Congestive HEART FAILURE

• A clinical syndrome that develops when the heart cannot maintain adequate output, or can do so only at the expense of elevated ventricular filling pressure. • Most common in the elderly 1% in those aged 50–59 years to over

10% in those aged 80–89 years.• The most common aetiology is coronary artery disease and

myocardial infarction. • Approximately 50% of patients with severe heart failure due to left

ventricular dysfunction will die within 2 years,

Mechanisms of heart failure• Reduced ventricular contractility• Ventricular outflow obstruction(pressure overload) • Ventricular inflow obstruction• Ventricular volume overload• Arrhythmia• Diastolic dysfunction

Pathophysiology-Starling’s Law.

An increase in myocardial contractility or a reduction in afterload will shift the curve upwards and to the left (green arrow).

• Cardiac output is determined by:• Preload• Afterload• Myocardial contractility• An increase in preload (end-diastolic volume,end-diastolic pressure, filling pressure or

atrial pressure) will therefore enhance function; however, overstretching causes marked deterioration.

• Impairment of ventricular myocardial function, leading to a fall in cardiac output. This can occur because of impaired systolic contraction, impaired diastolic relaxation, or both.

• Activates counterregulatory neurohumoral mechanisms• Stimulation of the renin–angiotensin–aldosterone system

Neurohumoral activation

Types of heart failure• Left-sided heart failure• Right-sided heart failure.• Biventricular heart failure. • Diastolic and systolic dysfunction• High-output failure• Acute and chronic heart failure

Clinical Features• Sudden onset of dyspnea• Agitated or drowsy, pale and clammy.• Peripheries are cool to the touch and the pulse is rapid.• The BP is usually high because of sympathetic nervous system

activation, but may be normal or low if the patient is in cardiogenic shock.• The jugular venous pressure (JVP) is usually elevated• A ‘gallop’ rhythm, with a third heart sound• Crepitations in the lung

Chronic heart failure• Relapsing and remitting course• Symptoms months to years.

Left heart failure Right heart failure

Systolic vs. Diastolic• Systolic dysfunction• EF < 45%• Usually from coronary disease• Due to ischemia-induced decrease in

contractility

• Diastolic dysfunction• EF normal or increased• Hypertension• Due to LVH and chronic replacement by

fibrous tissue - decrease in distensibility

Complications• Renal failure• Dyselectrolytemia• Impaired liver function• Thromboembolism• Atrial and ventricular arrhythmias

Investigations• Haemoglobin• Blood sugar,HbA1c,Serum urea, creatinine and electrolytes, Brain

natriuretic peptide (BNP),thyroid function • ECG • Chest X-ray• Echocardiography• Cardiac Catheterization

Radiological features of heart failure

Management of acute pulmonary oedema• Sit the patient up• Oxygen (high-flow, high-concentration).• Non-invasive positive pressure ventilation• IV glyceryl trinitrate(10–200 μg/min)• A loop diuretic, such as furosemide (40–120 mg IV). • Intravenous opiates like morphine 3-5 mg. • Inotropic agents in select cases• Insertion of an intra-aortic balloon pump(in select cases}

Management of chronic heart failure• Diuretic therapy :furosemide, bendroflumethiazide,spironolactone or

eplerenone• Angiotensin-converting enzyme inhibitors: act by preventing the

conversion of angiotensin I to angiotensin II or• Angiotensin receptor blocker therapy• Beta-adrenoceptor blocker therapy• Ivabradine :acts on the If inward current in the SA node,resulting in

reduction of heart rate• Digoxin

Sites of action of drugs used in the treatment of heart failure

Device Therapy/Surgery• Implantable cardiac defibrillators and resynchronisation therapy• Coronary revascularization• Ventricular assist devices• Heart transplantation

Biventricular pacemaker and defibrillator• The right ventricular lead (RV) is

in position in the ventricular apex and is used for both pacing and defibrillation. • The left ventricular lead (LV) is

placed via the coronary sinus, and the right atrial lead (RA) is placed in the right atrial appendage; both are used for pacing only.

ENHANCED EXTERNAL COUNTERPULSATION (EECP)

Newer Generation Artificial Hearts

REHABLITATION PROGRAMME

Summary• Heart failure is common and has high mortality.• It has to be initially diagnosed on clinical grounds.• Drug therapy improves survival• Newer device therapies are showing promise for symptom relief and

improved survival• Transplants remain rare, but technology for mechanical assist devices

continues to improve.

Thank You