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  1. HEART FAILURE Jorge Garcia, MD November 22, 2002

  2. CHF: we will talk about: • Part 1. Clinical Syndromes: Left ventricle vs Right Ventricular Failure. • Part 2. Diagnostic Syndromes: Systolic vs. Diastolic Failure. • Part 3. Treatment options.

  3. Part 1. There are 3 clinical “CHF” syndromes: 1. Pure RV failure.2. Pulmonary edema.3. Low output failure. What are the symptoms of these?

  4. What are the symptoms of pure Right Ventricle failure?

  5. Pure Right Ventricle failure: 1. JVD. 2. Dependent Pedal Edema.

  6. What are the symptoms of “CHF” caused by pulmonary edema?

  7. Pulmonary Edema causes Dyspnea: • Initially, DOE. • then PND. • Then dyspnea at rest. • Caused by…?

  8. Pulmonary Edema causes Dyspnea: • Initially, DOE. • then PND. • Then dyspnea at rest. • Caused by…LV failure.

  9. (Why does the patient experience dyspnea?)

  10. (Why does the patient experience dyspnea?) • Not hypoxia, but interstitial fluid causing stiff lungs and increased work of breathing. • Don’t be reassured by a decent O2 sat.

  11. So the first distinction is between pure right ventricular failure and pure left ventricular failure: • RV failure causes pedal edema. • LV failure causes pulmonary edema.

  12. Third “CHF” syndrome: • Low cardiac output (pump failure) • What are the symptoms?

  13. Low cardiac output (pump failure) causes: • Dyspnea • Swelling of the legs • Weakness, fatigue, lethargy, lightheadedness, and confusion

  14. Low output CHF syndrome is often mixed right and left heart failure. • most common. • patients have mix of symptoms.

  15. Do rales=CHF? • ?

  16. Rales • Rales present in < 25% of patients with HF, and absence does not rule it out.

  17. When else do you hear rales?

  18. When else do you hear rales? • Rales can be present in other lung conditions, such as pulmonary fibrosis, especially if not basilar, or present in entire respiratory cycle.

  19. What is the more reliable sign of “CHF”?

  20. S3 • S3 gallop in adults is considered pathognomonic for heart failure. • S3 in children and adolescents can be normal, and does not imply heart failure. • S4 in elders can be a result of long standing HTN, and not imply heart failure.

  21. What is the best way to hear an S3?

  22. Hearing an S3: • S3 is heard best heard with the bell, with the patient in a left lateral decubitus position.

  23. How do you check for JVD and HJR?

  24. How do you check for JVD and HJR? • Look at the internal jugular.

  25. What is the most common cause of pedal edema?

  26. What is the most common cause of pedal edema? • Venous insufficiency.

  27. Another common sign of “CHF” is the new onset of tachycardia. Why do you get sinus tachycardia with CHF?

  28. Sinus Tachycardia. • CO = HR x SV. If SV is reduced and fixed by heart failure, then an increase in CO will require an increase in HR. • Always suspect HF in a patient with unexplained sinus tachycardia.

  29. Part 2: the pathology of “CHF.”The distinction between systolic and diastolic dysfunction.

  30. Systolic dysfunction • Close to what was originally thought of as “CHF.” • After infarction, muscle “scar” is thinner and less contractile. After several MI s one is left with a large flabby heart. • Other causes of dilated cardiomyopathy:

  31. Diastolic dysfunction • May be the more common form of CHF. • Thick stiff heart after long history of HTN.

  32. Systolic dysfunction in more detail... • · Diffuse dilation of three (if not all four) heart chambers. • · Thin ventricular walls, poor global contractility. • Chest x-ray with cardiac enlargement, pear shaped heart: DDx includes pericardial effusion.

  33. Systolic dysfunction • Most common cause is CAD and infarctions, with remodeling of the ventricular wall. • Cardiomyopathies can also cause systolic dysfunction CHF. • The heart no longer works well in systole: it does not contract well.

  34. Diastolic dysfunction in more detail…What is the pathophysiology of diastolic dysfunction?

  35. Diastolic dysfunction: • The ventricle “fights” against hypertension and against increased afterload by becoming “stronger” and the heart muscle hypertrophies. • Concentric hypertrophy, directed inwardly, encroaches on the LV cavity. • Stiff, fibrotic LV muscle does not relax in diastole, does not fill enough. • Thus, reduced end diastolic volume.

  36. Diastolic dysfunction over time: · Reduced stroke volume, reduced cardiac output. · As it progresses, CAD will often develop and the pathology will overlap with systolic dysfunction.

  37. Diastolic dysfunction: · Common, especially in elders with long standing HTN. • Can’t be distinguished on exam from systolic dysfunction: • Chest film: the heart often looks normal. • need an echo

  38. Diastolic dysfunction on echo: · Contractility is preserved and ejection fraction is usually normal. · Concentric hypertrophy on echo. Inwardly directed ventricular hypertrophy.

  39. How can diastolic dysfunction lead to atrial fibrillation?