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HEART FAILURE

HEART FAILURE. Definition:. A state in which the heart cannot provide sufficient cardiac output to satisfy the metabolic needs of the body. Causes of left ventricular failure. Volume over load : Regurgitate valve High output status Pressure overload: Systemic hypertension

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HEART FAILURE

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  1. HEART FAILURE

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

  3. 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

  4. Classification of heart failure

  5. Pathophysiology • Hemodynamic changes • Neurohormonal changes • Cellular changes

  6. Hemodynamic changes • systolic dysfunction • diastolic dysfunction

  7. Neurohormonal changes

  8. Cellular changes  Changes in Ca+2 handling.  Changes in adrenergic receptors: •Slight  in α1 receptors • β1 receptors desensitization  followed by down regulation Changes in contractile proteins  Program cell death (Apoptosis)  Increase amount of fibrous tissue

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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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)

  16. Differential diagnosis • Pericardial diseases • Liver diseases • Nephrotic syndrome • Protein losing enteropathy

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

  18. Electrocardiogram • Old MI or recent MI • Arrhythmia • Some forms of Cardiomyopathy are tachycardia related • LBBB→may help in management

  19. ECG showing Entopic

  20. ECG showing LVH

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

  22. Chest X-Ray Upper lobe diversion B/L hilar congestion Fluid in transverse fissure cardiomegaly

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

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

  25. 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

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

  27. 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)

  28. 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

  29. 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)

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

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

  32. 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)

  33. β 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

  34. Vasodilators • Reduction of afterload By arteriolar vasodilatation hydralazin • Reduction of preload Byvenous dilation Nitrates

  35. Positive inotropic agents • β 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

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

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

  38. 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

  39. 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

  40. 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

  41. 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.

  42. Answer • a, b, c, and e.

  43. 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 ?

  44. 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.

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

  46. 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.

  47. 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.

  48. Thanks

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