Congestive Heart Failure

Texas Womens University

Spring 2015

Learning Objectives

Overview of Cardiology System

Pathophysiology
Etiology
Who is at risk
Signs and Symptoms
Diagnosis
Diagnostic Images
Treatments
Prevention
Psychosocial
Case Study

The Heart as a Pump

Divided in half by the septum creating 2 pumps:
Left heart: receives deoxygenated blood from the organs and pumps it
to the lungs
Right heart: receives oxygenated blood from the lungs and pumps it to
the organs
Each pump is composed of an atria (primers pumps of the ventricles) and
ventricles (propels blood into the circulation)
Has a conduction system that maintains its own rhythm

Cardiac Location & Anatomy

Lies to the left of the body
midline
Is in a close-fitting fiber-like
sac in the mediastinum
between the lungs
Between the heart and the
pericardial sac (pericardium) is
a lubricating fluid which allow
the heart to beat freely without
rubbing or sticking

Cardiac Anatomy
Composed of muscle linings:
endocardium: inner lining
is a thin strong membrane
also forming the heart
valves and lining the
blood vessels
myocardium: located
between the endocardium
and pericardium able to
contract with and without
stimulation and at a
continuous rate

Cardiac Anatomy
2 heart valves:
Tricuspid valve: separating the right atrium from the right ventricle
Called tricuspid because of its 3 cusps or flaps
Mitral or Bicuspid valve: separating the left atrium from the left
ventricles
Called Bicuspid because of its 2 flaps and its resemblance to a
bishops miter
The valves prevent backward blood flow
The left ventricle is thicker than the right because it needs to generate a
greater force to pump the blood upward into the aorta, in comparison to the
right ventricle pumping blood into the pulmonary artery

Cardiac Anatomy
Specialized conduction system consist of:
Sinus node: normal pacemaker because able to discharge faster
than the other tissues of the cardiac conduction system
Intrinsic discharge rate of 70 to 80 times per minute and sends
impulses to the AV node
AV node: receives impulses and sends impulses to the purkinje fibers.
Intrinsic discharge rate of 40 to 60 times per minute
Purkinje fibers: sends impulses to the heart muscle
Intrinsic discharge rate of 15 to 40 times per minute

Cardiac Circulation
Blood from the organs enters:

From the Lungs enters:

Right atrium

Left atrium

Tricuspid valve

Bicuspic (Mitral) valve

Right ventricle

left ventricle

Pulmonic valve

Aortic valve
Coronary Sinus

Pulmonary artery
To the organs and heart for organs perfusion
To the lungs for reoxygenation

Heart Failure
Heart Failure (HF) is called the new epidemic of cardiovascular disease of
the 21st century. This is mainly attributed to improvements in
management of both patients with ACS and chronic coronary disease.
These medical improvements have decreased mortality rates and increase
the number of patients living with ventricular dysfunction. But despite
advances in diagnosis and treatment, the prognosis of HF remains
unfavorable.
Common comorbidities with HF are atrial flutter and atrial fibrillation

Pathophysiology of Heart
Failure
Stroke Volume and HR are
positively correlated with
CardiacOutput
Anything that increases StrokeV or
HR, will also increase COutput
Anything that decreases SV and
HR will decrease CO

Pathophysiology of Heart
Failure
When body senses reduced COutput, the sympathetic nervous system tries
to compensate by releasing norepinephrine which stimulates the hearts
beta-adrenergic receptors resulting in an increase of COutput
Produces tachycardia (raises HR)
Increases contractility (raises SV)
Increases diastolic relaxation (allows ventricular dilation to
accommodate extra blood)
Increases stretching of myocardial walls or preload (boosts the
SV)

Pathology of Left Ventricular

Heart Failure
Myocardial injury and chronic increased loading conditions are associated
with structural and functional remodeling which are causing heart failure
(HF)
Despite the different cause of HF, the adaptive physiologic mechanisms are
the same
The goal is to maintain normal resting stroke (SV) which is left
ventricle (LV) performance
Function and ventricle size have important prognostic implications on
clinical outcomes
They have been used to determine the extent and therefore the
severity of HF

LV Function and Architecture

As the LV increases in size its shape changes from oval to round
As determine by ejection fraction (EF): inverse relationship exist between
LV size and cardiac function
EF declines as LV volume increases

LV Remodeling Post Myocardial

Infarct

Cardiac Performance and LV

Architecture
Resting LV is used as an
indicator of LV systolic
performance, remains
consistently and relatively
unchanged for EF 55% to 20%
With EF below 20%, SV
decreases significantly
LV dilation and increase LV load
leads to ventricular enlargement

Important Determinants of
Heart Failure
Important determinants along with prognosis value for the clinical course of
HF are:
age
left ventricular ejection fraction (LVEF)
renal function
diastolic and systolic blood pressure
Independent prognosis function is the etiology of HF
Ischemic HF, which imposes a greater strain on the left ventricle (LV), has a
worse prognosis than dilated cardiomyopathy

Left Atrial Function

Predicts Heart Failure
Left atrial (LA) contractile reserve impairment might be
an early sign of the progression of HF. Atrial dysfunction
could lead to impaired atrial emptying and in term
decreased cardiac output (CO). It could also be an early
indicator of cardiac congestion of failure if LVEF is
preserved.

Etiology: Left Ventricular

Failure

Etiology: Left
Ventricular Failure
Systolic Dysfunction (Ejection Fraction EF < 40%)
AKA depressed EF
Problem with the ventricle contracting
Decrease in stroke volume
Decrease in cardiac output

Etiology: Left
Ventricular Failure
Diastolic Dysfunction (EF>40%)
AKA preserved EF
Problem with the ventricle relaxing
Caused by any process that decreases relaxation,
decreases elastic recoil, or increases stiffness of
ventricle
Decrease in stroke volume

Etiology: Left
Ventricular Failure
Volume Overload
Arrhythmias
Mitral or Aortic Valve Regurgitation

Etiology: Left
Ventricular Failure
High Output Failure:
Systemic arteriovenous fistula
Hyperthyroidism
Anemia
Beriberi heart disease:thiamine deficiency
Pagets Disease of Bone
Disruption in normal bone recycling process
Pregnancy
Glomerulonephritis

Etiology: Left Ventricular

Failure
Pressure Overload
Hypertension
Outflow Obstruction
Aortic Stenosis
Loss of Contractility
Alcohol
Drugs (therapeutic or recreational)
Viral or Bacterial Infections

Etiology: Left
Ventricular Failure
Other causes *may fit multiple categories
Infection or inflammation
Congenital heart disease
Drugs (recreational or therapeutic)
Idiopathic cardiomyopathy
Rare conditions (endocrine, rheumatologic,
Neuromuscular)

Etiology: Right Ventricular

Failure
Left Ventricular Failure
Most common cause

Primary Right Ventricular Failure

CAD
Right Ventricular Infarction

Etiology
Heart failure is usually caused by a combination of
risk factors
Many possible causes; finding the proximate cause is
essential to therapy
Main goal of therapy is to prevent decompensation
Most common risk factors of Heart Failure
Coronary Artery Disease
Diabetes
Hypertension

Acute Decompensated Heart

Failure
Sudden or gradual onset of the signs or symptoms of heart failure
Seen when the intrinsic pathological process has advanced to critical point
Failure or exhaustion of compensatory mechanisms
Usually seen in worsening chronic HF
15%-20 % of cases are new HF diagnoses
Varies in severity

Acute Decompensated
Heart Failure
Most common causes:
Reduction in treatment
Uncontrolled hypertension
Cardiac arrhythmias

Signs and Symptoms

Breathlessness
Acute and/or chronic
Breathlessness at rest is either acute decompensation, end-stage condition
or other causes
Confounding comorbidities like respiratory disease or anemia
Orthopnea (shortness of breath when lying flat)
Soon after lying flat
Relieved by sitting up
Symptom of acute or advanced disease
Patients with severe chronic obstructive pulmonary disease (COPD) and
arthritis may sleep upright

Signs and Symptoms

Paroxysmal nocturnal dyspnoea (PND) (sudden difficulty breathing at night)
Soon after going to sleep
Symptom of acute or advanced disease
Sometimes with copious, frothy,even blood-speckled, sputum
Patients may also wake acutely breathless
Nocturnal cough
With or without PND
Sleep disorders
Sleep apnoea and left ventricular dysfunction associated
Cortisol release changes sleep patterns in heart failure

Signs and Symptoms

Fatigue
Common symptom but non-specific
Fatigue patterns and changes over time
Rule out other causes like anaemia, nutrition and
exercise levels
Reduced exercise capacity
Common symptom
Rule out other causes

Signs and Symptoms

Peripheral edema
Edema settles by gravity so usual pattern of progression through feet, ankles,
legs, genitalia/sacrum and abdomen
Edema due to heart failure is soft, pitting and bilateral
Persistent edema can compromise tissue and result in secondary cellulitis
Consider alternative systemic and local causes
Lung crepitation
Sign of possible fluid in lungs secondary to acute left ventricular failure
Also occurs in smokers and patients with respiratory disease
Weight changes
Rapid weight gain >2-3kg a week may be fluid retention

Signs and Symptoms

Bloated feeling
Associated acutely with fluid retention in the abdomen and chronically with
hepatomegaly
Confusion
Association between heart failure and progressive cognitive impairment.
Acute confusion with acute metabolic derangement secondary to heart failure
and/or its treatment

Signs and Symptoms

Palpitations
May be a symptom of sinus tachycardia, atrial or ventricular arrhythmia, or
ectopic (early or missed heart beats)
All of which are common in heart failure patients
Angina (chest pain of cardiac origin)
May indicate the underlying cause of heart failure or may be secondary
consequence of poor myocardial perfusion when cardiac output low

Signs and Symptoms

Syncope (transient loss of consciousness)
May occur with arrhythmias, hypotension and valve disorders
Depression and Anxiety
Common symptoms that affect morbidity and quality of life
Loss of appetite

Associated acutely with abdominal fluid retention and chronically with the
metabolic changes in end-stage disease

Signs and Symptoms

Tachycardia
High resting heart rate always significant and could be hemodynamic
compensatory response
Acute tachyarrhythmia can provoke heart failure in a patient with a normal
heart and likely to make patients with an abnormal heart unwell
Basal pleural effusions
Reduced basal air entry can suggest pleural effusions with/after acute
pulmonary edema
Hepatomegaly
Enlarged liver can occur with right heart failure

Signs and Symptoms

Abnormal pulse
An irregular pulse could be atrial fibrillation
A pattern of regular strong and weak pulse may be pulse alternance
A sign of advanced heart failure
Displaced apex beat
The apex beat is the point of maximal impulse on precordium
It can be displaced down and left laterally when the heart is dilated

Signs and Symptoms

Third heart sound: Gallop Rhythm
Raised jugular venous pressure, usually due to volume overload
Heart murmurs commonly noted in patients with heart failure are mitral
regurgitation, tricuspid regurgitation and aortic stenosis
Wheezing
New acute wheezing can be sign of acute lung congestion
Rule out alternative respiratory causes like acute asthma and COPD
exacerbation

Risk Factors
High blood pressure
Coronary artery disease
Heart attack
Diabetes
Sleep apnea
Congenital heart defects
Valvular heart disease

Viruses
Tobacco use

CT of a patient with congestive heart failure

Interior view of a normal and congestive heart.

Illustration of features that can be seen on a CXR in a patient with CHF.

Video Overview of CHF

http://youtu.be/3d-7uJ5Mz-o

Treatments
Medications
Surgery
Medical Devices

Medications to Treat CHF

Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers
Beta blockers
Diuretics
Aldosterone antagonists
Inotropes
Digoxin

Surgery to Treat CHF

Heart valve repair or replacement
Valvuloplasty: modifying the original valve to decrease backward flow
Reconnect/remove valve leaflets
Annuloplasty: tightening or replacing the ring around the valve
Prosthetic valve is placed when repair can not be achieved
successfully
Some repair and replacements can be performed without open heart
surgery
Minimally invasive surgery
Advanced cardiac catheterization techniques

Surgery to Treat CHF

Coronary bypass surgery
Blocked coronary articles are bypassed with blood vessels from your
leg, arm or chest

Medical Devices to Treat CHF

Implantable cardioverter-defibrillators (ICDs)
The ICD monitors the heart rhythm and if a dangerous rhythm or
asystole is recognized ICD paces or shocks the heart back to a
sustainable rhythm and has ability to pace during bradycardia
Cardiac resynchronization therapy (CRT), or biventricular pacing
A CRT electrical impulses to left and right ventricles to sync their
contractions

Medical Devices to Treat CHF

Heart pumps
ventricular assist devices (VADs) are placed in abdomen or chest in
simply help the ventricle contract.
The most common is an LVAD (left ventricle), but can be use for both
ventricles
Heart transplant

Heart Failure Prevention

Risk factors you can change to prevent heart failure starts with preventing other
cardiovascular risk factors:

Eat healthy well balanced diet

Stop Smoking
Exercise
Lose weight

Heart Failure Prevention

Decrease stress
Limit exposure to environmental toxins
Being able to manage other disease processes if present:
Hypertension
Diabetes type 2
Dyslipidemia

Preventing Worsening Heart Failure

Symptoms and Disease Progression
Take your prescribed medications
3-Drug Regimen:
Diuretic eliminates excess fluid and sodium
ACE/ARB relax blood vessels
Beta blocker lowers the hearts workload
Monitor fluid intake no more than 2 L/day
Weigh yourself daily/weekly call the doctor if you have an excess
of 2-3 lb weight gain in one day or 5-7 lb weight gain in 1 week

Preventing Worsening Heart Failure

Symptoms and Disease Progression

Listen to your body

Worsening shortness of breath

Palpitations
Syncope episodes
Keep blood pressure under control measure daily
Exercise and lose weight