Heart Failure (PDF)

# Heart failure ## Fشل القلب Heart failure is inability to pump enough blood to meet the body's requirements. ## Causes * **Cardiac disease** * MI * Cardiomyopathy * etc * **Increased body demands** * Severe anemia * Hyperthyroidism * Pregnancy * Li...

# Heart failure ## Fشل القلب Heart failure is inability to pump enough blood to meet the body's requirements. ## Causes * **Cardiac disease** * MI * Cardiomyopathy * etc * **Increased body demands** * Severe anemia * Hyperthyroidism * Pregnancy * Liver cell failure * etc ## Types of heart failure **Acute heart failure**: recent problem as * MI * Arrhythmia * etc **Chronic heart failure**: gradual problem as a result of hypertension ## Left sided heart failure * **Systolic or HFrEF**: heart failure with reduced ejection fraction * **Diastolic or HFpEF**: heart failure with preserved ejection fraction ## Right sided heart failure ## Stages of heart failure **NYHA** - New York Heart Association | Stage | Description | |---|---| | 1 | Cardiac disease, but no symptoms and no limitation in ordinary physical activity. | | 2 | Mild symptoms and slight limitation during ordinary activity. | | 3 | Significant limitation in activity due to symptoms. Comfortable only at rest.| | 4 | Severe limitations. Symptoms even while at rest. | ## Diagnosis of heart failure **Framingham criteria** Diagnosis of heart failure if: * 2 major criteria * 1 major + 2 minor criteria ### Major criteria * Paroxysmal nocturnal dyspnea (PND) or orthopnea * Neck veins 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 * Hepatomegaly * Dyspnea on ordinary exertion * Pleural effusion * Bilateral ankle edema * Heart rate > 120 ## Etiology ### Systolic HF (HFrEF) * Coronary artery disease (CAD) * Hypertension * Diabetes mellitus * Valvular heart disease * Inflammation or infections as myocarditis * Peripartum cardiomyopathy * Congenital heart diseases as TOF or TGA * Drugs * Rare: endocrine abnormalities - rheumatologic diseases - neuromuscular conditions * Idiopathic ### Diastolic HF (HFpEF) * Hypertension * DM * CAD * Valvular heart disease * Hypertrophic cardiomyopathy * Restrictive cardiomyopathy as in (amyloidosis -sarcoidosis) * Constrictive pericarditis as in (TB - post viral - post surgery) ### Left sided heart failure * Coronary artery disease (CAD) * Pulmonary hypertension * Pulmonary valve stenosis * Pulmonary embolism * Chronic pulmonary disease ### Right sided heart failure ### Acute heart failure * Acute valvular regurgitation * Myocardial infarction (MI) * Arrhythmia as (AF - VT ..... etc) * Drugs as cocaine * Sepsis * Pregnancy * Latrogenic ## Symptoms * Exertional dyspnea * Dyspnea at rest (severe cases) * Orthopnea * Paroxysmal nocturnal dyspnea * Chest pain * Palpitations * Acute pulmonary edema * Cough and wheezing * Lower limb edema * Ascites * Weight gain * Anorexia * Nausea * Cardiac cachexia * Fatigue * Bloating * Oliguria * Nocturia (late) * Anxiety * Decreased memory * Confusion * Headache * Insomnia * Bad dreams * Psychosis * Hallucinations ## Signs - findings * Orthopnea * Malnourishment * Congested neck veins * Central cyanosis * Jaundice * Malar flush * Ascites * Dark skin * Fever (peripheral vasoconstriction) * Tachycardia * Diaphoresis (sympathetic overactivity) * Rales on lung bases (moderate to severe cases) * Picture of pulmonary edema * Hepatojugular reflux * Bilateral lower limb edema * Hepatosplenomegaly * Signs of pleural effusion * S3 * Cardiomegaly * Pulsus alternans * Accentuation of P2 * Murmur * Cardiac cachexia * Signs of liver cell failure ## Investigations * BNP or NT pro BNP * CBC * Na * K * Ca * Mg * Urea * Creatinine * Urine analysis * ALT * AST * Bilirubin * Albumin * ABG: arterial blood gases * Genetic testing * Hypertrophic cardiomyopathy * Dilated cardiomyopathy (if no obvious cause) * ARVC: autosomal dominant arrhythmogenic RV cardiomyopathy * Long‐QT syndrome * Brugada syndrome * ECG * Exercise ECG testing * Chest X‐ray * Echocardiography (ECHO): transthoracic ECHO (TTE) * ECHO: transesophageal ECHO (TEE) * Stress ECHO * CT‐MRI * Catheterization and angiography * Nuclear imaging ## Treatment ### Systolic HF (HFrEF) #### Non pharmacologic measures * Salt restriction (2–3 g/d) * Water restriction (2 L/d) in severe cases * Stop alcohol and smoking * Reasonable exercise (very useful) * Weight reduction if overweight or obese * Daily weight measurement * Home monitoring (BL pr – O2 saturation – pulse... etc) * Patient education about his condition and warning symptoms * Stop drugs that can exacerbate HF #### Pharmacologic measures (drugs) * Diuretics (as Torsemide) * ACEIs or ARBs (as Ramipril) * Beta blockers (as Bisoprolol) * SGLT2 inhibitors (as Dapagliflozin) * I(f) inhibitors (as Ivabradine) * Vasodilators: Hydralazine – nitroprusside sodium * Vasodilators: Nitrates (as Nitroglycrin) * Inotropics: Digoxin – dopamine * Anticoagulation * Aspirin (low dose) ### Acute heart failure * ABC * Check glucose * Oxygen if hypoxia So2<92 * Diuretics (IV) * ACEIs or ARBs * Vasodilators as nitrates * Nesiritide: a recombinant human B‐type natriuretic peptide * When congestion is minimized (diuretics – AEls or ARBs + BB) * Inotropics as dopamine infusion * Mechanical support as ECMO * Control of arrhythmia: DC or drugs * Antigoagulation – treat the cause – ultrafilteration in some cases ### Diastolic HF (HFpEF) * Treat the cause as ischemia - opstructive sleep apnea. * Treat precipitating factors. * Weight loss if overweight – reasonable exercise – Low‐sodium diet – Restricted fluid intake – Daily measurement of weight. * Treat any comorbidities. * Diuretic therapy is recommended to reduce fluid retention. However, patients must be monitored carefully to avoid hypotension. * ( ACEIs/ARBs) are used as indicated for patients with atherosclerotic disease, prior myocardial infarction (MI), diabetes mellitus, or hypertension. * Sacubitril/valsartan to reduce the risk of cardiovascular death and hospitalization. * Beta-blockers are indicated for patients with prior MI or hypertension and for control of ventricular rate in those with AF. * no benefit for the routine use of nitrates or phosphodiesterase‐5 inhibitors.