HEART FAILURE Jorge Garcia, MD November 22, 2002
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.
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?
Pure Right Ventricle failure: 1. JVD. 2. Dependent Pedal Edema.
Pulmonary Edema causes Dyspnea: • Initially, DOE. • then PND. • Then dyspnea at rest. • Caused by…?
Pulmonary Edema causes Dyspnea: • Initially, DOE. • then PND. • Then dyspnea at rest. • Caused by…LV failure.
(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.
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.
Third “CHF” syndrome: • Low cardiac output (pump failure) • What are the symptoms?
Low cardiac output (pump failure) causes: • Dyspnea • Swelling of the legs • Weakness, fatigue, lethargy, lightheadedness, and confusion
Low output CHF syndrome is often mixed right and left heart failure. • most common. • patients have mix of symptoms.
Do rales=CHF? • ?
Rales • Rales present in < 25% of patients with HF, and absence does not rule it out.
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.
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.
Hearing an S3: • S3 is heard best heard with the bell, with the patient in a left lateral decubitus position.
How do you check for JVD and HJR? • Look at the internal jugular.
What is the most common cause of pedal edema? • Venous insufficiency.
Another common sign of “CHF” is the new onset of tachycardia. Why do you get sinus tachycardia with CHF?
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.
Part 2: the pathology of “CHF.”The distinction between systolic and diastolic dysfunction.
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:
Diastolic dysfunction • May be the more common form of CHF. • Thick stiff heart after long history of HTN.
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.
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.
Diastolic dysfunction in more detail…What is the pathophysiology of diastolic dysfunction?
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.
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.
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
Diastolic dysfunction on echo: · Contractility is preserved and ejection fraction is usually normal. · Concentric hypertrophy on echo. Inwardly directed ventricular hypertrophy.