Nothing can happen unless you first dream

Carl Sandburg

Congestive heart failurePresentation and Diagnosis

The most common reason for hospitalization in adults >65 years old

Dr Shahid Abbas

Consultant Interventional Cardiologist

Road Map– Definition

– Causes and pathophysiology

– Types of heart failure

– Compensatory mechanism of heart failure

– Clinical manifestations

– Classification of heart failure

– Diagnostic evaluation

– Management

Definition

A clinical syndrome that develops whenthe heart cannot maintain an adequatecardiac output

The heart pumps blood inadequately,leading to reduced blood flow, back-up(congestion) of blood in the veins andlungs Leading to

Other changes that may further weakenthe heart

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Etiology

• A syndrome of Pulmonary and/ or Systemic congestion due to C.O

• Heart is unable to pump enough blood to meet tissues O2 requirements

Pulmonary pressure fluid in alveoli (PULMONARY EDEMA)

Systemic pressure fluid in tissues

(PERIPHERAL EDEMA)

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Etiology

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

• About one third of clients experiencing myocardial infarction also develop heart failure

• Structural heart changes, such as valvulardysfunction, cause pressure or volume overload on the heart

Predisposing Cardiac Diseases

• Myocardial infarction

• Chronic ischemia

• Cardiomyopathy

• Arrhythmias

• Diastolic dysfunction

• Valvular diseases

– Aortic Stenosis

– Mitral Stenosis

– Mitral Regurgitation

Causes of congestive heart failure (cont…)

• Severe lung disease (pulmonary hypertension)

• Severe anemia

• Overactive thyroid gland (hyperthyroidism)

• Underactive thyroid gland (hypothyroidism)

• Abnormal heart rhythms ( atrial fibrillation)

• Kidney failure

Cardiac Physiology(remember this?)

• CO = SV x HR

• HR: parasympathetic and sympathetic tone

• SV: preload, afterload, contractility

Preload

• Passive stretch of muscle prior to contraction

• Measurement: Swan-Ganz

– LVEDP

• Really a function of LVEDV

• Affected by compliance

– Low compliance = higher LVEDP @ lower LVEDV

– False high estimate of preload

• Frank-Starling right?

Afterload

• Force opposing/stretching muscle aftercontraction begins

• Measurement: SVR

• Really a function of:

– SVR

– Chamber radius (dilated cardiomyopathies)

– Wall thickness (hypertrophy)

Contractility

• Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces

• In other words:

– How healthy is your heart muscle?

• Ischemia, Hypertrophy (?), Muscle loss

CHF: the heart muscle

March 2013 ghennersdorf DGK ESC SES

CHF: the heart muscle sarcomere

March 2013 ghennersdorf DGK ESC SES

Pathophysiology

Renin + Angiotensinogen

Angiotensin I

Angiotensin II

Peripheral Vasoconstriction

Afterload

Cardiac Output

Heart Failure

Cardiac Workload

Preload

Plasma Volume

Salt & Water Retention

Edema

Aldosterone Secretion

Renin-angiotensin system

Heart Failure

• Pathophysiology

• A. Cardiac compensatory mechanisms

– 1.tachycardia

– 2.ventricular dilation-Starling’s law

– 3.myocardial hypertrophy

• Hypoxia leads to dec. contractility

Acute decompensated heart failure

Pulmonary edema, often life-threatening

• Early

– Increase in the respiratory rate

–Decrease in PaO2

• Later

–Tachypnea

–Respiratory acidemia

Pulmonary edema begins with an increased

filtration through the loose junctions of the

pulmonary capillaries.

As the intracapillary pressure increases, normally

impermeable (tight) junctions between the alveolar cells

open, permitting alveolar flooding to occur.

Acute Decompensated Heart Failure

(ADHF) Pulmonary Edema

END RESULT

FLUID OVERLOAD > Acute Decompensated Heart Failure (ADHF)/Pulmonary Edema

Medical Emergency!

Person literally drowning in secretions

Immediate Action Needed

MildMild

Drugs

Diet

Fluid Restriction

Heart Failure

(progression)

CDHF(Pulmonary Edema) Severe End Stage

Cardiogenic shockCardiomyopathy

Irreversible

Needs new ventricle

VADIABPVADIABP

Heart Transplant

Control With

Emergency-Upright, O2, morphine, etc

Ventricular remodeling

Classifying Heart Failure

• Anatomically

– Left versus Right

• Physiologically

– Systolic versus Diastolic

• Functionally

– How symptomatic is your patient?

Congestive heart failure

Types

• Left-sided heart failureThere are two types of left-sided heart failure

Systolic dysfunction

Diastolic dysfunction

• Right-sided heart failure

Left versus Right Failure

Left Heart Failure

- Dyspnea

- Dec. exercise tolerance

- Cough

- Orthopnea

- Pink, frothy sputum

Right Heart Failure

- Dec. exercise tolerance

- Edema

- HJR / JVD

- Hepatomegaly

- Ascites

Systolic versus Diastolic

Systolic– “can’t pump”

– Aortic Stenosis

– HTN

– Aortic Insufficiency

– Mitral Regurgitation

– Muscle Loss

• Ischemia

• Fibrosis

• Infiltration

Diastolic- “can’t fill”

– Mitral Stenosis

– Tamponade

– Hypertrophy

– Infiltration

– Fibrosis

Classification of heart failureNew York Heart Association (NYHA) Functional Classification

Symptoms% of patientsClass

No symptoms or limitations in ordinaryphysical activity

35%I

Mild symptoms and slight limitationduring ordinary activity

35%II

Marked limitation in activity evenduring minimal activity. Comfortable

only at rest

25%III

Severe limitation. Experiencessymptoms even at rest

5%IV

Heart FailureClinical Manifestations

• Acute decompensated heart failure (ADHF)

• Physical findings

• Orthopnea

• Dyspnea, tachypnea

• Use of accessory muscles

• Cyanosis

• Cool and clammy skin

•Physical findings•*Cough with frothy, blood-tinged sputum•Breath sounds: Crackles, wheezes, rhonchi •Tachycardia•Hypotension or hypertension

ADHF/Pulmonary Edema(advanced L side HF)

When PA WEDGE pressure is approx 30mmHg

– Signs and symptoms

• wheezing

• pallor, cyanosis

• Inc. HR and BP

• S3 gallop

• Rales,copious pink, frothy sputum

Congestive heart failure Clinical manifestations

– Symptoms (back up of blood and fluid)

– Dyspnea

– Orthopnea

– Reduced exercise tolerance, lethargy,fatigue

– Nocturnal cough

– Wheeze

– Ankle swelling

– Anorexia

Congestive heart failure Clinical manifestations ( cont…)

–Signs– Cachexia and muscle wasting

– Tachycardia

– Pulsus alternans

– Elevated jugular venous pressure

– Crepitations or wheeze

– Third heart sound

– Oedema

– Hepatomegaly (tender)

– Ascites

Clinical Data

• HEART SOUNDS!!!

• Systolic Murmurs

– Mitral Regurg

– Aortic Stenosis

• Diastolic Murmurs

– Mitral Stenosis

– Aortic Insufficiency

• S3: Rapid filling of a diseased ventricle

Symptoms

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PULMONARY EDEMA

Rapid fluid accumulation in lung spaces that has leaked from engorged pulmonary capillaries

Etiology – most common cause is sudden deterioration of LV function

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Cardiogenic Shock

Significant reduction in SV & CO causes drop in pressure & poor tissue perfusion a/r/o LV MI

• Clinical signs:

– BP, pulse, peripheral pulses

– confusion/ agitation (cerebral hypoxia)

– cold/ clammy skin

– urine output

– Resp distress

– Chest pain

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(R) SIDED HF

Blood “BACKS UP” into venous circulation. High oncotic pressure pushes fluids into tissues.

CLINICAL SIGNS:

CVP SUDDEN WT. GAIN

JVD DEPENDENT EDEMA

FATIGUE LIVER CONGESTION

LETHARGY ASCITES

ORTHOPNEA ANOREXIA

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What does this show?

Can You Have RVF Without LVF?

• What is this called?COR PULMONALE

What is present in this extremity, common to right sided HF?

Heart FailureComplications

• 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 FailureComplications

• **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

Heart FailureDiagnostic Studies

• Primary goal- determine underlying cause

– History and physical examination( dyspnea)

– Chest x-ray

– ECG

– Lab studies (e.g., cardiac enzymes, BNP- (beta natriuretic peptide- normal value less than 100) electrolytes

– EF

Clinical Data

• CXR– Kerley’s lines : A and B

– Pulmonary Edema

– Cephalization

– Pleural Effusions (bilateral)

• EKG– Left atrial enlargement

– Arrhythmias

– Hypertrophy (left or right)

Cardiomegaly Pulm Oedema

Cardiomegaly/ventricular remodeling occurs as heart overworked> changes in size, shape, and function

of heart after injury to left ventricle. Injury due to acute myocardial infarction or due to causes that inc.

pressure or volume overload as in Heart failure

Clinical Data

• Laboratory Data

• Chemistry– Renal Function: Be Wary

• BNP– Used in ER departments the world over

– Good negative correlation

– Need baseline for positivity

– Pulmonary versus cardiac dyspnea

Transesophageal echocardiogram

TEE

But

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Goals of Treatment-ADHF/Pulmonary Edema)

MAD DOG• Improve gas exchange

– Start O2/elevate HOB/intubate

– Morphine –dec anxiety/afterload

– A- (airway/head up/legs down)

– D- (Drugs) Dig not first now- but drugs as • IV nitroglycerin; IV Nipride, Natrecor

– D- Diuretics

– O- oxygen /measure sats; • Hemodynamics, careful observation

– G- blood gases

– Think physiology