Heart Failure

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 Minor symptoms

Paroxysmal nocturnal dyspnea Bilateral ankle edema
Neck vein distention Nocturnal cough
Rales Dyspnea on ordinary exertion
Radiographic cardiomegaly (increasing Hepatomegaly
heart size on chest radiography) Pleural effusion
Acute pulmonary edema Decrease in vital capacity by one third
S3 gallop from maximum recorded
Increased central venous pressure (>16 Tachycardia (heart rate>120
cm H2O at right atrium) beats/min.)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in
response to treatment
Heart Failure

This means less oxygen is reaching the organs and

muscles which can make feel tired and short of
breath.

CONGESTIVE HEART FAILURE refers to the state

in which abnormal circulatory congestion exists a
result of heart failure
Types of Heart Failure

Systolic Dysfunction
Coronary Artery Disease
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
Etiology

Heart failure is caused by systemic hypertension in 75% of cases.

Structural heart changes, such as valvular dysfunction, cause pressure
or volume overload on the heart.
Heart is unable to pump enough blood to meet tissues O2
requirements
Congenital heart defects
Severe lung disease
Diabetes
Severe anemia
Overactive thyroid gland (hyperthyroidism)
Abnormal heart rhythms
Etiology

Increase in Pulmonary pressure results fluid in alveoli

(PULMONARY EDEMA)
Increase in Systemic pressure results in fluid in tissues
(PERIPHERAL EDEMA)

Health conditions that either damage the heart or make it work

too hard
Coronary artery disease
Heart attack
Heart muscle diseases (cardiomyopathy)
Heart inflammation (myocarditis)
Epidemiology

Five millions Americans have CHF

550,000 New cases every year
800,000 Patients with CHF hospitalized every year
250,000 die every year
50% Patients die with in five years
150% increase in the last 20 year
2.6% total population has this disease
Incidence and associated morbidity and mortality is
expected to increase in future
Risk Factors

Hypotension
Fluid retention & worsening CHF

Bradycardia & heart block

Contraindication in pts with CHF

exacerbation
Pathophysiology

In order to maintain normal cardiac output, several

compensatory mechanisms play a role as under:
Compensatory enlargement in the form of cardiac
hypertrophy, cardiac dilatation, or both.

Tachycardia (i.e. increased heart rate) due to

activation of neurohumoral system e.g. release of
norepinephrine and atrial natrouretic peptide,
activation of renin-angiotensin aldosterone
mechanism.
Pathophysiology

STARLINGS LAW
Within limits, the force of ventricular contraction is a
function of the end-diastolic length of the cardiac
muscle, which in turn is closely related to the ventricular
end-diastolic volume.
This is achieved by increasing the length of
sarcomeres in dilated heart
Increases the myocardial contractility and thereby
attempts to maintain stroke volume.
Pathophysiology

Heart failure results in DEPRESSION of the

ventricular function curve
COMPENSATION in the form of stretching of
myocardial fibers results
Stretching leads to cardiac dilatation which
occurs when the left ventricle fails to eject its
normal end diastolic volume
Compensatory Mechanisms

Sympathetic nervous system stimulation

Renin-angiotensin system activation

Myocardial hypertrophy

Altered cardiac Rhythm

Pathophysiology
 Pathophysiology
Renin-angiotensin system
Renin + Angiotensinogen

Angiotensin I

Angiotensin II

Aldosterone Secretion
Peripheral
Vasoconstriction
Salt & Water Retention

Plasma Volume
Afterload Edema

Preload
Cardiac Output
Cardiac Workload

Heart Failure
Pathophysiology

Ventricular remodeling

Altered cardiac
rhythm
Signs and symptoms of CHF

Shortness of breath often with activities or while lying

flat
Weakness and fatigue
Awakening short of breath at night
Need for increased pillows at night helps lungs
drain of excess fluid
Coughing or wheezing
Swelling of feet and legs or other dependent areas
Anorexia/loss of appetite
Weight gain
Symptoms of HF

Fatigue
Activity decrease

Cough (especially supine)

Edema

Shortness of breath
 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)
I Asymptomatic
B Structural heart disease but without
symptoms of heart failure

II Symptomatic with moderate exertion

C Structural heart disease with prior or
current symptoms of heart failure
III Symptomatic with minimal exertion

D Refractory heart failure requiring IV Symptomatic at rest

specialized interventions

1Hunt SA et al. J Am Coll Cardiol. 2001;38:21012113.

2New 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
Kerley B lines
 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

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
DIET Approach With Heart Failure
Educate
Diagnose Diet
Etiology Exercise
Severity (LV dysfunction) Lifestyle
Initiate CV Risk
Diuretic/ACE inhibitor Titrate
-blocker
Optimize ACE
Spirololactone
inhibitor
Digoxin
Optimize -blocker
Treatment (Medication)

ACE Inhibitors

Diuretics

Inotropic Agents

Beta Blockers

Calcium Channel Blockers

DRUGS USED TO TREAT CONGESTIVE
HEART FAILURE
VASODILATORS INOTROPIC AGENTS
-CAPTOPRIL
-ENALAPRIL -DIGOXIN
-FOSINOPRIL -DIGITOXIN
-LISINOPRIL
-QUINAPRIL -DOBUTAMINE
-HYDRALAZINE
-ISOSORBIDE -AMRINONE
-MINOXIDIL -MILRINONE
-SODIUM
DIURETICS
NIITROPRUSSIDE

-BUMETANIDE
-FUROSEMIDE
-HYDROCHLOROTHIAZIDE
-METALAZONE
 DRUGS USED TO TREAT CONGESTIVE
HEART FAILURE

Beta blocker
Metoprolol
Carvidilol
Bisoprolol
Calcium channel blockers
Nifedipine
Diltiazem
Verapamil
Amlodipine
Felodipine
 Treating Congestive Heart failure

Upright position
Nitrates
Lasix
Oxygen
ACE inhibitors
Digoxin

Fluids(decrease)
After load (decrease)
Sodium retention
Test (Dig level, ABGs, Potassium level)
 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. Worsening or Decompensated Chronic Heart Failure
2. Hypertensive Heart Failure
3. Pulmonary Oedema
4. Cardiogenic Shock
5. Isolated Right HF
6. ACS and HF
 Clinical classifications

Dry and warm Wet and warm

Tissue perfusion

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
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
Patient counseling

Lifestyle changes

Monitoring for changes

Medications

Surgery
Patient counseling

Lifestyle changes
Stop smoking
Loose weight
Avoid or limit alcohol
Avoid or limit caffeine
Eat a low-fat, low-sodium diet
Exercise
Patient counseling

Reduce stress
Keep track of symptoms and weight
and report any changes or concern to
the doctor
Limit fluid intake
See the doctor more frequently
Conclusion

PREVENTION IS BETTER THAN CURE.

Newer device therapies are showing promise for

symptom relief and improved survival
Biventricular pacing.
Transplants remain rare, but technology for
mechanical assist devices continues to improve- stay
tuned.
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
 Thank
you