• A 40 years old gentleman comes in OPD with
two years history of worsening dyspnea on
exertion. He also experiences shortness of
breath in midnight while lying flat for which
he has to get up to catch his breath.
• He’s never had chest pain. There has been
occasional dry cough with dyspnea but no
history of sputum or wheezing.
• What is the likely cause of his dyspnea?
Heart Failure
• Failure: Inability to perform the expected
function
• Function of Heart:
– Left Heart: To perfuse the body organs
– Right heart: To receive blood from body and
promptly send it to lungs
DR M NAEEM AFZAL
FCPS, Dip-DIABTES (UK)
ASSOCIATE PROFESSOR
EAST MEDICAL WARD
MAYO HOSPITAL/KING EDWARD MEDICAL UNIVERSITY, LAHORE
Definition
• Heart failure is a complex syndrome that can
result from any structural or functional cardiac
disorder that impairs the ability of the heart to
function as a pump to support a physiological
circulation.
HFpEF
HFrEF
• A 40 years old gentleman comes in OPD with two
years history of worsening dyspnea on exertion.
He also experiences shortness of breath in
midnight while lying flat for which he has to get
up to catch his breath.
• He’s never had chest pain. There has been
occasional dry cough with dyspnea but no history
of sputum or wheezing.
• He also has history of sudden cardiac death in his
family.
• What are the likely causes of his heart failure?
Causes of heart failure
• Hypertension
• Myocardial ischemia/infarction
• Valvular heart disease (Obstructive/Regurgitant)
• What is left?
• Muscle itself
History
• Progression of disease (Acute or chronic?)
• Associated features (ischemic chest pain, palpitations)
• Family history of cardiac illness or sudden cardiac
death
• Occupational/Exposure history
• History of systemic diseases
Investigations???
•
•
•
•
•
ECG
CXR PA view
Cardiac Enzymes
Echocardiography
Pro-BNP levels
Cardiomyopathies
• Disorders characterized by morphologically
and functionally abnormal myocardium in the
absence of any other disease that is sufficient,
by itself, to cause the observed phenotype.
• Primary (Genetic/Acquired)
• Secondary to systemic diseases
Examination
• Pulse, Blood pressure
• JVP, edema
• Apical impulse (location, character)
• Heart sounds & Murmurs
• Systemic examination (Lungs, Joints, Skin, Muscles)
Dilated Cardiomyopathy (DCMP)
DILATED CARDIOMYOPATHY
Major Causes of Dilated Cardiomyopathy
Myocarditis
• Inflammation of heart muscles
• Acute/subacute presentation of heart failure and
elevated cardiac enzymes (with normal
coronaries)
• Clinically behaves as dilated cardiomyopathy
• Viruses/bacteria/drugs/Immune
Peri-Partum cardiomyopathy
• Last trimester of pregnancy up to six months
post-partum
• Increased maternal age, increased parity, twin
pregnancy, malnutrition, pre-eclampsia
• Cardiac function usually recovers overs weeks
to months
Other important causes
• Alcohol, Cocaine, amphetamines
• Thiamine deficiency (beware; it may also
occur in high users of highly processed food)
• Chemotherapeutic agents
• Hyperthyroidism
Takutsubu cardiomyopathy
• Stress induced cardiomyopathy
– Sudden intense emotional or physical stress
• Apical ballooning syndrome
• May cause sudden death
• EF may recover with time
RESTRICTIVE CARDIOMYOPATHY
Restrictive
Cardiomyopathy
• Diastolic heart failure
• Infiltration of elements in
ventricular muscles
• Apical impulse at normal
position
• Preserved EF
HYPERTROPHIC CARDIOMYOPATHY
Hypertrophic
cardiomyopathy
HCM with or
without outflow
obstruction
• Jerky pulse, S4
gallop
• Crescendo/Decres
cendo systolic
ejection murmur.
Its intensity
increases with
Valsalva.
• Holosystolic
apical blowing
murmur of mitral
regurgitation
Risk factors for sudden death in HOCM
The ultimate fate
• Every cardiomyopathy ultimately turns into
dilated cardiomyopathy
• “Heart failure is not a disease; it is a final
common pathway”.
Summary
QUESTIONS ???