Heart Failure

HEART FAILURE

BY
DR. ARWA MAHMOOD FUZI

HEART FAILURE WORLD WIDE

HF is a major cause of morbidity & mortality in developed and developing countries,

HF is a disease of elderly with a median age of around 75 years. In octogenarians, the prevalence of HF increase sharply to >10%.

Patients with HF have a worse quality of life than those with other chronic diseases including COPD, kidney failure & arthritis.

Up to 40% of patients with HF die within one year of diagnosis.

HF is expensive disease, consuming 2-3% of the overall health care budget.

DEFINITION:

A COMPLEX CLINICAL SYNDROME THAT CAN RESULT FROM
ANY CARDIAC DISORDER THAT IMPAIRS THE ABILITY OF THE
VENTRICLES TO EJECT BLOOD, SO THE HEART CANNOT MAINTAIN
ADEQUATE CARDIAC OUTPUT , OR CAN DO SO ON EXPENSE OF
ELEVATED FILLING PRESSURES RESULTING IN SIGNS
&SYMPTOMS OF PULMONARY CONGESTION, SYSTEMIC FLUID
RETENTION, OR INADEQUATE CARDIAC PERFUSION.

PATHOPHYSIOLOGY OF H.F.

CARD. OUT PUT = STROKE VOLUME BY H.R.
STROKE VOLUME :
1- PRELOAD
2-THE AFTERLOAD
3-MYOCARDIAL CONTRACTILITY.
STARLING LAW
VENTRICULAR PERFORMANCE IS RELATED TO THE DEGREE OF MYOCARDIAL STRECHING , SO INCREASE PRELOAD WILL INHANCE FUNCTION , HOWEVER OVERSTRECHING WILL CAUSE MARKED DETERURATION

COMPENSATORY MECHANISIMEIN H. F.

1-ACTIVATION OF SYMPATHATIC N. SYSTEM.

2-ACTIVATION OF RENIN-ANGIOTENSIN –ALDOSTERON SYSTEM.

3-RELEASE OF A.D.H.


4-RELEASE OF N.U. PEPTIDE.

5-INCREASE PEREPH.O2 EXTRACTION.

6-LOCAL CHANGES IN THE HEART:
a-CHAMER ENLARGMENT
b-CARDIAC HYPERTROPHY
c-INCREASE H. R.

COMPENSATED H. F.

IMPAIRED CARDIAC FUNCTION, BUT ADAPTIVE CHANGE HAVE PREVENTED THE DEVELOPMENT OF OVERT HEART FAILUR

CAUSES OF HEART FAILURE

• DECREASE VENT.CONTRACTILITY(MYOCARDITIS,CMP, MI )
• VENT. OUTFLOW OBSTRUCTION (HYPERTENSION,AS,PULM.HYPERT.,PS.)
• VENT. INFLOW OBSTRUCTION (MS,TS.)
• VENT. VOLUME OVERLOAD (MR,AR,ASD,VSD&INC.MET.DEMAND)
• ARRHYTHMIA (AF,TACHYCARDIA MYOPATHY, COMPL. H.BLOCK)
• DIASTOLIC DYSFUNCTION (CONSTR.PERICARDITIS,RESTRICTIVE CMP,LVH,LV FIBROSIS. CARDIAC TAMPONADE).


PRECIPITATING FACTORS FOR H.F.
1-MYOCARDIAL INFARCTION OR ISCHEMIA.
2-INTERCURRENT ILLNESS.
3-ARRTHYMIAS.
4-REDUCTION OF THERAPY.
5-DRUGS ( B.BLOCKERS, NSAID, STEROIDES.)
6-PULM. EMBOLISM.
7-INC. METABOLIC DEMAND.
8-I.V.F. OVERLOAD.

TYPES OF HEART FAILURE

• ACUTE(DECOMPENSATED)HF & CHRONIC (COMPENSATED) H.F.
• LEFT SIDED , RT SIDED & BIVENT. F.
• FORWORED H.F(INADEQUIT C.O) & BACKWORED H.F(MARKED VENOUS CONGESTION).
• DIASTOLIC H.F(ABNOR VENT. RELAXAT) &SYSTOLIC(ABNOR VENT CONTRACTION)
• HIGH OUTPUT F (AV SHUNT, BERI BERI, ANEMIA, THYROTOXICOSIS) &LOW OUTPUT H. F.

CLINICAL FEATURES OF H.F.

LOW C.O.P &HYPOPERFUSION TO THE TISS.

FLUID &WATER RETENTION WITH PULM. CONGESTION L.V.F.

SYSTEMIC VENOUS CONGETION IN RT. V.F.

SYMPTOMES OF H.F

• DYSPNIA .ORTHOPNIA & PND.(LEFT SIDE H.F)
• FATIGUE &RED. EXERCISE CAPACITY. (L&R SIDE)
• ANOREXIA, NAUSIA, ABD. PAIN &FULLNESS.WT LOSS (L&R)
• ANKLE SWELLING (R SIDE F).
• CEREBRAL SYMPTOMES.
• NUCTURIA.

PHYSICAL FINDINGS

• PULSE (TACKYCARDIA, PULS.ALTERNANCE )
• BP (HYPOTENTION, DEC.PULSE PRESS.)
• DISTENTION OF JVP.(R SIDE F)
• S3 &S4.
• PULM. CREPITATION.(L SIDE F)

• CARDIAC OEDEMA.(R SIDE F)

• PL. EFFUSION.
• ASCITES.(RSIDE F)
• CONGESTIVE HEPATOMEGALY.(R SIDE F)
• JOUNDICE.(R SIDE F)
• CARDIAC CACHEXIA.
• COLD ,PALE EXTR.(ACUTE H F)
• PRE RENAL AZOTEMIA &DEC.UOP.

COMPLICATIONS OF H.F.

• UREAMIA
• HYPOKALEMIA, HYPERKALEMIA &HYPONATREMIA.
• IMPAIRED LIVER F. T.
• THROMBOEMBOLISM (DVT &SYST. EMBOLISATION)
• ARRHYTHMIAS.(V ECTOPICS, VT)
• SUDDEN DEATH.(50% OF PT)

INVESTIGATIONS

AIMES:
CONFIRM THE DIAGNOSES.

DEFINE TYPE.

EXCLUDE TREATABLE CAUSES.

• LAB. TEST:

• BLOOD GAS ANALYSIS
• INC. LIVER ENZYMES
• INC.WBC COUNT
• INC.B.UREA &S.CREATNIN
• BNP
• ECG (MI,LVH,RVH,ARRYTHMIAS)
• CXR (CARDIOMEGALY ,PULM.EDEMA)

ECHOCARDIOGRAPHY

DETERMINE PRIM. ABN.
LV. EF
ASSES DIMENTION,THICKNESS&REGIONAL MOTION
EVALUATION OF PERICARDIAL,VALV.&VASC.STR.
RADIONUCLIDE VENTRICULOGRAPHY
MRI