Untitled Quiz

Heart Failure Overview

• Heart failure is the inability to pump enough blood to meet the body's needs.
• Cardiac disease, severe anemia, hyperthyroidism, pregnancy, and liver failure can increase body demands.

Types of Heart Failure

• Acute heart failure: Characterized by a sudden problem, e.g., myocardial infarction (MI), arrhythmia.
• Chronic heart failure: Develops gradually, often as a result of hypertension.
• Left-sided heart failure:
  • Systolic (HFrEF): Heart failure with reduced ejection fraction.
  • Diastolic (HFpEF): Heart failure with preserved ejection fraction.
• Right-sided heart failure

Stages of Heart Failure (NYHA)

• Stage 1: No symptoms, no limitations on activity.
• Stage 2: Mild symptoms, slight limitation on activity.
• Stage 3: Symptoms limit activity, comfortable only at rest.
• Stage 4: Severe symptoms, symptoms present even at rest.

Diagnosis of Heart Failure (Framingham Criteria)

• Diagnosis based on major and minor criteria.
• 2 major or 1 major + 2 minor criteria are needed.

Major Criteria

• Paroxysmal nocturnal dyspnea (PND) or orthopnea
• Neck vein distention
• Pulmonary rales
• Acute pulmonary edema
• Hepatojugular reflux
• Cardiomegaly
• S3 gallop
• 4.5 kg weight loss in 5 days in response to treatment

Minor Criteria

• Nocturnal cough
• Dyspnea on ordinary exertion
• Bilateral ankle edema
• Hepatomegaly
• Pleural effusion
• Heart rate > 120

Etiology (Causes)

• Systolic Heart Failure (HFrEF):
  • Coronary artery disease (CAD)
  • Hypertension
  • Diabetes mellitus
  • Valvular heart disease
  • Myocarditis
  • Peripartum cardiomyopathy
  • Congenital heart disease (TOF/TGA)
  • Drugs
  • Other (rare)
• Diastolic Heart Failure (HFpEF):
  • Hypertension
  • Diabetes Mellitus
  • CAD
  • Valvular heart disease
  • Hypertrophic cardiomyopathy
  • Restrictive cardiomyopathy
  • Constrictive pericarditis
• Right-sided Heart Failure:
  • Left-sided heart failure is a common cause
  • Pulmonary artery hypertension
  • Pulmonary valve stenosis
  • Pulmonary embolism
  • Chronic pulmonary disease
• Acute Heart Failure:
  • Acute valvular regurgitation
  • Myocardial infarction (MI)
  • Arrhythmias (AF, VT)
  • Drugs (e.g., cocaine)
  • Sepsis
  • Pregnancy
  • Iatrogenic (due to treatment)

Symptoms

• Exertional dyspnea
• Orthopnea
• Chest pain
• Palpitations
• Acute pulmonary edema
• Cough
• Wheezing
• Lower limb edema
• Ascites
• Weight gain
• Anorexia
• Nausea
• Cardiac cachexia
• Fatigue
• Bloating
• Oliguria
• Nocturia
• Anxiety
• Decreased memory
• Confusion
• Headache
• Insomnia
• Bad dreams
• Psychosis
• Hallucinations

Signs and Findings

• Orthopnea
• Congested neck veins
• Central cyanosis
• Jaundice
• Malar flush
• Ascites
• Dark skin
• Fever
• Tachycardia
• Diaphoresis
• Rales
• Pulmonary edema
• Hepatojugular reflux
• Bilateral lower limb edema
• Hepatosplenomegaly
• Pleural effusion
• S3 gallop
• Cardiomegaly
• Murmur
• Signs of liver cell failure

Investigations

• Blood tests: BNP/NT proBNP, CBC, electrolytes (Na, K, Ca, Mg), urea, creatinine, urine analysis, ALT, AST, bilirubin, albumin, ABG (arterial blood gases).
• Genetic testing: For specific cardiomyopathies.
• ECG: Comprehensive electrocardiogram
• Exercise ECG: Measures ECG response during exercise.
• Chest X-ray
• Echocardiography: Transthoracic (TTE) and transesophageal (TEE)
• Stress echocardiography
• CT
• MRI
• Catheterization and angiography: Invasive test for detailed heart structure and function.
• Nuclear imaging

Treatment (Systolic HF - HFrEF)

• Nonpharmacologic:
  • Salt restriction (2-3 g/day)
  • Water restriction
  • Stop alcohol and smoking
  • Reasonable exercise
  • Weight reduction
  • Daily weight measurement
  • Home monitoring
  • Patient education
  • Stop exacerbating drugs
• Pharmacologic:
  • Diuretics (e.g., torsemide)
  • ACEIs or ARBs (e.g., ramipril)
  • Beta blockers (e.g., bisoprolol)
  • SGLT2 inhibitors (e.g., dapagliflozin)
  • Vasodilators (e.g., hydralazine, nitrates)
  • Inotropics (e.g., digoxin, dopamine)
  • Anticoagulation (e.g., aspirin, low dose)

Treatment (Diastolic HF - HFpEF)

• Treat underlying cause (ischemia, obstructive sleep apnea)
• Treat precipitating factors, such as weight loss, exercise, low-sodium diet, restricted fluid intake, and daily weight measurement.
• Treat comorbidities.
• Diuretic therapy is needed to reduce fluid excess and should be used cautiously to avoid hypotension.
• May use ACEIs/ARBs, or Sacubitril/Valsartan,
• Beta-blockers are also indicated to control ventricular rate in AF.
• Avoid the routine use of nitrates or phosphodiesterase-5 inhibitors.

Treatment (Acute Heart Failure)

• ABCs: Airway, breathing, circulation
• Check blood glucose
• Oxygen if hypoxia
• IV diuretics
• ACE inhibitors or ARBs
• Vasodilators (e.g., nitrates)
• Nesiritide (if congestion is significant)
• Inotropics (e.g., dopamine)
• Mechanical support (ECMO)
• Control arrhythmias (defibrillation, drugs)
• Address the underlying cause and/or treat complications