HEART FAILURE

1. HEART FAILURE

2. Definition: A state in which the heart cannot provide sufficient cardiac output to satisfy the metabolic needs of the body

4. Causes of left ventricular failure Volume over load: Regurgitate valve High output status Pressure overload: Systemic hypertension Outflow obstruction Loss of muscles: Post MI, Chronic ischemia Connective tissue diseases Infection, Poisons (alcohol,cobalt,Doxorubicin) Restricted Filling: Pericardial diseases, Restrictive cardiomyopathy, tachyarrhythmia

5. Classification of heart failure

6. Pathophysiology Hemodynamic changes Neurohormonal changes Cellular changes

7. Hemodynamic changes systolic dysfunction diastolic dysfunction

8. Neurohormonal changes

9. Cellular changes ? Changes in Ca+2 handling. ? Changes in adrenergic receptors: � Slight ? in a1 receptors � �1 receptors desensitization ? followed by down regulation ? Changes in contractile proteins ? Program cell death (Apoptosis) ? Increase amount of fibrous tissue

10. Symptoms � SOB, Orthopnea, PND, cough with frothy sputum � Low cardiac output symptoms � Abdominal symptoms: Anorexia, nausea, abdominal fullness, Rt hypochondrial pain

11. NYHA Classification of heart failure Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Unable to carry out physical activity without discomfort

12. Physical Signs High diastolic BP & occasional decrease in systolic BP (decapitated BP) JVP Rales (Inspiratory) Displaced and sustained apical impulses Third heart sound � low pitched sound that is heard during rapid filling of ventricle. Fourth heart Sound (S4) Usually at the end of diastole Pale, cold sweaty skin

13. Framingham Criteria for Dx of Heart Failure Major Criteria: PND JVP Rales Cardiomegaly Acute Pulmonary Edema S3 Gallop Positive hepatic Jugular reflex ? venous pressure > 16 cm H2O

14. Dx of Heart Failure (cont.) Minor Criteria Lower Limb edema, Night cough Dyspnea on exertion Hepatomegaly Pleural effusion ? vital capacity by 1/3 of normal Tachycardia 120 bpm Weight loss 4.5 kg over 5 days management

15. Forms of Heart Failure Systolic & Diastolic High Output Failure Pregnancy, anemia, thyrotoxisis, A/V fistula, Beriberi, Pagets disease Low Output Failure Acute large MI, aortic valve dysfunction--- Chronic

16. Forms of heart failure ( cont.) Right vs Left sided heart failure: Right sided heart failure : Most common cause is left sided failure Other causes included : Pulmonary embolisms, pulmonary hen, RV infarction's Usually presents with: LL edema, ascites, hepatic congestion cardiac cirrhosis (on the long run)

17. Differential diagnosis Pericardial diseases Liver diseases Nephrotic syndrome Protein losing enteropathy

18. Laboratory Findings Anemia Hyperthyroid Chronic renal insuffiency, electrolytes abnormality Pre-renal azotemia Hemochromatosis

19. Electrocardiogram Old MI or recent MI Arrhythmia Some forms of Cardiomyopathy are tachycardia related LBBB?may help in management

20. ECG showing Entopic

21. ECG showing LVH

22. Chest X-ray Size and shape of heart Evidence of pulmonary venous congestion (dilated or upper lobe veins ? perivascular edema) Pleural effusion

23. Chest X-Ray

24. Echocardiogram Function of both ventricles Wall motion abnormality that may signify CAD Valvular abnormality Intra-cardiac shunts

25. Cardiac Catheterization When CAD or valvular is suspected If heart transplant is indicated

26. TREATMENT Correction of reversible causes Ischemia Valvular heart disease Thyrotoxicosis and other high output status Shunts Arrhythmia A fib, flutter, PJRT Medications Ca channel blockers, some antiarrhythmics

27. Diet and Activity Salt restriction Fluid restriction Daily weight (tailor therapy) Gradual exertion programs

28. Diuretic Therapy The most effective symptomatic relief Mild symptoms HCTZ, Chlorthalidone, Metolazone More severe heart failure ? loop diuretics Lasix (20 � 320 mg QD), Bumex (Bumetanide 1-8mg),Torsemide (20-200mg)

29. K+ Sparing Agents Triamterene & amiloride � acts on distal tubules to ? K secretion Spironolactone (Aldosterone inhibitor) recent evidence suggests that it may improve survival in CHF patients due to the effect on renin-angiotensin-aldosterone system with subsequent effect on myocardial remodeling and fibrosis

30. Angiotensin Converting Enzyme Inhibitors They block the R-A-A system and ? Bradykinin degradation Delay onset & progression of HF in pts with asymptomatic LV dysfunction ? cardiac remodeling Angiotensin II receptor blockers Can be used in certain conditions when ACE I are contraindicated (angioneurotic edema, cough)

32. Side effects of ACE inhibitors Angioedema Hypotension Renal insuffiency Rash cough

33. Digitalis (cont.)Mechanism of Action +ve inotropic effect Vagotonic effect Arrhythmogenic effect Digitalis Toxicity Anorexia,Nausea, vomiting, Headache, Xanthopsia scotoma, Disorientation

34. Digitalis Toxicity Cardiac manifestations Sinus bradycardia and arrest A/V block (usually 2nd degree) Atrial tachycardia with A/V Block Development of junctional rhythm in patients with a fib PVC�s, VT/ V fib (bi-directional VT)

35. � Blockers Has been traditionally contraindicated in pts with CHF In addition to improved LV function multiple studies show improved survival The only contraindication is severe decompensated CHF

36. Vasodilators Reduction of afterload By arteriolar vasodilatation hydralazin Reduction of preload By venous dilation Nitrates

37. Positive inotropic agents � adrenergic agonists, dopaminergic agents dopamine, dobutamine, milrinone, amrinone Several studies showed ? mortality with oral inotropic agents So the only use for them now is in acute sittings as cardiogenic shock

38. New Methods Implantable ventricular assist devices Biventricular pacing (only in patient with LBBB & CHF) Artificial Heart

39. Cardiac Transplant It has become more widely used since the advances in immunosuppressive treatment Survival rate 1 year 80% - 90% 5 years 70%

40. Prognosis Annual mortality rate depends on patients symptoms and LV function 5% in patients with mild symptoms and mild ? in LV function 30% to 50% in patient with advances LV dysfunction and severe symptoms 40% � 50% of death is due to SCD

41. Learning strategies Student should be able to Differentiate b/w Rt and Lt sided heart failure Identify the clinical features of heart failure Pick up the abnormailities on investigations Know emergency and long term treatment plan

42. Psychomotor skills Student should Demonstrate method of looking at raised JVP Look for chest and CVS abnormalities Identify the risk factor by history taking and examining the patient

43. MCQ The following chest radiograph signs suggest left ventricular failure: �(a) Cardiomegaly. (b) Upper lobe blood diversion. (c) Pleural effusion. (d) Oligaemic lung fields. (e) Kerley B lines.

44. Answer a, b, c, and e.

45. CASE SCENARIO A 50 year old female is seen in the emergency department with complaints of shortness of breath for 2 weeks and bony pain, particularly in the hips, for several months. she as progressive dyspnea on exertion,orthopnnea and paroxysmal nocturnal dysnea, she takes no medications an has no allergy. What is your clinical impression ?

46. CASE SCENARIO On physical exam she has elevated jugular venous pressure and peripheral edema as well as tachycardia without a third heart sound. Electrocardiogram ,besides sinus tachycardia is normal. A chest radiograph shows mild pulmonary vascular congestion, and plain film of the hips show severe and diffuse bony changes consistent with Pagets disease.

47. CASE SCENARIO WHAT ARE THE DIFFENETIAL DIAGNOSIS ? HOW WILL YOU MANAGE THIS CASE ?

48. CASE SCENARIO The patients presents with high output failure in the setting of pagets disease. in addition to this disorder, several other conditions have been associated with high output states, including anemia, arteriovenous fistulas,pregnancy,hyperthyroidism and beriberi.

49. CASE SCENARIO In this case ,in light of lack of clinical risk facors,ischemic cardiomyopathy is very unlikely. Patients with high output heart failure in general respond well to treatment of underlying conditions, with subsequent improvement of heart failure symptoms. Diuretics are helpful for symptomatic relief. Although sinus tachycardia is common in this patient population, ventricular tachycardia is rare.

50. Thanks