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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 statusPressure overload: Systemic hypertension Outflow obstruction Loss of muscles: Post MI, Chronic ischemia 29820
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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
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
PVCs, 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