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Heart Failure

Definition
Heart failure could be divided into:
1* Low-output heart failure
2* High-output heart failure, which is a rare condition
We routinely use the term "heart failure" to describe low-output heart failure.
Heart failure is defined as: failure of the left ventricular muscle to eject
enough blood into the circulation and deliver enough O2 and nutrients to the
body tissues. So it is a mechanical problem. The doctor added a new component
to the definition which is: "Failure of the diastolic filling of the left ventricle."
and the reason for this addition is that, there is a variant that is called
Diastolic heart failure.
Diastolic heart failure (impaired ventricular filling) is caused mainly by:
1- Left ventricular hypertrophy. (LVH)
2- Constrictive pericarditis.
In this condition (diastolic heart failure), there is NO problem in the ejection,
i.e. normal ejection fraction. So that:
HF (heart failure) is: mechanical pumping failure of the left ventricle to
deliver enough oxygen and nutrients into the circulation, with/without
inability to retain blood in the diastolic phase of cardiac cycle.
Concerning the high-output heart failure, there are certain causes of this rare
condition including:
* Thyrotoxicosis.
* Arteriovenous fistula.
* Paget's disease of the bone.
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In Paget's disease of the bone, there is excessive breakdown and


formation of bone tissue, with every new bone tissue formation, there is
neovascularization. The newly formed blood vessels are going to form AV
fistulas which will cause the lager-output HF.
In the aforementioned three conditions, the blood volume is normal, the
ejection fraction is also normal, the O2 content of the blood is normal as
well, BUT the tissues in the above three conditions are in increasing
demand for blood.
Another RARE cause of High-output heart failure is:
Defective utilization of O2 by the body tissues as in the cases of: Gram
negative septicemia, and Cyanide poisoning.

Types of heart failure

First, by the side affected:


* Left ventricular failure.
* Right ventricular failure.
* Congestive heart failure, which is a biventricular failure, i.e. the
patients are presented with symptoms and signs of right and left heart
failure, and it is the medium stage in the process of transition of HF from
the left to the right.
There is what is called FORWARD and BACKWARD heart failure! The
doctor mentioned them because they are written in some books, and he
thinks that it should not be mentioned nowadays.
Forward heart failure:
Low left ventricular ejection fraction Blood pooling in the left ventricle
Increased left ventricular diastolic volume and pressure Pressure
will transit into the left atrium Pressure will transit into the pulmonary
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veins till it reaches the alveolar capillaries, when the pressure there is
elevated above 25 mmHg, transudation of fluids takes place in the alveoli,
and then into the pulmonary interstitial spaces, then the complaints of
left heart failure which are dyspnea (as a symptom) and basal lung
crepitations (as a sign), will start.
Backward heart failure:
Following the previous scenario (the forward heart failure, or the left
ventricular heart failure), when the pressure is elevated in the alveolar
capillaries, this will lead to elevated pressure in the pulmonary venules i.e.
secondary pulmonary hypertension (It is secondary to left heart failure).
The pulmonary hypertension will lead to dilatation of the right ventricle,
at this moment the previous signs and symptoms of left heart failure
(Dyspnea and basal lung crepitaions) will be replaced by the signs and
symptoms of right heart failure (Elevated jugular venous pressure, liver
congestion, ascites, lower limbs edema).
So:
* Forward heart failure = Left ventricular failure.
* Backward heart failure = Right ventricular failure.
So forget about these two terms (forward and backward HF).
Second, by the onset:
* Acute heart failure.
* Chronic heart failure.
Again, when we use the term "Heart failure", we mean by that chronic
heart failure. Acute heart failure occurs just in certain conditions. The
patient is healthy, with a normal heart, so, what is the etiology of acute
heart failure?
Acute heart failure occurs in the following 4 conditions:
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1- Blunt trauma to the chest, as in conditions of RTA.


2- Infective endocarditis, which is a valvular heart disease, which could
lead to rupture of the aortic valve or mitral valve, and thus severe mitral
regurgitation or aortic regurgitation.
3- Dissecting aortic aneurysm, which causes severe aortic
regurgitation.
4- Post-MI, which will lead to papillary muscle rupture or septal
perforation and mitral valve regurgitation. The septal perforation
occurs 2 to 3 days following MI, not before.
All of these cases could be diagnosed easily by ECHO.
The Treatment of all of the above causes of AHF is Surgery.
Otherwise, all other conditions (other than the above 4) lead to chronic
heart failure.

Causes of Left ventricular heart failure


1- Ischemic heart disease (IHD). (Common)
2- Hypertensive heart disease. (Common)
3- Cardiomyopathies.
4- Valvular heart disease.
5- Rheumatic heart disease.
6- Congenital heart disease. (HOCM: Hypertrophic Obstructive
CardioMyopathy and VSD: Ventricular Septal Defect)
The aforementioned causes of left ventricular failure can also cause
congestive heart failure.

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Causes of right ventricular failure


The most common cause of right heart failure is a long standing

left heart failure.


The following disorders cause "Pure" right heart failure:
1- Mitral valve stenosis with pulmonary hypertension.
2- Primary pulmonary hypertension.
3- Secondary pulmonary hypertension.
4- Pulmonary embolism.
5- Certain congenital heart diseases affecting the right side (i.e. pulmonary
stenosis, ASD with reversed shunt, Tricuspid artesia, Ebstein anomaly, RV
dysplasia)
6- Cor pulmonale.
In the adulthood, the causes of right heart failure are mostly three: Cor
pulmonale, pulmonary embolism, pulmonary hypertension whether primary or
secondary (ASD is the most common cause of secondary pulmonary
hypertension in adults).
In Childhood, the causes of right heart failure are congenital in origin:
pulmonary stenosis, ASD with reversed shunt, Tricuspid artesia, Ebstein
anomaly, RV dysplasia).
Again, remember that: All causes of LV failure that proceeds into pulmonary
hypertension will result in congestive heart failure. (Sx and Sx of right and left
heart failure)
The following scenario takes place in patients with HF:
Patients develop Left ventricular failure for some reasons within two years
(two years at most), they proceed into congestive heart failure after
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a period of 6 to 7 years, the manifestations of left heart failure will disappear


and then, signs and symptoms of right heart failure will appear.

The precipitating causes of heart failure


First of all, you have to distinguish between "the Etiology" of heart failure and
"the precipitating" causes of heart failure.
The etiology of heart failure was mentioned previously in this lecture.
Now, concerning the precipitating causes of heart failure, these are conditions
that will cause a patient, who was previously diagnosed as having HF and was put
on medications, to present again with heart failure.
The precipitating causes of HF include the following:
1- Cardiac arrhythmias.
2- Hypertensive crises.
3- Chest infections.
4- Drugs such as certain beta blockers.
5- Excessive salt intake.
6- Fluid overload.
7- Pregnancy.
8- Thyrotoxicosis.
9- Anemia.
So, in these conditions, we have to eliminate the precipitating factors with the
administration of medications.

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Symptoms of left heart failure

1- Cardiac dyspnea: The single most important symptom of left heart failure is
cardiac dyspnea in its different components, exertional, PND and orthopnea.
2- Fatigue: rarely left heart failure causes fatigue; fatigue is mostly caused by
right heart failure.
3- Isolated nocturia: It means impaired diurnal variation. Normal adults
urinate two to three times per 24 hours; two times during the daytime, and one
time during the night, OR only during the daytime. If the condition is reversed,
like, if he/she urinates two or three times during the night, and one time during
the daytime (i.e. night > daytime) this is isolated nocturia and is related to
several conditions:
1- Early stages of left heart failure.
2- Early stages of renal failure.
3- In children with nocturnal enuresis.
You have to differentiate between: isolated nocturia, Polyuria and frequency.
* Isolated nocturia: mentioned previously.
* Polyuria: is a condition usually defined as excessive or abnormally large
production or passage of urine. It occurs in conditions like:
Diuretics use, DM, DI, Addison's disease, chronic renal failure
* Increased frequency in conditions like: Irritation of the trigone of the
bladder by cystitis, tumors, stones.
Again, the most important symptom of left heart failure is cardiac dyspnea.
The elements of cardiac dyspnea (exertional, PND and orthopnea) come in
order. So it is unlikely to have orthopnea without experiencing the stage of
exertional dyspnea. If the exertional dyspnea is not treated, it will proceed
into PND and orthopnea.
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Remember that although it is called nocturnal dyspnea, it is related to the


supine position rather than to the night time. In supine position, the venous
return to the heart will be increased increasing the work load on the heart
increasing the pressure in the left ventricle which will transit back into
the pulmonary circulation, thus causing more fluid aggregation within the alveoli.
The paroxysmal nocturnal dyspnea is resolved by sitting up from the supine
position and dangling the legs down, which will cause pooling of blood and
decrease in the venous return.
Now if the nocturnal dyspnea is not relieved by sitting up, this means that the
patient has a condition called pulmonary edema. So, what is pulmonary edema?
Pulmonary edema: This term should be reserved for "severe and suddenonset" form of left ventricular heart failure, and it has special features on
chest x-ray.
Orthopnea always demanding upright posture and the severity can be graded by
the number of pillows the patient using before feeling comfortable.

Signs of left heart failure


1- Dyspnea! So dyspnea is a symptom and is a sign as well.
* Dyspnea could be a symptom only, without any sign, for example: dyspnea in
obese people, or psychogenic dyspnea.
* On the other hand, patients with heart failure or pulmonary embolism have
the sign of dyspnea, which equals tachycardia + use of accessory respiratory
muscles.
2- Signs of cardiac dilatation or hypertrophy, like: hyper-dynamic precordium
and sustained apex beat.
3- Third heart sound, pulsus alternans.
4- Sinus tachycardia.
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5- Lung crepitations and pleural effusion.


6- Signs of the underlying casue.
But remember that, the most important signs of left sided heart failure are:
dyspnea and lung crepitations.

Symptoms of right heart failure


1- Fatigue.
2- Dependent edema.
3- Enlarged congested liver.
4- Anorexia and abdominal distension.
Q: What is the exact cause of their easy fatigability?
A: As we said before, the most common cause of right heart failure is left
heart failure, so the patient will proceed from the signs and symptoms of left
heart failure to have the signs and symptoms of right heart failure, so at this
stage (right heart failure), there is no dyspnea, no lung crepitaions, the chest
X-ray will show cardiomegaly with resorption of fluids from the lungs i.e. the
lungs will appear clear. Despite all of the apparent improvement of the patient's
condition, he had entered a late stage of heart failure with an ejection fraction
below 22%, this ejection fraction is not sufficient to meet the demands of the
working muscles so the patient will have easy fatigability, which is the main
symptom of Right heart failure.

Signs of right heart failure


1- High JVP with positive hepato-jugular reflux.
2- Dependent edema.
3- Ascites.
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4- Pleural effusions.
5- Tricuspid regurgitation murmurs.
6- Specific signs for the underlying cause.

Diagnosis of heart failure


1- History, mentioned above.
2- Signs, mentioned above.
3- Chest X-ray, which shows cardiomegaly and pulmonary congestion.
The doctor said that "in Davidson and Kumar it is mentioned that we need
ECHO in addition to the above three components in order to diagnose heart
failure, which is WRONG" (3la RASI WALLAH 2l self-confidence), because in
diastolic heart failure, the ejection fraction (which is calculated by the ECHO)
is normal despite of the "failing" heart. So the ECHO is not necessary to
diagnose heart failure.
But of course, the ECHO is a very good tool and it has a big role in cardiology,
In addition to creating two-dimensional pictures of the cardiovascular system,
an echocardiogram can also produce accurate assessment of the velocity of
blood and cardiac tissue. This allows assessment of cardiac valve areas and
function, any abnormal communications between the left and right side of the
heart, any leaking of blood through the valves (valvular regurgitation), and
calculation of the cardiac output as well as the ejection fraction.

Further investigations
1- Chest X-ray.
2- ECG, which may detect arrhythmia, conduction defects, previous MIs.
3- Echocardiography.
4- CBC, Renal profile, Fasting blood sugar (FBS), Lipids, ABGs.

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Treatment of Heart failure

1- Bed rest, should not be needed for more than two to three days, because the
patient should be mobilized as early as possible.
2- Oxygen: The patient should not be put on O2 for more than 2 to 3 days as
well, when the O2 saturation is less than 84%. Once the congestion and the
capillary pressure in the alveoli are reduced, his need for O2 should stop.
But, what if a patient has a continued need for O2, for example: an HF patient
was put on oxygen and diuretics for more than 7 days, whenever the O2 is
removed, the O2 saturation drops down below normal?!
A: This should pay the attention into another condition in addition to the HF,
for example: COPD, Pulmonary embolism...
3- Low salt diet.
4- Treatment of the precipitating cause.
5- Treatment of the underlying cause.
6- Drug therapy, which includes:
a) Spironolactone, which is associated with increased survival in patients with
HF.
b) ACE inhibitors: They are vasodilators and preload acting drugs, and they are
associated with increased survival in patients with HF.
c) Diuretics.
d) Beta-blockers: Remember that not all beta-blockers can be used in the
treatment of HF patients, for example, if a patient is presented to the hospital
with heart failure, and he/she is already on beta blockers, we have to STOP
beta-blockers.SO:
Q: How can beta-blockers be used in the treatment of HF?
A: There are four points:
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*) Not all beta-blockers could be part of the treatment of HF; there are
certain beta-blockers which have mostly alpha/beta antagonistic activity which
includes 4 agents:
1- Carvedilol 2- Metoprolol (I think it has selective B1 antagonistic activity!),
3-Bisoprolol 4- Nebivolol (has nitric oxide-potentiating vasodilatory effect).
*) Beta-blockers are not used in all conditions of HF; they are used mostly as
part of the treatment of HF due to CardioMyopathies. So they are not used for
diastolic-dysfunction heart failure.
*) These agents are introduced during compensation, not during
decompensation.
Note: Compensated Vs. Decompensated HF (from Lippincot).
The falling heart evokes three major compensatory mechanisms to enhance cardiac
output. Although initially beneficial, these alterations ultimately result in further
deteriorations of cardiac function. These mechanisms include:
- Increased Sympathetic activity.
- Activation of the renin-angiotensin system.
- Myocardial hypertrophy.
If these mechanisms adequately restore cardiac output, the HF is said to be
compensated. However, these compensations increase the work of the heart and
contribute to further decline in cardiac performance. If the adaptive mechanisms
fail to maintain cardiac output, the HF is termed as decompensated.

*) These drugs should be used under the supervision of a physician or a


cardiologist; the majority of patients will have improved symptoms and ejection
fraction, but some patients will not respond to this modality of treatment.
e) Digitalis.
f) Anticoagulation (Warfarin).
Digitalis and warfarin are indicated in two conditions of HF:
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^ End-stage HF with an ejection fraction below 22%, because at this stage,


there will be pooling of the blood in the left ventricle, clot formation which can
fragment and eventually embolize, so warfarin is used to prevent clot formation
and digoxin is used to enhance myocardial contractility.
^^ In conditions of AF (Atrial Fibrillation), this will lead to clot formation, so
we use warfarin to prevent clot formation and embolization and digoxin to
enhance myocardial contractility.
7- Implantable Cardioverter Defibrillator (ICD): Not every patient with endstage heart failure or refractory heart failure should implant ICD; ICD is
indicated in patients who had cardiac arrest and survived it, because cardiac
arrest is either asystole or ventricular fibrillation; ICD can discover the
arrhythmia and deliver a shock.
8- Cardiac transplantation: which is not an easy choice at all, but in general it is
indicated if:
1- The suspected survival rate is less than 6 months.
2- The pulse pressure is low.
3- End-stage HF when the ejection fraction is below 22%.
4- Decreased perfusion to the tissues which is manifested as:
* Decreased mentality.
* Oliguria.
Cardiac transplantation surgery is not present in Jordan. This surgery costs
1,000,000$.
Note: Spironolactone, ACE inhibitors and the ICD are the only three lines that
are found to increase the survival in HF patients; the other drugs (betablockers, digitalis, and anticoagulants) are not associated with increased
survival in HF patients.
Some examples for chest x-rays for patients with heart failure (please see the
soft copy):
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This chest x-ray


shows:
1- Kerley B lines:
Transverse lines
which represent
visible interlobular
septa mostly in the
base of the lungs,
and they appear in
chronic recurrent
attacks of heart
failure, not in a
single attack.
2- Cardiomegaly.

This X-ray shows:


1) Upper lobe
venous congestion.
2) Hilar congestion.
3) Cardiomegaly.
4) Concentric left
ventricular
hypertrophy.

The best way to


diagnose concentric LVH is by ECHO, and then comes the ECG and then the
CXR. Here, the left ventricular hypertrophy is apparent by the CXR.
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Note: Concentric LVH means: the chamber radius may not change; however,
the wall thickness greatly increases. (Compare with eccentric hypertrophy.)

This one shows:


1) Cardiomegaly.
2) Hilar
congestion.
3) Right basal
congestion.
4) Concentric
hypertrophy.

This one shows:


1) Cardiomegaly.
2) Kerley B lines.
3) Pleural effusion.
Observe a line
extending from the
surface of the
pleural effusion into
the axilla. (The
doctor mentioned
the name of this
line, but I didn't
hear it well, I think it was Domensiuo or sth. WALLAH W5ATYARET, YA
TAWFIQ)
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This CXR is for the


same patient above,
after one week of
treatment, where
the effusion and
the Kerley B lines
disappeared, and
the heart size
slightly decreased.

The END
:B1
) (situs inversus totalis ) (....
) ( ) ( ) ( )
( ) (
:B1 ///
/
// //
/ / / .

Attack

(T.I.A) Transient Ischemic

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