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Symptoms
Major symptoms
Minor symptoms
Anatomy
Heart Failure
Heart
fatigue, weakness,
lethargy
wt. gain, inc. abd.
girth, anorexia
elevated neck veins
Hepatomegaly +HJR
may not see signs of
LVF
artery
disease
Hypertension (LVH)
Valvular heart
disease
Alcoholism
Infection (viral)
Diabetes
Congenital
heart defects
Other:
Obesity
Age
Smoking
High or low hematocrit lev
Obstructive Sleep Apnea
12
10
10
8
6
4
4.7
3.5
2
0
1991
2000
2037*
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
Asymptomatic
New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890897.
Cardiomegaly
Kerley B lines
ECG
Heart
rate
Rhythm
Conduction
Ischaemic
Infarction
Hypertrophy
BBB
Prolonged QT interval
Perimyocarditis
Chest X-ray
Should
Laboratory test
Blood
count
Electrolyte (Na, K)
Urea, creatinine
Glucose
Albumin
Hepatic enzymes
INR
Cardiac markers
Natriuretic peptides (BNP & NT-pro BNP)
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
Myocardial tagging
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
Afterload
Cardiac Output
Heart Failure
Preload
Cardiac Workload
Edema
Drug Therapy
What it does
ACE inhibitor
(angiotensin-converting
enzyme)
ARB (angiotensin
receptor blockers)
Betablocker
Digoxin
Diuretic
Aldosterone
blockade
Improve Symptoms
Diuretics (water
pills)
digoxin
Improve Survival
Betablockers
ACE-inhibitors
Aldosterone blockers
Angiotensin receptor
blockers (ARBs)
Lifestyle Changes
What
Why
Lose weight
Reduce or eliminate
alcohol and caffeine
Quit Smoking
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.
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
Valvular
Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection
Myopathies
Postpartum cardiomyopathy
Acute myocarditis
Hypertension/arrhythmias
Circulatory failure
Septicaemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism
Volume overload
Infection
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug and alcohol abuse
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
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
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Loop diuretics
Vasodilators
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Inotropic agents
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