Heart Failure

1. Heart Failure By:DawitAyele(MD,Internist)

2. Definition • “Heart (or cardiac) failure is the pathophysiological state in which • the heart is unable to pump blood at a rate commensurate with • the requirements of the metabolizing tissues or can do so only • from an elevated filling pressure.” • - Eugene Braunwald • “Congestive heart failure (CHF) represents a complex clinical • syndrome characterized by abnormalities of left ventricular • function and neurohormonal regulation, which are accompanied • by effort intolerance, fluid retention, and reduced longevity” • - Milton Packer

3. Heart Failure: Epidemiology 􀁺 Burden of CHF is staggering 􀁺 5 million in US (1.5% of all adults) 􀁺 500,000 cases annually 􀁺 In the elderly 􀁺 6-10% prevalence 􀁺 80% hospitalized with HF 􀁺 250,000 death/year attributable to CHF 􀁺 $38 billion (5.4% of healthcare cost)

4. Underlying Etiologies • Alcohol-- • Diabetes— • Cardiomyopathies • Coronary artery disease- • HTN--both • Valvular heart disease (especially aorta and mitral disease)--chronic • Congenital

5. Precepitating factors • Infection • Arrhythmia • Physical,Fluid,Dietary,Env’tal,Emotional excess • MI • Anemia • Pulmonary embolism • Worsening of HTN • Thyrotoxicosis • Infective endocarditis • Rheumatic,viral or other myocarditis..

6. Forms of Heart Failure • SYSTOLIC VERSUS DIASTOLIC FAILURE • LOW-OUTPUT VERSUS HIGH-OUTPUT HEART FAILURE • ACUTE VERSUS CHRONIC HEART FAILURE • RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE • BACKWARD VERSUS FORWARD HEART FAILURE

7. Typical presentations of heart failure • 1. Syndrome of decrease exercise tolerance • 2. Syndrome of fluid retention • 3. No symptoms but incidental discovery of LV • dysfunction

8. Heart Failure is a Clinical Diagnosis • 􀁺 Minor Criteria • 􀁺 Ankle edema • 􀁺 Night cough • 􀁺 Exertionaldyspnea • 􀁺 Hepatomegaly • 􀁺 Pleural effusion • 􀁺 Tachycardia (>120) • 􀁺 Decrease VC • 􀁺 Weight loss with CHF tx • Framingham Criteria • Major Criteria • 􀁺 Orthopnea/PND • 􀁺 Venous distension • 􀁺 Rales • 􀁺 Cardiomegaly • 􀁺 Acute pulm edema • 􀁺 Elevated JVP • 􀁺 HJR • 􀁺 Circ time >25s

9. NYHA Class 􀁺 • Class I: Symptoms with more than ordinary activity • Class II: Symptoms with ordinary activity • Class III: Symptoms with minimal activity • Class IIIa: No dyspnea at rest • Class IIIb: Recent dyspnea at rest • Class IV: Symptoms at rest

10. Stages of Heart Failure At Risk for Heart Failure: STAGE A High risk for developing HF • STAGE B Asymptomatic LV dysfunction • Heart Failure: • STAGE C Past or current symptoms of HF • STAGE D End-stage HF

11. Stages of Heart Failure • Designed to emphasize preventability of HF • Designed to recognize the progressive nature of LV dysfunction

12. Stages of Heart Failure • COMPLEMENT, DO NOT REPLACE NYHA CLASSES • NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) • Stages - progress in one direction due to cardiac remodeling

13. Left Ventricular Failure with PE • When pressure becomes too high, the fluid portion of the blood is forced into the alveoli. • decreased oxygenation capacity of the lungs • AMI common with LVF, suspect • Occurs when the left ventricle fails as an effective forward pump • back pressure of blood into the pulmonary circulation •  pulmonary edema • Cannot eject all of the blood delivered from the right heart. • Left atrial pressure rises  increased pressure in the pulmonary veins and capillaries

14. Signs and Symptoms of LVF • Diaphoresis— • Results from sympathetic stimulation • Pulmonary congestion • Often present • Rales—especially at the bases. • Rhonchi—associated with fluid in the larger airways indicative of severe failure • Wheezes—response to airway spasm • Severe resp. distress– • Evidenced by orthopnea, dyspnea • Hx of paroxysmal nocturnal dyspnea. • Severe apprehension, agitation, confusion— • Resulting from hypoxia • Feels like he/she is smothering • Cyanosis—

15. Jugular Venous Distention—not directly related to LVF. • Comes from back pressure building from right heart into venous circulation • Vital Signs— • Significant increase in sympathetic discharge to compensate. • BP—elevated • Pulse rate—elevated to compensate for decreased stroke volume. • Respirations—rapid and labored

16. Compensatory Mechanisms in CHF • Neurohormonalsystem • Renin-angiotensin-aldosteronesystem • Ventricular hypertrophy

18. Neurohormonal Activation Contributes to the Progression of CHF Myocardial Disease Impedance LV Dysfunction LV RemodelingVascular Remodeling Vasoconstriction Neurohormonal Activation Renal Blood Flow Preload Na Retention

19. Renin-Angiotensin Mechanism • Decreased renal blood flow secondary to low cardiac output triggers renin secretion by the kidneys • Aldosterone is released  increase in Na+ retention  water retention • Preload increases • Worsening failure

20. Ventricular Hypertrophy • Long term compensatory mechanism • Increases in size due to increase in work load ie skeletal muscle

21. Patient approach & Mgt • Principles:thoroughHx & P/E • Supplemental investigations especially:BNP,ECG,Echocardiography,CXR • Management:(1) general measures; (2) correction of the underlying cause; (3) removal of the precipitating cause; (4) prevention of deterioration of cardiac function; and (5) control of the congestive HF state

22. Heart Failure: Disease Management Control Volume Slow Disease Progression + Diuretic RAAS Inhibition Beta-Blockade Treat residual symptoms DIGOXIN SPIRONOLACTONE Am J Cardiol 1999;83(suppl 2A):9A-38A