessness) occurs in left heart failure. At first the pulmonary vascular beds become congested.

Later fluid builds up in the interstitium (the space between capillary endothelial cells and alveolar lining cells), and this is known as interstitial oedema.

Finally fluid enters the alveoli giving pulmonary oedema as shown in the radiograph.


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PULMONARY OEDEMA


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DYSPNOEA

In the early stages of pulmonary oedema, crepitations (fine crackles) are heard on auscultation.

In severe pulmonary oedema frothy sputum can be produced. Occaisionally this can be bloodstreaked, for example in pulmonary oedema due to mitral stenosis.


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DYSPNOEA: SPECIAL TYPES

On lying down dependent vascular and extravascular fluid

enters the central circulation.

In heart failure the heart cannot cope with the increase load and pulmonary congestion and oedema result


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DYSPNOEA: SPECIAL TYPES

The two clinical syndromes associated with this are:

Orthopnoea: dyspnoea on lying down flat.

Paroxysmal nocturnal dyspnoea: intermittent attacks of dyspnoea while in bed. The patient typically goes to an open window gasping for breath and waits for recovery.


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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CARDIAC FAILURE: AGE DIFFERENCES

Babies and old people sometimes do not give classical symptoms and signs of heart failure.

Babies typically show rapid breathing (tachypnoea), rapid heartbeat (tachycardia) and poor feeding.

Old people can simply be lethargic with nausea and vomiting.


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CARDIAC FAILURE

INTRODUCTION

CAUSES

LEFT HEART FAILURE

RIGHT HEART FAILURE

CONGESTIVE CARDIAC FAILURE

DIAGNOSIS

DYSPNOEA

AGE EFFECTS

HIGH OUTPUT FAILURE


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CARDIAC FAILURE: HIGH OUTPUT FAILURE

In most cases of heart failure the cardiac output is low. In rare situations, there may be no intrinsic heart disease, but the heart is put under such a high load that it cannot cope and eventually fails. This is known as high output failure.

Examples of this include very severe anaemia and hyperthyroidism.

Massively enlarged thyroid gland in hyperthyroidism.


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END OF PRESENTATION

Return to Cardiovascular Pathology Index Page


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