Heart Failure

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CHF
Umer Ahmed, MS III
Daniel Mehrhoff, MS III
Tazeen Al-Haq, MS III
Definitions
• Forward Heart Failure – heart unable to maintain adequate
cardiac output to meet systemic demands and/ or able to
do so only by elevating filling pressure.
• Backward Heart Failure – Heart unable to accommodate
venous return resulting in vascular congestion (systemic or
pulmonary)
• Heart Failure can involve left side of heart, right side of
heart or both(biventricular failure)
• Components of ineffective filling (diastolic
dysfunction)and/or emptying-systolic dysfunction
• Most cases of HF are associated with poor cardiac
output(low-output HF);however HF may not be due to
intrinsic cardiac disease,but due to increased demand-HOP
Pathophysiology
• Primary insults (myocyte loss,overload) -> pump
dysfunction, which leads to remodeling (dilation,
hypertrophy) and neurohumoral activation>necrosis and apoptosis.
• Both pathways result in further damage (restarting the cycle), edema, tachycardia,
vasoconstriction, congestion
• Compensatory response to myocardial stress –
• increased end-systolic ventricular
pressure(pressure overload) e.g. aortic stenosis->
hypertrophy.
Pathophysiology
Increased end-diastolic ventricular volume (volume
overload) e.g. aortic regurgitation
->cardiac dilation
Systemic response to ineffective circulating volume
results in activation of sympathetic nervous and
renin-angiotensin-alsosterone systems which
causes
-Salt and water retention with intravascular
expansion
- increased heart rate and myocardial contractility
- increased afterload
Classification of Heart Failure by
Hemodynamic Abnormality
Diastolic Heart Function
About 30% of heart failure
Characterize by impaired LV relaxation
The hemodynamic abnormality is an elevated
LVEDP – normally it should relax down to
around 5-10 mmHg
The elevated LVEDP causes increased left atrial
and pulmonary capillary pressures
Diastolic Heart Failure
Fluid is transudated across the pulmonary
Capillaries causing intestitial edema and
dyspnea
Systolic performance is initially normal or
hyperdynamic, but later fails.
Examples include hypertensive heart disease,
HCM, and diabetic cardiomyopathy
High Output Systolic Heart Failure
Pure forms of systolic heart failure are
uncommon and are characterize by:
A low LVEDP
Normal or hyper dynamic left ventricular
function
Tachycardia
And increased cardiac output
High Output Systolic Heart Failure
• Occurs with peripheral shunting with large
AV fistulas, large hepatic hemangiomas, and Paget’s disease
• Occurs with decrease peripheral resistance, as in Gram
negative sepsis
• Other causes are hyperthyroidism, beriberi,
• Carcinoid, anemia and pregnancy
• Note: it is either due to a dramatic decrease in after load or
an increase in preload. Basically High output heart failurediffers from the usual heart failure in that the heart may
pump out its usual amount of blood, but that still may not
be enough to meet the body's needs
Low Output Systolic Heart Failure
The vast majority of systolic failure involves
both decreased systolic dysfunction and an
elevated LVEDP
Decreased forward output causes weakness,
fatigue, fluid retention.
Note: which leads to increased LVEDP
Causes of Low Output Systolic HF
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Coronary artery disease – 40%
Dilated cardiomyopathy – 30%
Valvular heart disease – 15%
Hypertensive heart disease – 10%
Restrictive cardiomyopathy - < 1%
Pathophysiology of Heart Failure
• Decreases Stroke Volume -> Decrease cardiac
output – > decrease Renal perfusion –>
increase Renin –> increased Angiotensin>increased Angiotensin II –> increased Sodium
retention –> increased water retention –>
increased Preload –> increased Ventricular
filling pressures –> Exacerbation of heart
failure –>
Morbidity and Mortality
• 50% die with progressive heart failure, 40% of
sudden death due to VT/VF
• LVEF is closely associated with prognosis!
• Other markers of poor outcome include low
sodium, high BUN, low potassium, high or low
magnesium, high catecholamine levels
• Exercise tolerance does not predict outcome
Classifications of Heart Failure by
Myocardial Abnormality
Myocardial Abnormalities
Ischemic
Hypertensive
Dilated
Restrictive
Hypertrophic
Ischemic Cardiomyopathy
• Caused by coronary disease
• By far the most common cause of
heart failure
• Characterized on echo by
segmental wall motion
abnormalities.
.
Hypertensive Cardiomyopathy
• Chronic HTN causes LVH, which increases LV
stiffness and elevates LVEDP
• Systolic function may be normal,
hyperdynamic, or eventually, decreased
• Characterized on echo by concentric LVH
Dilated Cardiomyopathy
• 50% are idiopathic, presumably post viral
• Other causes include alcohol, cocaine, inhaled
glue, chemotherapy, late hemochromotosis,
and selenium and carnitine dificiencies
• Characterized on echo by four chamber
cardiac enlargement
Peripartum Dilated Cardiomyopathy
• Occurs from the beginning of the third
trimester to six months postpartum
• There is predilection of older women in
African Americans
• About two thirds resolve spontaneously
• There is increased risk of occurrence with
subsequent pregnancies
Dilated Cardiomyopathy and Embolization
• About 2% of patients form mural thrombi and
can have arterial embolization
• Pulmonary emboli can arise from the RV
• Anticoagulation is indicated even if no mural
thrombi can be detected
Restrictive Cardiomyopathy
< 1%
• Caused by infiltrative diseases, such as
amyloid, sarcoid, hemochromotosis, and lipid
storage diseases
• Presents with left and right heart failure,
initially from diastolic dysfunction, but later
from systolic failure also. HF from due to
restrictive cardiomyopathy usually presents as
refractory left and right sided heart failure.
Restrictive Cardiomyopathy
• Characterized an echo by normal sized
ventricles, huge atria, and (in Amyloidosis) by
a “sparkling” appearance of the LV
myocardium.
• The venticles cannot enlarge, because they
have already been enlarged.
Hypertrophic Cardiomyopathy
• There are disordered myocytes in the region
of the hypertrophy, especially in the region of
the upper ventricular septum
• Areas other than the septum can be affected;
Asians frequently have an apical form
• Occasionally there is a concentric LVH
• Sudden death is probably due to ventricular
arrhythmias
Hypertropic Cardiomyopathy
• Hypertrophic cardiomyopathy (HCM) is
associated with sudden cardiac death,
especially in exercising young people with the
familial form
• The severity of the LV outflow gradiant is not
related to the risk of sudden death
• There is no cure except heart transplant
.
New York Heart Association (NYHA)
Functional Classification of Heart Failur
• Class I: ordinary physical activity does not cause
symptoms of HF
• Class II: comfortable at rest, ordinary physical
activity results in symptoms
• Class III: marked limitation of ordinary activity;
less than ordinary physical activity results in
symptoms.
• Class IV: inability to carry out any physical activity
without discomfort; symptoms may be present at
rest.
Acute Versus Chronic Heart Failure
• Acute heart failure is the patient who is
entirely well but who suddenly develops a
large myocardial infarction or rupture of a
cardiac valve.
• Chronic heart failure is typically observed in
patients with dilated cardiomyopathy or
multivalvular heart disease that develops or
progresses slowly
Acute Versus Chronic Heart Failure
• Acute heart failure is usually largely systolic
and the sudden reduction in cardiac output
often results in systemic hypotension without
peripheral edema.
• In chronic heart failure, arterial pressure tends
to be well maintained until very late in the
course, but there is often accumulation of
peripheral edema .
Backward versus forward heart failure
• Forward heart failure-Is the inability of the
heart to pump enough blood to meet the
needs of the body for oxygen during exercise
or at rest.
• Backward heart failure-Is the inability of the
heart to meet the oxygen needs of the body
when heart filling pressures are too high
Redistribution of Cardiac Output
• Finally, the redistribution of cardiac output is
an important compensatory mechanism when
cardiac output is reduced. This redistribution
is most marked when a patient with HF
exercises, but as heart failure advances,
redistribution occurs even in the basal state.
Demographics
• The most expensive medical problem in the US
• The most common diagnose in hospitalized
elderly patients
Note: It is the most expensive medical problem,
because in the later stages patient are
hospitalized over and over again as the disease
progressed with frequent exacerbations and
remissions.
CHF Diagnosis
Tazeen Al-Haq
CHF Diagnosis
• Four components involved in the diagnosis of
CHF
– History
– Physical
– Labs
– Imaging
History
– Classical manifestations of
heart failure include
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Fatigue
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal
dyspnea
• Fluid retention
– Older patients with heart
failure often present with
nonspecific symptoms
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Nocturia
Insomnia
Irritability
Anorexia
Physical Examination
• Left heart failure
– Low cardiac output (forward)
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Fatigue
Syncope
Systemic hypotension
Cool extremities
Slow capillary refill
Peripheral cyanosis
Pulsus alternans
Mitral regurgitation
S3 aka Kentucky gallop
– Occurs at the beginning of diastole after S2 and is lower in pitch than S1
and S2
– Will increase on expiration
Pulsus Alternans
•Is a physical finding with arterial pulse
waveform alternating strong and weak beats
•Almost always indicative of left ventricular
systolic impairment and also occurs in aortic
and mitral valve stenosis, hypertrophic and
congestive cardiomyopathy, pericarditis and
use of general anesthesia
•Carries a poor prognosis
•EF is decreased in left ventricular dysfunction
which causes an increase in EDV
•In the next cycle of systolic phase, the
myocardial muscles are stretched more than
usual causing an increase in muscle
contraction and a stronger systolic pulse
Physical Examination
• Left heart failure
– Venous congestion (backward)
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Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Cough
Crackles
Physical Examination
• Right heart failure
– Low cardiac output (forward)
• Can mimic most of the symptoms of forward left heart
failure if decreased right ventricle output leads to left
ventricle underfilling
• Tricuspid regurgitation
• S3 (right-sided)
– will increase on inspiration
Physical Examination
• Right Heart failure
– Venous congestion (backward)
• Peripheral edema
• Elevated JVP with abdominal jugular reflex
• Kussmaul’s sign
– Rise in JVP with inspiration
– Usually JVP falls with inspiration due to reduced pressure in the
expanding thoracic cavity
– Suggests impaired filling of the right ventricle
• Hepatomegaly
• Pulsatile liver
– Signifies severe tricuspid regurgitation or constrictive pericarditis
Investigation
• Identify and assess precipitating factors and treatable causes of CHF
• HEART FAILED
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HTN (common)
Endocarditis
Anemia
Rheumatic heart disease and other valvular disease
Thyrotoxicosis
Failure to take meds (very common)
Arrhythmia (common)
Infection/Ischemia/Infarction (common)
Lung problems (PE, pneumonia, COPD)
Endocrine (pheochromocytoma)
Dietary indiscretions (common)
Investigations
• Blood work
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CBC
Electrolytes
BUN and Creatinine
TSH
Ferritin
Cardiac biomarkers
B-type/Brain natriuretic peptide (BNP)
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Secreted by ventricles due to LV stretch and wall tension
Sensitive marker of ventricular pressure and volume overload
Higher levels are suggestive of heart failure
Lower levels (<100 pg/mL) is most useful for ruling out heart
failure
Cardiac Biomarkers
• Provide diagnostic and prognostic information
• Identify increased risk of mortality in acute coronary
syndromes
• Troponin I and T
– Peak at 1-2 days and remain elevated up to 2 weeks
– DDx: MI, CHF, acute pulmonary embolism, myocarditis,
chronic renal insufficiency, sepsis, hypovolemia
• CK-MB
– Peak at 1 day and remain elevated for 3 days
– DDx: MI, myocarditis, pericarditis, muscular dystrophy,
cardiac defibrillation
Investigations
• Chest X-Ray
– HERB-B
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Heart enlargement/Cardiomegaly
Pleural Effusion
Re-distribution (alveolar edema)
Kerley B-lines
Bronchiolar-alveolar cuffing
Chest X-Ray
Chest X-Ray
Cardiomegaly
CHF Treatment
Umer Ahmed
General Principals in the Treatment of CHF
• No one simple treatment regimen is suitable
for all patients.
• The following are a general guideline, but the
order of therapy may differ among patients
and/or with physician preferences.
General Principles in the Treatment of CHF
Mild CHF (NYHA Class I to II)
• Mild restriction of sodium intake (no-addedsalt diet of <4 g sodium) and physical activity
(aka Lifestyle Changes).
• Start a loop diuretic if volume overload or
pulmonary congestion is present.
• Use an ACE inhibitor as a first-line agent.
General Principles in the Treatment of CHF
Mild to Moderate CHF (NYHA Class II to III)
• Start a diuretic (loop diuretic) and an ACE
inhibitor
• Add a β-blocker if moderate disease (class II or
III) is present and the response to standard
treatment is suboptimal
General Principles in the Treatment of CHF
Moderate to Severe CHF (NYHA Class III to IV)
• Add digoxin (to loop diuretic and ACE inhibitor)
• Note that digoxin may be added at any time for
the relief of symptoms in patients with systolic
dysfunction. (It does not improve mortality.)
• In patients with class IV symptoms who are still
symptomatic despite the above, adding
spironolactone can be helpful.
Monitoring a Patient with CHF
• Weight—unexplained weight gain can be an
early sign of worsening CHF
• Clinical manifestations (exercise tolerance is
key); peripheral edema
• Laboratory values (electrolytes, K, BUN,
creatinine levels; serum digoxin, if applicable)
Medical Devices
• Ventricular assist device (VAD). When your
weakened heart needs help pumping blood,
surgeons may implant a VAD into your
abdomen and attach it to your heart. These
mechanical heart pumps can be used either as
a "bridge" to heart transplant or as permanent
therapy for people who aren't candidates for a
transplant.
Medical Devices
• Cardiac resynchronization therapy (CRT)
device (biventricular cardiac pacemaker). It
sends specifically timed electrical impulses to
your heart's lower chambers. CRTs are suitable
for people who have moderate to severe
congestive heart failure and abnormal
electrical conduction in the heart.
Medical Devices
• Internal cardiac defibrillator (ICD). Doctors
implant ICDs under the skin to monitor and
treat fast or abnormal heart rhythms
(arrhythmias), which occur in some people
who have heart failure. The ICD sends
electrical signals to your heart if it detects a
high or abnormal rhythm to shock your heart
into beating more slowly and pumping more
effectively.
Surgery
Heart valve repair or
replacement.
Cardiologists may
recommend heart valve
repair or replacement
surgery to treat an
underlying condition
that led to congestive
heart failure. Heart valve
surgery may relieve your
symptoms and improve
your quality of life.
Surgery
Coronary bypass
surgery. Cardiologists
may recommend
coronary bypass
surgery to treat your
congestive heart
failure if your disease
results from severely
narrowed coronary
arteries.
Surgery
Myectomy. In a
myectomy, the surgeon
removes part of the
overgrown septal
muscle in your heart to
decrease the blockage
that occurs in
hypertrophic
cardiomyopathy.
Surgeons may perform
myectomy when
medication no longer
relieves your symptoms.
Surgery
Heart
transplant.
Some people
who have
severe
congestive
heart failure
may need a
heart
transplant.
Two Questions
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