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Heart failure

Heart failure. DEFINITION. HEART FAILURE the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirement of the metabolizing tissues or can do so only from an elevated filling pressure.

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Heart failure

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  1. Heart failure

  2. DEFINITION • HEART FAILURE • the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirement of the metabolizing tissues or can do so only from an elevated filling pressure. • Usually caused by a defect in myocardial contraction (myocardial failure).

  3. DEFINITION • CONGESTIVE HEART FAILURE • Clinical manifested as • Pulmonary congestion • Systemic congestion • Inadequate tissure blood perfusion • HEMODYNAMICALLY heart failure (cardiac dysfunction) is diagnosed when • LVEDP>18mmHg or • RVEDP>10mmHg

  4. UNDERLYING CAUSES • Primary myocardial dysfunction (systolic and/or diastolic) • Cardiomyopathy • Primary or secondary metabolic disturbances of myocardium • Overloading of heart • Pressure overloading • Volume overloading • limited diastolic function

  5. UNDERLYING CAUSES Age 70.3±10.1 yr. Causes CHD 65.8% Hypertension 36.0% Dila. Cardiomy. 11.9% With 2°DM 14.9% Shanghai OPD, Chin J Cardiol 2001;29:644

  6. Precipitating factors • infection • arrhythmias • Pulmonary embolism • overfatigue • Pregnancy and delivery • Anemia and hemorrhage • others

  7. Pathophysiology • Frank-Starling mechanism • Activation of neurohormonal pathway (SAS and RAS) • Myocardial damage and remodeling • Diasatolic heart failure

  8. “

  9. CLINICAL CLASSIFICATION • A cute vs. chronic heart failure • Right-sided vs. left-sided Heart failure • Low-output vs high-output heart failure • Systolic vs diastolic heart failure • Asymptomatic vs congestive heart failure

  10. Chronic left-sided HF ：symptoms • Respiratory distress • Exertional dyspnea • Paroxysmal nocturnal dyspnea • Orthopnea • Acute pumnonary edema • Cough (nonproductive), and hemoptysis • Reduced exercise capacity • Fatigue and weakness • Urinary symptoms

  11. Chron. left-sided HF ：Physi. findings • General appearance • Dyspnetic • Cyanosis, icterus, malar flush, diminished pulse pressure, reduced SBP, rapid, weak and thready pulse in severe HF • Evidence of ↑adrenergic activity • Peripheral vasoconstriction (pallor, coldness of extremities and cyanosis of the digits ). • Diaphoresis with sinus tachycardia

  12. Chron. left-sided HF ：Physi. finding • Cardiac findings • Cardiomegaly • S3 gallops • Accentuation of P2 • Systolic murmur • Pulsus alternans • Pulmonary rales • Moist rales over • the lung bases • Rhonchi wheezes • ↓BS

  13. Chron. right-sided HF ：symptoms • Gastrointestinal symptoms • Symtoms of urinary system • Dull ache in right upper quadrant. • dyspnea

  14. Chron. right-sided HF ：Physi. finding • Cardiac findings • Hepatojugular reflux • Congetive hepatomegaly or tenderness • Edema • Hydrothorax and ascites • Others (cyanosis, and etc.)

  15. Chronic HF ：labolaroty findings • Routine lab. And serum electrolytes & liver function tests • ECG • Echocardiography • Chest Roentgenogram

  16. ECG • Suggesting basic presence of basic heart diseases • Atrial and ventricular hypertrophy, myocardial ischemia or infarction , arrhythmia • V1ptf＜－0.03mm／s，indicating left atrial overloading.

  17. Echocardiogram • M mode, 2D echo and Dopler technique for systolic and diastolic function of LV • LVDd and LVDs（Dd andDs） • LV fraction of shortening （△D％ ＝（Dd - Ds ）／Dd × 100％） • mVCF ＝（Dd - Ds）／Dd × LVET • SV • LVEF

  18. Chest X ray • Left-sided heart failure • cardiomegaly (cardiothorax ratio＞50%) • dilated pulmonary vein • pulmonary infiltrates. • prominent bronchovascular markings • Interstitial edema, Kerley.s B line, alveolar edema, pleural effusion when PCWP＞25～30mmHg. • Right-sided HF • Cardiomegaly

  19. Invasive hemodynamic monitoring • Using Swan-Ganz cather and thermodilution method for measurement of • Intracardiac and vascular pressure • Cardiac output to asses cardiac function

  20. Invasive hemodynamic monitoring • CVP（中心静脉压）6～12cmH2O • PAP（肺动脉压）12～30/4～l3mmHg • PCWP（肺毛细血管楔嵌压）6～12mmHg • SV（心搏量）60～70ml • SI（心搏指数）4l～51ml/m2 • CO（心排血量）5～6L/min • CI（心排指数）2.6～4.0L/min.m2 • EF（射血分数）0.5 ～ 0.6

  21. Chronic HF ：diagnosis • causes • anatomy • pathology • arrhythmia • Functional classification

  22. Functional classification（NYHA) • Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation • Class II-slight limitation of physical activity:Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. • Class III-marked limitation of physical activity:although patients are comfortable at rest, less than ordinary activity will lead to symptoms. • Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.

  23. Chronic HF ：diff. diagnosis • Left-sided HF • With pulmonary dyspnea: COPD,asthma • Metabolic acidosis • Cardiac neurosis • Right-sided HF • Pricarditis • Hepatic, renal edema.

  24. Functional classification（NYHA) • Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation • Class II-slight limitation of physical activity:Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. • Class III-marked limitation of physical activity:although patients are comfortable at rest, less than ordinary activity will lead to symptoms. • Class IV-inability to carry on any physical activity without discomfort:symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.

  25. Chronic HF ：diff. diagnosis • Left-sided HF • With pulmonary dyspnea: COPD, asthma • Metabolic acidosis • Cardiac neurosis • Right-sided HF • Pricarditis • Hepatic, renal edema.

  26. TREATMENT OBJECTIVES Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF Symptoms

  27. Chronic HF: treatment • correcting PF and cause of HF • Reducing load • Rest and tranquilizer • Control salt intake • Water intake • diuretics • Vasodilators • Improve CO • digitalis • non-digitalis positive inotropic agents • aldost. antagonist • β-bloker • diastolic HF • dificult HF cases

  28. Diuretics • Thiazides • Hydrochlorothiazide • Potassium-sparing diuretics • Spironolactone • amiloride • Loop diuretics • Frusemide

  29. Vasodilators • Nitrates • Nitroglycerine • Isosorbide dinitrate • Mononitrates • Nitroprusside • ACE inhibitor • ARB (Angiotensin receptor blocker)

  30. Acute heart failure • Definition • Etioloogy and mechanism • Clinical picture • Diagnosis • treatment

  31. 谢 谢

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