CARDIAC FAILURE

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What is Cardiac Failure / Heart Failure?

• Heart failure is defined as a clinico patholigical condition in which the cardiac muscles are unable to pump out sufficient amount of blood into circulation at a rate that meets the requirements of metabolizing tissues inspite of normal or above normal filling pressures.

• Almost all forms of heart disease may lead to heart failure.

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Aetiology

• Depending on the origin it is divided into two types

CARDIAC CAUSES (where the lesion is in the heart)

NON CARDIAC CAUSES (due to increased work load)

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Cardiac Causes

• Depending on the part involved it is further divided into three types

Pericardial Causes

Myocardial Causes

Endocardial Causes

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Pericardial Causes

• Pericarditis• Haemopericardium• Pyopericardium• Pericardial Effusion

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Myocardial Causes

• Myocardial Infarction• Myocarditis• Ischemic Heart Disease• Conduction Defects

Endocardial Causes

• Tricuspid Stenosis & Regurgitation• Mitral Stenosis & Regurgitation• Aortic Stenosis & Regurgitation• Pulmonary Stenosis & Regurgitation• Rupture of Cordiae Tendinae• Atrial Septal Defect (ASD)• Ventricular Septal Defect (VSD)

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Non-Cardiac Causes

• Anaemia• Hypo proteinaemia• Hypertension• Beriberi• Cor pulmonale• Thyrotoxicosis

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• Cardiac Output = Heart Rate x Stroke Volume

• Changes in Cardiac Output =

Changes in Heart Rate & Changes in Stroke Volume

• Heart Rate is Controlled by

Autonomic Nervous System & Hormonal System

• Stroke Volume is Controlled by

Preload, Afterload and Myocardial Contractility

Patho-Physiology

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Patho-Physiology

• Cardiac output is the function of Pre load (the stretching of the ventricular myocardium after filling just before contraction), After load (the resistance against which myocardium has to contract and eject the blood out) and Myocardial Contractility, and is controlled by Neuro-Hormonal System

• This forms the basis of Starling’s Law.

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Patho-Physiology

• Starling’s Law:

The force of

contraction

of heart is directly

proportional to the

initial length of the

muscle fibers before

the onset of

contraction

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• In Heart failure due to inability of ventricles to fulfill metabolic demand Renin angiotensin aldosterone system gets activated.

• This system causes vasoconstriction, salt and water retention and sympathetic nervous system activation.

• Activation of the sympathetic nervous system may initially maintain cardiac output through an increase in myocardial contractility, heart rate and peripheral vasoconstriction.

Patho-Physiology

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• However, prolonged stimulation often reduce cardiac output by causing an inappropriate and excessive increase in peripheral vascular resistance, cardiac myocyte apoptosis, hypertrophy and focal myocardial necrosis.

• Ultimately a vicious cycle is established which cause further Neuro hormonal activation and increase peripheral vascular resistance.

• The onset of Pulmonary and Peripheral oedema is due to high atrial pressures compounded by salt and water retention.

Patho-Physiology

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Patho-Physiology

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Mechanisms of Cardiac Failure

• Reduced Ventricular Contractility• Ventricular outflow obstruction• Ventricular inflow obstruction• Ventricular volume overload• Arrhythmia• Diastolic dysfunction

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1. Acute and Chronic Heart Failure:• Heart Failure may develop suddenly, as in Myocardial

Infarction known as Acute Heart Failure.

• It may develop in a gradual manner, as in Progressive Valvular Heart Disease known as Chronic Heart Failure.

• In the gradual impairment, a variety of compensatory changes may took place which although initially improve cardiac function, but as the disease progresses they often become counterproductive.

Types of Heart Failure

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2. Left, Right and Biventricular Heart Failure:• If there is reduction in the Left Ventricular output and/or

increase in Left atrial or pulmonary venous pressure then it is Left sided Heart Failure.

• If there is reduction in the Right Ventricular output for any given Right atrial pressure then it is Right sided Heart Failure.

• Failure of Both Left and Right sided Heart is Biventricular Heart Failure.

Types of Heart Failure

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Types of Heart Failure

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3. Forward and Backward Heart Failure:• If in the forward blood circulation there is inadequate

cardiac output then it is Forward Heart Failure.

• In some cases there is normal or near normal cardiac output but with marked salt and water retention causing pulmonary and systemic venous congestion then it is Backward Heart Failure.

Types of Heart Failure

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4. Systolic and Diastolic Heart Failure:• Systolic Cardiac failure is due to impaired systolic

function or poor ventricular contractility.

• Diastolic Cardiac failure is due to impaired diastole or poor ventricular filling because of abnormal relaxation.

Types of Heart Failure

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SYMPTOMS:

Left Ventricular Failure• Dyspnoea (Exertional Dyspoea, Orthopnoea, Paroxysmal

nocturnal dyspnoea)• Cough (with pink frothy sputum)• General Weakness• Fatigue

Clinical Features

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SYMPTOMS:

Right Ventricular Failure• Oedema feet• General Weakness• Fatigue• Anorexia• Nausea• Insomnia

Clinical Features

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SIGNS:

Left Ventricular Failure• Pulmonary oedema• Pleural effusion• Bilateral basal Creptations• Cardiomegaly• Audible S3, S4 heart sounds• Murmurs• Cheyne’s Strokes Respiration• Pulsus alterans

Clinical Features

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SIGNS:

Right Ventricular Failure• Peripheral pitting oedema• Raised JVP• Hepatomegaly• Ascites• Murmurs

Clinical Features

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Classification

• Class I : No limitation of Physical Activity.• Class II : Slight limitation of physical activity, comfortable at

rest. • Class III: Marked limitation of physical activity, comfortable at

rest. Less than ordinary activity causes fatigue,

palpitation, dyspnoea, or anginal pain. • Class IV: Inability to carry on any physical activity without

marked discomfort. Symptoms of heart failure may

be present even at rest. If any physical activity is

undertaken, discomfort is increased.

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• Renal Failure• Hypokalaemia• Hyperkalaemia• Hyponatraemia• Impaired Liver Function• Atrial and Vetricular Arrhythmias• Shock• Death

Complications

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• Chest X-Ray• ECG• 2D Echo• TMT• Serum Electrolytes• Serum Urea• Serum Creatinine

Investigations

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1. Bronchial Asthma:• Dyspnoea is present• It has seasonal attacks• In Bronchial Asthma Cough is followed by Dyspnoea• Basal Creptations are absent but there is wheezing all

over the chest• In X-Ray no Abnormality is detected

Differential Diagnosis

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2. Pneumonia:• Dyspnoea is present,• In Pneumonia Expectorant Cough is present with high

fever and flushing of face.• Creptations are present in middle and lower zone of Lung• X-Ray shows consolidation in middle and lower zone

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Differential Diagnosis

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3. Plueral Effusion:• Dyspnoea is present,• Cough is not prominent.• Movements of chest wall is restricted, chest pain occurs

while inspiration• X-Ray shows opacity in the lower and lateral side of the

chest

Differential Diagnosis

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4. Renal Disease:• Dyspnoea and Cough are present,• Oedema of upper body especially face is present.• Oliguria is present• Increased Serum Urea and Creatinine• Ultrasound shows degeneration of Renal Parenchyma

Differential Diagnosis

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Management

General Measures: • Treat the underlying cause• Education of the Patient and attendants• Bed rest• Restricted Salt Diet• Cessation of Alcohol, Smoking• Oxygen Therapy (Acute Condition)

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Management

Drug Therapy:• Diuretic therapy• Vasodilators• ACE inhibitors• Digoxin• Nitrates• Amiodarone

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