Congestive Heart Failure

Classification

Generally classified as the following:

• Left vs right failure

• Systolic vs diastolic dysfunction

• Backward vs forward failure

• Low output vs high output cardiac failure

• The degree of functional impairment conferred by the abnormality (as in the NYHA functional classification)

New York Heart Association Functional Classification

• Class I: No limitation experienced in any activity and no symptoms from ordinary activities.

• Class II: Mild limitation of activity and comfortable at rest or mild exertion

• Class III: Marked limitation of any activity and comfortable only at rest

• Class IV: Any physical activity brings discomfort and symptoms appear at rest

Signs and symptoms

Left Sided Failure- Symptoms

Backward Failure: Respiratory compromise

• Dyspnea on exertion• Dyspnea at rest (severe)• Orthopnea (on lying flat)• Paroxysmal nocturnal dyspnea

(cardiac asthma)• Nocturnal cough

Left Sided Failure- Symptoms

Forward Failure: Poor systemic circulation

• Dizziness• Confusion• Cool extremities at rest• Easy fatigueability• Exercise intolerance

Right Sided Failure- SymptomsBackward Failure: Congestion of

systemic capillaries

• Excess fluid accumulation in the body

• Peripheral edema/ anasarca• Dependent edema (foot, ankle,

sacral)• Nocturia • Ascites• Liver congestion (hepatomegaly,

jaundice and coagulopathy)

Forward Failure: Hypotension

Left Sided Failure- Signs

Non specific signs of respiratory distress:

• Tachypnea• Increased work of breathing• Decreased vital capacity Development of pulmonary

edema:• Rales/Crackles – initially at base,

throughout the lung when severe

Extremely severe pulmonary edema:

• Cyanosis (severe hypoxemia)

Left Sided Failure- Signs

• Laterally displaced apex beat (heart enlargement)

• S3 gallop rhythm (increased blood flow/ increased intra cardiac pressure)

• Heart murmurs- indicative of valvular diseases (Cause or result of heart failure)

Right Sided Failure- Signs

• Peripheral pitting edema• Hepatomegaly• Jugular venous pulse

accentuated by hepatojugular reflux (marker of fluid status)

• Positive abdominojugular test• Parasternal heave (increased

RV pressure)• Ascites (late onset)

Ascites

Pitting Edema of Ankle

Cardiomegaly

Pulmonary Edema

Biventricular Failure

• Pleural effusions- more common in biventricular failures.

• Unilateral failures cause right sided effusions (large area of right lung)

Signs:• Dullness of lung fields• Reduced breath sounds at lung

bases

Other signs

• Cardiomegaly

• Weight loss

• Tachycardia (>120 bpm)

• Pink frothy sputum (severe)

Measuring elevated JVP

Common symptoms of CCF (overview)

References

• Internet www.wikipedia.org www.wrongdiagnosis.com www.medicinenet.com

• Davidson’s Principles and Practice of Medicine, 20th Ed.

• Harrison’s Manual of Internal Medicine, 17th Ed.

Thank You