lecture (4) heart failure & Symptoms (7).ppt

HEART Failure By, Assistant professor Dr. Amr reda  The heart has four valves, which separate its chambers.  One valve lies between each atrium and ventricle, and one valve rests at the exit of each ventricle  The valves between the atria and ventricles are called the a...

HEART Failure By, Assistant professor Dr. Amr reda  The heart has four valves, which separate its chambers.  One valve lies between each atrium and ventricle, and one valve rests at the exit of each ventricle  The valves between the atria and ventricles are called the atrioventricular valves.  Between the right atrium and the right ventricle is the tricuspid valve.  Between the left atrium and left ventricle is the mitral valve.  Two additional valves sit at the exit of each of the ventricles.  The pulmonary valve is located at the base of the pulmonary artery.  The aortic valve is at the base of the aorta.  The right heart consists of two chambers, the right atrium and the right ventricle, separated by a valve, the tricuspid valve.  The right heart collects deoxygenated blood from two large veins, the superior and inferior venae cavae.  When the right atrium contracts, the blood is pumped through the tricuspid valve into the right ventricle.  As the right ventricle contracts, the tricuspid valve closes and the blood is pumped into the pulmonary trunk through the pulmonary valve.  The pulmonary trunk divides into pulmonary arteries and progressively smaller arteries throughout the lungs, until it reaches capillaries.  As these pass by alveoli carbon dioxide is exchanged for oxygen.  The left heart has two chambers: the left atrium and the left ventricle, separated by the mitral valve.  The left atrium receives oxygenated blood back from the lungs via one of the four pulmonary veins  It is then pumped into the left ventricle through the mitral valve and into the aorta (large artery) through the aortic valve for systemic circulation.  The left ventricle pumps blood to the body through the aortic valve and into the aorta.  The aorta is a large artery that branches into many smaller arteries, arterioles, and ultimately capillaries.  In the capillaries, oxygen and nutrients from blood are supplied to body cells for metabolism, and exchanged for carbon dioxide and waste products.  Capillary blood, now deoxygenated, travels and collect in the superior and inferior vena cavae, and into the right heart. The heart has four chambers:  The right atrium receives blood from the veins and pumps it to the right ventricle.  The right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with oxygen.  The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle.  The left ventricle (the strongest chamber) pumps oxygen- rich blood to the rest of the body. The left ventricle’s vigorous contractions create our blood pressure.  The left ventricle is much thicker as compared with the right, due to the greater force needed to pump blood to the entire body.  The coronary arteries run along the surface of the heart and provide oxygen-rich blood to the heart muscle The cardiac cycle refers to the sequence of events in which the heart contracts and relaxes with every heartbeat. The period of time during which the ventricles contract, forcing blood out into the aorta and main pulmonary artery, is known as systole, while the period during which the ventricles relax and refill with blood is known as diastole. The atria and ventricles work in concert, so in systole when the ventricles are contracting, the atria are relaxed and collecting blood. When the ventricles are relaxed in diastole, the atria contract to pump blood to the ventricles. he left ventricle is the thickest of the heart's chambers and is responsible for pumping oxygenated blood to tissues all over the body. By contrast, the right ventricle solely pumps blood to the lungs  Stroke volume: (SV)= 70ml in the average. It is the volume of blood pumped by each ventricle in one beat. It depends on :  Preload (volume load or diastolic load)  Afterload (pressure load or systolic load)  Contractility: Force of contraction of cardiac muscle.  Cardiac output (CO) = SV×HR(5L/MIN)  It is the volume of blood pumped by each ventricle in one minute  It depends on as SV.  Heart failure Definition: inability of heart to pump an adequate amount of blood to satisfy the metabolic requirements of the body.  Classifications HF Systolic failure : decrease contractility Diastolic failure :decrease filling Mixed Aetiology: 1) Left side heart failure: a) Left atrial failure: Mitral stenosis b) Left ventricular failure:  Increase cardiac load: 1) Volume overload: Mitral regurge & aortic regurge. 2) Pressure overload: Aortic stenosis & Systemic hypertension.  Myocardial disease: MI, Myocarditis, Cardiomyopathy. 2) Right side heart failure: a) Right atrial failure: tricuspid stenosis b) Right ventricular failure:  Increase cardiac load: 1) Volume overload: Tricuspid regurge. Hyperdynamic circulation (anemia, hepatic failure, hyperthyrodism). 2) Pressure overload: Pulmonary hypertension due to massive pulmonary embolism. Pulmonary stenosis.  Myocardial disease: MI, Myocarditis, Cardiomyopathy. Precipitating factors: Infection: infective endocarditis, Rheumatic activity. Myocardial infarction Excessive salt intake Corticosteroid treatment Physical & emotional stress.  Clinical picture Left sided heart failure: 1) SYMPTOMS OF LOW CARDIAC OUTPUT:  Anginal pain  Pulse: weak  BP: low  Pallor, coldness, peripheral cyanosis.  Dizziness ,blurring vision  Easy fatiguability  Oliguria. 2) SYMPTOMS OF LUNG CONGESTION:  Recurrent chest infection  Cough  Haemoptysis  Dyspnea: exertional, at rest, orthopnea, PND  Bilateral basal crepitation  Pleural effesion Heart Failure Symptoms Right sided heart failure:  SYMPTOMS OF LOW CARDIAC OUTPUT.  SYMPTOMS OF SYSTEMIC CONGESTION:  Congested pulsating neck vein.  Pleural effeusion.  Ascites.  Pain in Rt hypochondrium & epigastrium.  Enlarged tender liver.  Anorexia, nausea, vomiting, dyspepsia.  Oedema of lower limb Right Heart Failure What does this show? What is present in this extremity, common to right sided HF? Symptoms  Heart Failure Diagnostic Tests Arterial Blood gas (ABG) Serum urea and serum creatinine Complete blood count (CBC) Cardiac Troponins Thyroid-stimulating hormone (TSH) Serum electrolytes. Fasting and postprandial blood sugar. liver function tests. ECG Chest X ray Ecchocardiography.  Treatment HF  The treatment includes 3 main approaches: 1) Treatment of the cause : Medical treatment: hypertension. Surgical treatment : congenital & valvular lesion. 2) Treatment precipitating factors: infection, anemia, and thyrotoxicosis. 3) Treatment of HF: Rest( physical & emotional) Restriction salt Diuretics: loop as frusemide & thiazide as dihydrochlorothiazide drugs. Vasodilators: angiotensin converting enzyme inhibitors (captopril) & direct (nitroglycerine) Symptoms of cardiac diseases I) SYMPTOMS OF LUNG CONGESTION A) Dyspnea: Definition: Uncomfortable awareness of breathing. Types of cardiac dyspnea: A) Exertional dyspnea: Grade І: dyspnea on severe exertion. Grade ІІ: dyspnea on moderate exertion. Grade ІІІ: dyspnea on mild exertion Grade ІV: dyspnea at rest. B) Orthopnea: Dyspnea on lying flat which is improved by sitting.  Causes: pulmonary congestion (excessive or abnormal accumulation of blood in the lungs) when a patient lies down and blood moves from the lower part of the body to the lungs. In normal individuals this has little effect, but in heart failure patients, the diseased left side of the heart can't pump out the additional volume. So blood backs up in the vessels of the lungs, causing shortness of breath. Fluid overload excess fluid that accumulates in the lower part of the body during the day and moves into the lungs when the patient lies down, so insufficient amount of oxygen reach to lung  C) Paroxysmal nocturnal dyspnea: PND (common in LSHF) Def: attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep 1-2h after sleep  Cause: as orthopnea.  The patient arises with → Cough with frothy expectoration Wheezy chest due to bronchospasm. Severe inspiratory dyspnea Slight cyanosis Cold sweating. The patient →  sits up in bed or  stand beside an open window or  After a variable peroid of time , the condition is relieved spontaneous or with treatment.  The condition may pass into acute pulmonary oedema.  CARDIAC ASTHMA BRONCHIAL ASTHMA 1. AGE Any age Young age 2.Past Cardiac symptoms Chest symptoms history 3. Sputum Frothy blood tinged Thick pellets 4.Dyspnea present Present 5. Duration Short Long 6. Time of 1-2h after sleep In the morning attack 7.ECG abnormal normal 8. Effect of drugs: Contraindication Improves Adrenaline Improves condition condition Morphine Contraindication 3) Haemoptysis :  Definition: expectoration (coughing up) of blood or of blood-stained sputum from the respiratory tract( bronchi, larynx, trachea, or lungs).  Causes: 1.Pulmonary congestion (LSHF). 2.Severe hypertension: rare. Hemoptysis Hematemesis Cough of blood Vomiting of blood Bright red due to Dark red [acid hematin] oxyhemoglobin Frothy mixed with air Mixed with food particles Alkaline pH Acidic pH No melena : black feces that are associated with upper Followed by melena gastrointestinal bleeding Angina pectoris: Chest pain result from myocardial ischemia. Site: Retrosternal (pain behind the sternum ). Radiation: left shoulder, arm ,forearm, epigastrium. Character: discomfort, tightness and sense of suffocation. Precipitation: muscular exercise, emotional stress, smoking. Relief: rest Duration : few minutes (less than 15minute) Associated symptoms: dyspnea, palpitation, sweating, dizziness and vomiting Myocardial infarction: Ischemic necrosis part of the cardiac muscle. Character: It is more severe and more crushing or squeezing in nature. Duration : it is more prolonged (occurs in the early morning hours). Precipitation : occur without precipitating factors. Relief: not relieved by rest. Associated symptoms: it associated with many complication ( heart failure, shock, arrythmia and pericarditis) 2) Syncope:  Def: transient loss of consciousness due to cerebral ischemia. If cerebral ischemia is prolonged → convulsion & coma and death may occur.  Aetiology: 1) Cardiac syncope:  HF  Severe hemorrhage  Arrythmia (tachcardia& bradycardia) 2) Vasomotor syncope:  Vasovagal attack (stimulation): Fear, pain & trauma to testis.  C/P: Bradycardia, hypotension, sweating and pallor. 3) Postural syncope(orthostatic):  Normally, reflex vasoconstriction blood vessels of lower limbs occur in standing to prevent pooling of blood in lower limbs.  If this mechanism is defective ,BP will be markedly decreased in the standing position and syncope may occur.  Causes:  Idiopathic  DM  Pregnancy  Prolonged recumbency. 4) other causes: severe anemia & high altitudes  DD: epilepsy& hypoglycemia. 3)Cyanosis:  Definition: is the bluish or purplish discolouration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.  Cyanosis is divided into two main types: central (lips, and tongue) and peripheral (only the extremities or fingers).  Central cyanosis may be due to the following causes: 1. Central nervous system: Intracranial hemorrhage Drug overdose(e.g. heroin) 2. Respiratory system: Pneumonia Bronchiolitis Bronchospasm (e.g. asthma) 3. Cardiovascular diseases: Congenital heart disease Heart failure Valvular heart disease Myocardial infarction  Peripheral cyanosis:  Peripheral cyanosis is the blue tint in fingers or extremities, due to an inadequate or obstructed circulation. The blood reaching the extremities is not oxygen-rich.  All factors contributing to central cyanosis can also cause peripheral symptoms to appear. Small blood vessels may be restricted and can be treated by increasing the normal oxygenation level of the blood.  Peripheral cyanosis may be due to the following causes:  All common causes of central cyanosis  Reduced cardiac output (e.g. heart failure)  Cold exposure  Chronic obstructive pulmonary disease (COPD)  Arterial obstruction (e.g. peripheral vascular disease)  Venous obstruction (e.g. deep vein thrombosis)  Central Peripheral Sites : Skin & mucous Skin (hands) membrane (hand & tongue) Hands : warm Cold Clubbing and Absent polycythemia : usually present O2 inhalation: improved No effect Warming : no effect Improved Heart rate: It is number of heart beat per minute. Palpitation : awareness of heart beats.  Aetiology:  Abnormality in heart rate: tachycardia & bradycardia.  Abnormality in heart rhythm: irregular heart (AF)  Forcible cardiac contraction.  Neurosis.  Sinus tachycardia: Def: Pulse rate > 100 beat/min. Causes:  Physiological: exercise-emotional stress-pregnancy.  Pathological: fever-shock-HF-Myocarditis  Pharmacological: atropine-adrenaline. Character: Rapid regular palpitation of gradual onset and termination.  Sinus bradycardia: Def: Pulse rate < 60 beat/min. Causes:  Physiological: sleep -in athletic  Pathological: hypothyroidism.  Pharmacological: B.blocker 