Heart Failure

By: Muhammad Zubair

 Congestive Heart Failure
• 2013 ACC/ AHA DEFNITION-
– Heart Failure is defined as “ a complex
clinical syndrome that results from any
structural or functional impairment of
ventricular filling(diastole) or ejection of blood.
(systole) ”
 Congestive Heart Failure
Sign & Symptoms:
• Exertional dyspnea and/or dyspnea at rest
• Breathing worsens with lying flat (Orthopnea)
• Acute pulmonary edema > congestion
• Chest pain/pressure and palpitations
• Tachycardia
• Fatigue and weakness> low CO
• Nocturia and oliguria
• Anorexia, weight loss, nausea
• Exophthalmos and/or visible pulsation of eyes
• Distention of neck veins
• Weak, rapid, and thready pulse
• Rales, wheezing
• S 3 gallop and/or pulsus alternans
• Increased intensity of P 2 heart sound
• Hepatojugular reflux
• Ascites, hepatomegaly, and/or anasarca
• Central or peripheral cyanosis, pallor
AETIOLOGY OF HEART FAILURE
 Types of Heart Failure
• Systolic (or squeezing) heart failure
– Decreased pumping function of the heart, which results in fluid
back up in the lungs and heart failure

• Diastolic (or relaxation) heart failure

– Involves a thickened and stiff heart muscle
– As a result, the heart does not fill with blood properly
– This results in fluid backup in the lungs and heart failure

• Left-sided-inability of the left ventricle to pump enough blood,

causing fluid back up into the lungs
– Most common form
– Blood backs up through the left atrium into the pulmonary veins
• Pulmonary congestion and edema
– Eventually leads to biventricular failure
 Cont...
• Right sided-inefficient pumping of the right side of the heart, causing
fluid buildup in the abdomen, legs, and feet
– Results from diseased right ventricle
– Blood backs up into right atrium and venous circulation
– Causes
• LVF
• Cor pulmonale
• RV infarction
• Right-sided failure
– Venous congestion
• Peripheral edema
• Hepatomegaly
• Splenomegaly
• Jugular venous distension
 Acute vs Chronic
• Acute—an emergency situation in which a patient was completely
asymptomatic before the onset of heart failure; seen in acute heart
injury such as MI
Pulmonary edema
– Agitation
– Pale or cyanotic
– Cold, clammy skin
– Severe dyspnea
– Tachypnea
– Pink, frothy sputum
• Chronic—long-term syndrome in which a patient exhibits symptoms
over a long period of time, usually as a result of a preexisting
cardiac condition
 Chronic Heart Failure
Chronic—long-term syndrome in which a patient exhibits symptoms
over a long period of time, usually as a result of a preexisting cardiac
condition
• Fatigue
• Dyspnea
– Paroxysmal nocturnal dyspnea (PND)
• Tachycardia
• Edema – (lung, liver, abdomen, legs)
• Nocturia
• Behavioral changes
– Restlessness, confusion,  attention span
• Chest pain (d/t  CO and ↑ myocardial work)
• Weight changes (r/t fluid retention)
• Skin changes
– Dusky appearance
 Risk Factors for Heart Failure
• Coronary artery
disease • Diabetes
• Hypertension (LVH) • Congenital heart defects
• Valvular heart disease • Other:
– Obesity
• Alcoholism
– Age
• Infection (viral)
– Smoking
– High or low hematocrit level
– Obstructive Sleep Apnea

CAD=coronary artery disease; LVH=left ventricular hypertrophy.

 Physical Examination
• Patient will present with laboured breathing in an acute LVF. He/she
may not be able to finish the sentence due to shortness of breath.
He / she may have difficulty to talk due to shortness of breath.
• Blood pressure may be normal or high in early HF may decrease
consequently and is usually low.
• Low pulse pressure (reduced stroke volume)
• Sinus tachycardia (increased sympathetic activity) cool peripheries,
cyanosis of tips of fingers andnail bed.
• Jugular venous pressure –
– Indicates right atrial pressure
– It is measured in terms of (cm of H2O)
– Normal < 8 cm of H2O
– Method – measure highest point of JVP vertically from sternal
angle and add 5 cm of H2O
– Positive Abdomino- Jugular reflex
• Respiratory system
– Bilateral rales/crepitations may be present as a result of transudate of
fluid from intravascular space to intra alveolar space.
– May be accompanied by expiratory wheeze (cardiac asthma).
– Pleural effusion may/may not be present. (common in CCF)
• Cardiovascular system
– Apical impulse may shift inferiorly / laterally.
– Sustained apical impulse is felt in severe LVH.
– S3 gallop (protodiastolic gallop) can be heard.
– Left parasternal impulse in cases if severe RVH
– S4 gallop is usually present in diastolic dysfunction.
– MR or TR may be present additionally
• Per abdomen
– Hepatomegaly is present (tender / pulsatile)
– Pulsations in liver indicate tricuspid regurgitation
– Ascites , Jaundice , raised liver enzymes
– Peripheral edema can be pre tibial or pre sacral edema

• Cardiac cachexia
– Cause for cachexia is multifactorial
• Elevation of BMR
• Elevated circulating cytokines like TNF
• Congestion of intestinal veins
 A Key Indicator for Diagnosing Heart
Failure
Ejection Fraction (EF)
• Ejection Fraction (EF) is the percentage of blood that is
pumped out of your heart during each beat
• Normal Heart EF = 50-70%
• Damaged Heart Muscle EF = 40%
• Potential Heart Transplant EF = 20%
CLASSIFICATION OF HEART
FAILURE
Pathophysiology
How Heart Failure Is Diagnosed
• Medical history is taken to reveal symptoms
• Physical exam is done
• Tests
– Chest X-ray
– Blood tests
– Electrical tracing of heart (Electrocardiogram or “ECG”)
– Ultrasound of heart (Echocardiogram or “Echo”)
– X-ray of the inside of blood vessels (Angiogram)
 Heart Failure Treatments:
Medication Types
Type What it does
•ACE inhibitor •Expands blood vessels which lowers
(angiotensin-converting blood pressure, neurohormonal
enzyme) blockade

•ARB (angiotensin receptor •Similar to ACE inhibitor—lowers

blockers) blood pressure

•Beta-blocker •Reduces the action of stress

hormones and slows the heart rate
•Digoxin •Slows the heart rate and improves the
heart’s pumping function (EF)
•Diuretic •Filters sodium and excess fluid from the
blood to reduce the heart’s workload

•Aldosterone •Blocks neurohormal activation and controls

blockade volume
 Lifestyle Changes

What Why
•Eat a low-sodium, low-fat •Sodium is bad for high blood pressure,
diet causes fluid retention

•Lose weight •Extra weight can put a strain on

the heart

•Stay physically active •Exercise can help reduce stress

and blood pressure

•Reduce or eliminate alcohol •Alcohol and caffeine can weaken an

and caffeine already damaged heart

•Quit Smoking •Smoking can damage blood vessels and

make the heart beat faster