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Heart Failure: Living

with a Hurting Heart

Congestive Heart Failure

Heart (or cardiac) failure is the state in


which the heart is unable to pump blood at a
rate commensurate with the requirements of
the tissues or can do so only from high
pressures
Braunwald 8th Edition, 2001

Congestive Heart Failure


Framingham Criteria for Congestive Heart
Failure
Diagnosis of CHF requires the simultaneous
presence of at least 2 major criteria or 1 major
criterion in conjunction with 2 minor criteria.
The Framingham Heart Study criteria are 100%
sensitive and 78% specific for identifying persons
with definite congestive heart failure.

Symptoms
Major symptoms

Paroxysmal nocturnal dyspnea


Neck vein distention
Rales
Radiographic cardiomegaly
(increasing heart size on chest
radiography)
Acute pulmonary edema
S3 gallop
Increased central venous
pressure (>16 cm H2O at right
atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in
response to treatment

Minor symptoms

Bilateral ankle edema


Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Decrease in vital capacity by
one third from maximum
recorded
Tachycardia (heart rate>120
beats/min.)

Anatomy

A normal heart pumps blood in a smooth and


synchronized way.

Heart Failure
Heart

A heart failure heart has a reduced ability to


pump blood.

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

Right Heart Failure

Signs and Symptoms

fatigue, weakness,
lethargy
wt. gain, inc. abd.
girth, anorexia
elevated neck veins
Hepatomegaly +HJR
may not see signs of
LVF

What does this


show?

Can You Have RVF Without LVF?

What is this called?


COR PULMONALE

Risk Factors for Heart Failure


Coronary

artery

disease
Hypertension (LVH)
Valvular heart
disease
Alcoholism
Infection (viral)

Diabetes
Congenital

heart defects

Other:

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

Obesity
Age
Smoking
High or low hematocrit lev
Obstructive Sleep Apnea

Epidemiology of Heart Failure


in the US
Heart Failure Patients in US
(Millions)

12

10

10

More deaths from heart


failure than from all forms
of cancer combined

550,000 new cases/year

4.7 million symptomatic


patients; estimated 10
million in 2037

8
6
4

4.7
3.5

2
0
1991

2000

2037*

*Rich M. J Am Geriatric Soc. 1997;45:968974.


American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

Heart Failure
Complications
Pleural effusion
Atrial fibrillation (most common
dysrhythmia)
Loss of atrial contraction (kick) -reduce CO by
10% to 20%
Promotes thrombus/embolus formation inc. risk
for stroke
Treatment may include cardioversion,
antidysrhythmics, and/or anticoagulants

Heart Failure
Complications

**High risk of fatal dysrhythmias (e.g.,


sudden cardiac death, ventricular
tachycardia) with HF and an EF <35%

HF lead to severe hepatomegaly, especially


with RV failure
Fibrosis and cirrhosis - develop over time

Renal insufficiency or failure

Classifying Heart Failure:


Terminology and Staging

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

Classification of HF: Comparison Between


ACC/AHA HF Stage and NYHA Functional Class
ACC/AHA HF Stage1

NYHA Functional Class2


None

A At high risk for heart failure but without


structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
B Structural heart disease but without
symptoms of heart failure

C Structural heart disease with prior or


current symptoms of heart failure

D Refractory heart failure requiring


specialized interventions

Asymptomatic

II Symptomatic with moderate exertion


III Symptomatic with minimal exertion
IV Symptomatic at rest

Hunt SA et al. J Am Coll Cardiol. 2001;38:21012113.

New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890897.

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)

Cardiomegaly

Pulmonary vessel congestion

Pulmonary Edema due to Heart


Failure

Kerley B lines

ECG
Heart

rate
Rhythm
Conduction
Ischaemic
Infarction
Hypertrophy
BBB
Prolonged QT interval
Perimyocarditis

Chest X-ray
Should

be perform as soon as possible


Cardiomegaly
Congestion
Effusion
Infiltrates
Limitations of a supine film should be
noted

Laboratory test
Blood

count
Electrolyte (Na, K)
Urea, creatinine
Glucose
Albumin
Hepatic enzymes
INR
Cardiac markers
Natriuretic peptides (BNP & NT-pro BNP)

Arterial blood gas


analysis
Assessment
Respiratory
Acid-base

of oxygenation (pO2)
function (pCO2)

balance (pH)
Should be assessed in severe respiratory
distress

Echocardiography
General findings:
Size and shape of the ventricle
LV ejection fraction (LVEF)
Regional wall motion; synchronicity of ventricular
contraction
LV remodeling (concentric versus eccentric )
LV or RV hypertrophy (DDhypertension, COPD,
valve disease)
Morphology and severity of valve lesions
Mitral inflow and aortic outflow properties; RV
pressure gradient
Output state (low or high)

Echocardiography
(cont.)
Systolic dysfunction:
Reduced LVEF (<45%)
Enlarged left ventricle
Thin LV wall
Eccentric LV remodeling
Mild or moderate mitral regurgitation
Pulmonary hypertension
Reduced mitral filling
Signs of increased filling pressure

Echocardiography
(cont.)
Diastolic dysfunction:
Normal LVEF (45%-50%)
Normal LV size
Thick LV wall, dilated atria
Concentric LV remodeling
No or minimal mitral regurgitation
Pulmonary hypertension
Abnormal mitral filling pattern
Signs of increased filling pressure

Cardiac Magnetic Resonance Imaging


Dark blood imaging

Wall thickness, morphology of the


myocardium, tumor masses

Bright blood imaging

Wall thickness, geometry of the


ventricle
Cardiac rotation, shear motion,
torsion, myocardial twist

Myocardial tagging

Phase contrast imaging


Contrast enhancement
MR coronary angiography
Stress imaging

Perfusion and diffusion imaging


Spectroscopy

Blood flow velocity, cardiac


output, pressure gradients
Myocardial fibrosis, ischemic
zone, infarct size
Coronary anatomy, coronary
plaques
Wall motion abnormalities,
recruitable stroke work, ischemic
territory
Perfusion abnormalities, territory,
ischemic zone
Viability, energy-rich
phosphosphate

Indications for Coronary Angiography


Heart failure patients with angina
Patients with prior myocardial infarction or known
coronary artery disease
Patients (younger than 65 yr) with unexplained
heart failure
Positive exercise test in patients with
cardiovascular risk factors
Heart failure patients with positive scintigraphy,
stress echocardiography, or positron emission
tomography results
Heart failure patients with severely dyskinetic
myocardium

Pathophysiology

Pathologic Progression of CV
Disease
Sudden
Death

Coronary
artery disease
Hypertension
Diabetes

Myocardial
injury

Pathologic
remodeling

Low ejection
fraction

Cardiomyopat
hy
Valvular
disease

Death

Pump
failure

Neurohormon
al
stimulation
Myocardial
toxicity
Adapted from Cohn JN. N Engl J Med. 1996;335:490498.

Symptoms:
Dyspnea
Fatigue
Edema

Chronic
heart
failure

Compensatory Mechanisms:
Renin-Angiotensin-Aldosterone
System

Beta
Stimulation
CO
Na+

Renin + Angiotensinogen
Angiotensin I
ACE
Angiotensin II

Peripheral
Vasoconstrictio
n

Kaliuresis

Aldosterone Secretion

Fibrosis

Salt & Water Retention


Plasma Volume

Afterload
Cardiac Output

Heart Failure

Preload
Cardiac Workload

Edema

Drug Therapy

Heart Failure Treatments:


Medication Types
Type

What it does

ACE inhibitor
(angiotensin-converting
enzyme)

Expands blood vessels which


lowers blood pressure,
neurohormonal blockade

ARB (angiotensin
receptor blockers)

Similar to ACE inhibitor


lowers blood pressure

Betablocker

Reduces the action of stress


hormones and slows the heart
rate
Slows the heart rate and improves
the hearts pumping function (EF)

Digoxin
Diuretic
Aldosterone
blockade

Filters sodium and excess fluid from


the blood to reduce the hearts
workload
Blocks neurohormal activation and

Rational for Medications


(Why does my doctor have me on so many
pills??)

Improve Symptoms
Diuretics (water
pills)
digoxin

Improve Survival

Betablockers
ACE-inhibitors
Aldosterone blockers
Angiotensin receptor
blockers (ARBs)

Lifestyle Changes
What

Why

Eat a low-sodium, low-fat


diet

Sodium is bad for high blood


pressure, 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 and caffeine

Alcohol and caffeine can weaken an


already damaged heart

Quit Smoking

Smoking can damage blood vessels


and make the heart beat faster

Other Therapies?
Transplant
Artificial hearts
New gadgets to help doctors manage
heart failure

Heart Transplantation
A good solution to the failing heart get a
new heart
Unfortunately we are limited by supply, not
demand
Approximately 2200 transplants are
performed yearly in the US, and this
number has been stable for the past 20
years.

Newer Generation Artificial


Hearts

Acute Heart Failure


Rapid onset of symptoms and signs secondary to
abnormal cardiac function
Can present as new onset and without previously
known cardiac dysfunction or ADHF
Often life threatening and requires urgent treatment

AHF may present with one or several clinical


conditions:
1.
2.
3.
4.
5.
6.

Worsening or Decompensated Chronic Heart Failure


Hypertensive Heart Failure
Pulmonary Oedema
Cardiogenic Shock
Isolated Right HF
ACS and HF

Tissue perfusion

Clinical classifications
Dry and
warm

Wet and
warm

Dry and
cold

Wet and
cold
Pulmonary
congestion

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Causes and precipitating factors


Ischaemic heart disease

Acute coronary syndrome


Mechanical complications of acute MI
RV infarction

Valvular

Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection

Myopathies

Postpartum cardiomyopathy
Acute myocarditis

Hypertension/arrhythmias
Circulatory failure

Septicaemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism

Decompensation of pre-existing CHF

Volume overload
Infection
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug and alcohol abuse

Diagnostic of Acute Heart Failure


Based

on presenting symptoms and


clinical findings
History
Physical examination
ECG
Chest X-ray
Echocardiography
Laboratory (BGA, etc)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Monitoring
Non invasive:
Vital Sign
Oxygenation
Urine output
ECG
Invasive:
Arterial line (haemodynamic unstable)
Central venous lines
Pulmonary artery catheter
Coronary angiography

Goals of treatment
Immediate (ED/ICU/ICCU)
Improved symptom
Restore oxygenation and improve organ perfusion
Limit cardiac/renal damage
Minimize ICU length of stay
Intermediate (hospital)
Stabilize patient & optimize treatment strategy
Initiate appropriate pharmacology therapy
Consider device therapy
Minimize hospital length of stay
Long term and pre discharge management
Plan follow up strategy
Education
Prevention
Quality of life

Management
Immediate

symptomatic treatment
Patient distressed or in pain >> analgesia,
sedation
Pulmonary congestion >> diuretic,
vasodilator
Arterial oxygen saturation < 95% >>
increase FiO2, consider CPAP, NIPPV,
mechanical ventilation
Heart rate and rhythm disorder >>
pacing, antiarrhythmics, electroversion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Oxygen

As early as possible in hypoxaemic patients to


achieve O2 saturation 95% (> 90% in COPD).

Class I, level C
NIV with PEEP as soon as possible in every
patient with acute cardiogenic pulmonary
oedema
Contraindication:
- unconscious patients
- anxiety
- immediate need ET intubation
- severe obstructive airway disease
- severe Right HF

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Morphine

Morphine should be considered in the early stage


of severe AHF with restlessness, dyspnoea,
anxiety, chest pain.
Respiration should be monitored
Caution: hypotension, bradycardia, advanced AV
block, CO2 retention

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Loop diuretics

Diuretics are recommended in AHF patients with


congestion and volume overload.
Class I, level B
Adverse effect:
- hypokalaemia, hyponatraemia
- hyperuricaemia
- hypovolaemia and dehydration
- neurohormonal activation
- may increase hypotension following ACEI/ARB
therapy
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Vasodilators

Vasodilators are recommended at an early stage


for AHF without hypotension or serious
obstructive valvular disease.
Class I, level B
Adverse effect:
- headache (nitrat)
- tachyphylaxis (nitrat)
- hypotension (NTG or nesiritide infusion)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

Inotropic agents

Inotropic agents should be considered in low


output states, in the presence of hypoperfusion or
congestion.
Dobutamine (class IIa, level B)
Dopamine (class IIb, level C)
Milrinone and enoximone (class IIb,level B)
Levosimendan (class IIa, level B)
Norepinephrine (class IIb, level C)
Cardiac glycoside (class IIb, level C)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008

What have we
learned?

In Summary.
Heart failure is common and has high
mortality
Drug therapy improves survival

Betablockers, ACE-I, aldosterone antagonists

Newer device therapies are showing promise


for symptom relief and improved survival
Biventricular pacing, ICDs

Transplants remain rare, but technology for


mechanical assist devices continues to
improve- stay tuned!

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