Heart Failure PDF

 Objectives  Definition  Types of Heart Failure  Causes of Heart Failure  Investigations of HF  Treatment  HF is a common clinical syndrome with symptoms caused by impaired ability of the heart to pump blood at a rate proportional with the requirements of the met...

 Objectives  Definition  Types of Heart Failure  Causes of Heart Failure  Investigations of HF  Treatment  HF is a common clinical syndrome with symptoms caused by impaired ability of the heart to pump blood at a rate proportional with the requirements of the metabolizing tissues due to a structural or functional cardiac disorder  It is a common end point for many diseases of cardiovascular system  Acute Heart Failure Syndrome (AHF): Refers to the rapid onset or worsening of symptoms and signs of heart failure, requiring urgent therapy. It can develop in patients with previously diagnosed heart failure (acute decompensated heart failure) or manifest as the first presentation of heart failure  Chronic Heart Failure (CHF): Is a long-term condition in which the heart is unable to pump blood effectively to meet the body’s needs. It develops gradually over time, often as a result of underlying cardiovascular diseases  Types of Heart Failure 1. Systolic vs. Diastolic Heart Failure a. Systolic Heart Failure (Heart Failure with Reduced Ejection Fraction - HFrEF) The heart muscle is weak and cannot pump blood effectively. Characterized by a reduced ejection fraction (EF < 40%). Commonly caused by conditions like coronary artery disease and heart attacks. b. Diastolic Heart Failure (Heart Failure with Preserved Ejection Fraction - HFpEF) The heart muscle becomes stiff and cannot relax properly, leading to inadequate filling of blood. Ejection fraction is preserved (EF > 50%). Often associated with hypertension, aging, and diabetes 2. Left-Sided vs. Right-Sided Heart Failure a. Left-Sided Heart Failure Most common type of heart failure.The left ventricle cannot pump blood efficiently to the body.Leads to pulmonary congestion Subtypes:  Systolic failure: Reduced ejection fraction.  Diastolic failure: Preserved ejection b.Right-Sided Heart Failure The right ventricle fails to pump blood effectively to the lungs lead to → fluid retention in the lower extremities, abdomen, and organs. Often a result of left-sided heart failure or pulmonary hypertension 3. Congestive Heart Failure (CHF) CHF can affect both sides of the heart and is characterized by fluid accumulation throughout the body. Causes of Heart Failure  Normal heart forced to do excessive work until it fails:  Excessive pressure as hypertension.  Excessive volume as aortic regurge.  Excessive body needs as anemia.  Diseased heart muscle as cardiomyopathy.  Combined excessive work and heart muscle disease. 1. Coronary Artery Disease (CAD) The most common cause of left-sided heart failure. 2. Hypertension (High Blood Pressure) Chronic high blood pressure forces the left ventricle to work harder to pump blood. 3. Heart Attack (Myocardial Infarction) A heart attack occurs when blood flow to part of the heart muscle is blocked, leading to damage. 4.Cardiomyopathy  Diseases of the heart muscle that impair its ability to pump blood.  Dilated Cardiomyopathy: The left ventricle enlarges and weakens, reducing its pumping efficiency. Hypertrophic Cardiomyopathy: The heart muscle thickens abnormally, making it harder for the left ventricle to pump blood. 4. Aortic Valve Disease Types: a. Aortic Stenosis: Narrowing of the valve causes the left ventricle to work harder to push blood through. b. Aortic Regurgitation: The valve doesn’t close properly, allowing blood to leak back into the left ventricle.  Mechanism: Both conditions increase the workload on the left ventricle, leading to faluire 5.Mitral Valve Disease Dysfunction of the mitral valve, located between the left atrium and left ventricle.  Types: ◦ Mitral Stenosis: Narrowing of the mitral valve restricts blood flow into the left ventricle. ◦ Mitral Regurgitation: The valve allows blood to leak back into the left atrium during contraction.  Mechanism: These valve issues cause blood flow problems, increasing pressure in the left atrium and leading to failure. 6. Arrhythmias (Irregular Heart Rhythms) Abnormal heart rhythms, such as atrial fibrillation, can impair the heart’s ability to pump blood efficiently.  Mechanism: Fast or irregular heartbeats reduce the time available for the left ventricle to fill with blood, weakening its function over time. 1. Left-Sided Heart Failure (The Most Common Cause) 2. Pulmonary Hypertension High blood pressure in the arteries of the lungs (pulmonary arteries).  Mechanism: The right ventricle has to work harder to pump blood into the lungs, and over time, this extra workload can weaken and enlarge the right ventricle, leading to right-sided heart failure. 3. COPD (Chronic obstructive lung disease 4. Pulmonary Embolism 5. Right Ventricular Myocardial Infarction (Heart Attack) 6. Tricuspid Valve Disease Tricuspid valve regurgitation (leakage) or stenosis (narrowing) can cause blood to back up into the right atrium, increasing pressure and leading to right heart failure. 7. Congenital Heart Disease such as atrial septal defects  Most common cause of Left side HF:  Ischemic heart disease.  Hypertension.  Most common cause of Right side HF:  Left-sided heart failure.  Diastolic heart failure:  Due to impaired filling.  High COP failure:  As in anemia & thyrotoxicosis Left-sided Heart Failure  Low COP symptoms.  Pulmonary congestive symptoms. 1. Pulse – may be rapid, weak and thready if there is considerable failure. Watch out for arrhythmias and pulsus alternans (alternate strong and weak beats), which is a sign of LVF. 2. look for abnormal pulse character because it may reveal a possible aetiology for the cardiac failure (e.g. water hummer pulse in aortic regurgitation). 3. Blood pressure – this may be normal, low in forward failure, or high in the hypertensive patient (remember that, worldwide, hypertension is a very common cause of heart failure). 4. Jugular venous pressure (JVP) – this is elevated in CCF and pure right-sided failure (the normal jugular venous pressure is 2–3 cm above the sternal angle). 5. Apex beat – may be displaced downward and laterally in a patient who has an enlarged left ventricle. A diffuse apex beat is a sign of severe left-ventricular dysfunction 6. RV heave: left parasternal (pulmonary hypertension) 6. Heart sounds – on auscultation there may be a third heart sound. Tachycardia combined with a third (or fourth heart sound) is referred to as a gallop rhythm. 7. Murmurs – these may signify a possible cause of heart failure (e.g. aortic valve murmurs and mitral valve murmurs). 8. Peripheral oedema – this may be elicited over the sacrum or over the ankle. Take care because oedema may be tender. The extent to which the oedema extends up the legs is an indication of the extent of the fluid overload.  cyanosis,  bilateral basal fine end-inspiratory crepitations extending from the bases upwards. This is classic of pulmonary oedema.  There might also be pleural effusions and expiratory wheeze (secondary to cardiac asthma). orthopnea   Low cardiac output sign  Tachypnea  Cyanosis  Tachycardia  Cool, Clammy Skin: Lung congestive sign Bilateral basal crepitation displaced apex (LV dilatation), RV heave (pulmonary hypertension)  Right side heart failure  Low COP symptoms.  Systemic congestive symptoms : 1)Pain right upper abdomen due to hepatic congestion 2)GIT Congestion:anorexia, nausea, vomiting and dyspepsia 3)CNS congestion:confusion, headache, insomnia, lack of memory and encephalopathy in advanced heart failure 4)Edema Lower limb 5)Ascites  General 1. Cyanosis 2. Jaundice 3. Congested neck veins 4. Peripheral edema 5. Weight Gain:Rapid, due to fluid retention  Local signs 1. Enlarged tender liver 2. Ascites 3. Congestive splenomegaly 1. History and Physical Examination 2. Blood Tests: 3. ECG 4. CXR 5. Echo/Doppler 6. Coronary Angiography 7. Cardiopulmonary Exercise Testing (CPET): 8. Cardiac catheterization  Symptoms: Common symptoms include dyspnea, fatigue, fluid retention (edema), and reduced exercise tolerance.  Physical Signs: Tachycardia, hypotension, jugular venous distension, lung crackles, peripheral edema, and hepatomegaly. a. Complete Blood Count (CBC): To rule out anemia or infection. b. Renal Function (Urea, Creatinine): To assess kidney involvement. c. Liver Function Tests: May indicate hepatic congestion. d. Thyroid Function Tests: To rule out hyperthyroidism or hypothyroidism, which may precipitate or worsen HF. e. Electrolytes: Sodium and potassium levels, especially important for patients on diuretics or ACE inhibitors. f. B-type Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT- proBNP): Elevated levels suggest HF and can be used to assess the severity. ◦ BNP ≥ 100 pg/mL ◦ NT-proBNP ≥300 pg/mLc 3. Electrocardiogram (ECG) To detect arrhythmias, ischemia, myocardial infarction, left ventricular hypertrophy, or other abnormalities. 4. Chest X-Ray Useful for detecting pulmonary congestion, cardiomegaly, or pleural effusion. 5. Echocardiography Provides detailed information on left ventricular ejection fraction (LVEF), heart structure, valve function, wall motion, and any pericardial effusion. Differentiates between systolic and diastolic dysfunction. Acute infero-lateral myocardial infarction: marked ST elevation in the inferior leads (II, III, aVF), but also in V 5 and V 6 Add the S wave in V1 plus the R wave in V5 or V6. If the sum is greater than 35 mm, LVH is present.  There may be cardiomegaly indicating a dilated left ventricle.  alveolar oedema. 6. Coronary Angiography Performed in cases where ischemic heart disease is suspected or to evaluate coronary anatomy in patients who may benefit from revascularization (e.g., percutaneous coronary intervention or coronary artery bypass grafting). 7. Cardiopulmonary Exercise Testing (CPET): Used for assessing exercise tolerance and providing prognostic information in HF. 8. Cardiac catheterization Is procedure used to diagnose and treat certain cardiovascular conditions. It involves inserting a thin, flexible tube (catheter) into a blood vessel, typically through the groin, arm, or neck, and guiding it to the heart. This allows for detailed examination of the heart’s function, the coronary arteries, and the chambers of the heart. Correction of reversible causes Ischemia Valvular heart disease Thyrotoxicosis and other high output status Arrhythmia Diet and Activity  Salt restriction  Fluid restriction  Daily weight  Gradual exertion programs  Renin-Angiotensin Aldosterone System RAS system is activated early in the course of heart failure and plays an important role in the progression of the syndrome  Angiotensin converting enzyme inhibitors  Angiotensin receptors blockers  Spironolactone (MRA: Mineralocorticoid receptor antagonist)  The role of digitalis has declined somewhat because of safety concern  Recent studies have shown that digitals does not affect mortality in CHF patients but causes significant Reduction in hospitalization  Reduction in symptoms of HF  +ve inotropic effect  Now they are the main stay in treatment on CHF & may be the only medication that shows improvement in LV function  In addition to improved LV function multiple studies show improved survival  The only contraindication is severe decompensated CHF  Atrial fibrillation  H/o embolic episodes  Left ventricular apical thrombus 1- Ivabradine  Decreases resting heart rate  Does not alter ventricular repolarization, myocardial contractility, and blood pressure 2- Enteresto  Sacubtril-valsartan New Methods  Biventricular pacingCRT (Cardiac resynchronization therapy).  ICD (Implantable cardioverter device)  Cardiac Transplant