Heart Failure

Common Costly Disabling Deadly

Heart Failure (HF)

Definition Pathophysiology Types of HF

When do we suspect HF ?
Investigations ? Management of HF

Definition of HF
A clinical syndrome following the inability of the heart to maintain adequate Cardiac output due to a structural (or functional) defect of the heart.

Structural defect - commonly

Ventricular dysfunction Valvular malfunction - rarely Abnormal shunts or pericardial disease

Framingham -Survival after HF onset was overall poor and didn't differ significantly between patients with systolic or diastolic heart failure, 5 year mortality reached 74% and didn't vary significantly by sex.

Types of Heart failure

Left heart failure

Right heart failure

Congestive heart failure

Causes of Left Heart Failure

Coronary artery disease Hypertension

Cardiomyopathy
Valvular disease ( congenital or acquired)

Hypertension to HF
Obesity Diabetes IGT

LVH

Diastolic Dysfunction CHF

HTN
CAD

Smoking Lipids Diabetes

MI

Systolic Dysfunction
Overt HF

Normal LV Structure and Function

LV Remodeling

Subclinical LV Dysfunction

Adapted with permission from: Vasan RS, Levy D. Arch Intern Med. 1996;156:1790.

Causes of Right Heart Failure (RHF)

No 1 cause of RHF is Left Heart Failure

Chronic Lung disease Cor Pulmonale Recurrent Pulmonary embolism Congenital Heart Disease- ASD,VSD,PDA Primary Pulmonary H/T

Neurohormonal activation in HF(1)

1.Sympathetic activation Vasoconstriction Sinus tachycardia

(Afterload) (Preload)

2.Renin angiotensin system Vasoconstriction (Afterload) salt & water retention (Preload)
Preload - volume of blood in the LV immediately before systole Afterload - resistance to blood flow in arteries

Neurohormonal activation in HF (2)

3. Natriuretic peptides Atrial natriuretic peptides ( ANP)
Secreted from atria

Brain natriuretic peptides ( BNP)

Secreted from ventricles (cardiac) diuresis, vasodilatation (by reducing angiotensin, aldosterone, & endothelin) Reduction of preload and afterload

Final Common Pathway in Heart Failure

Cardiac dysfunction leads to elevated filling pressures Right atrial pressure increases from 2-5 to > 7-20 mmHg
leads to ascites, liver congestion and peripheral oedema

Left atrial pressure increases from 5-12 to >18-40 mmHg

results in dyspnoea, pulmonary edema and pleural effusions

Symptoms of Left heart failure

1. Shortness of breath on exertion
2. Impaired exercise tolerance 3. Paroxysmal nocturnal dyspnoea 4. Orthopnoea ( indicative of fluid overload) 5. Fatigue

Signs of Left heart failure

Increased respiratory rate
Cyanosis central or peripheral Increased heart rate regular/irregular Cardiomegaly Displaced apex

Third heart sound, Murmur

Lung crepitations

Symptoms of Right heart failure

1. Dyspnoea

2.
3. 4.

Peripheral oedema
Abdominal distension GI symptoms- Nausea, vomiting, loss of appetite

Signs of Right heart failure

1.
2.

Raised JVP
Parasternal heave RV enlargement

3.
4. 5. 6.

Murmur, third heart sound

Hepatomegaly with signs of liver dysfunction Leg or sacral oedema Ascites

Investigations of Heart Failure

ECG CXR Echocardiography BNP / NT-pro BNP Blood tests -FBC, U &E , LFT, TFT , Glucose

Role of Echocardiography in HF
Gold standard investigation Confirms HF Differentiates Systolic and diastolic function

LVEF quantifies Systolic function (N> 55 %)

Identify the cause of heart failure

ESC Guidelines for Heart Failure Diagnosis

Suspected Heart Failure because of symptoms & signs

Assess presence of cardiac disease by ECG, X-ray or BNP (where available)

Normal Heart Failure unlikely

Test abnormal Normal Heart Failure unlikely

Imaging by echocardiography Test abnormal Assess aetiology, degree, precipitating factors & type of cardiac dysfunction

Additional diagnostic tests Where appropriate (e.g. coronary angiography)

Eur Heart Journal (2001)22, 1527-1560

Choose therapy

Goals of Heart Failure Therapy

Relieve HF symptoms
Make patients feel better Stabilize acute episodes of decompensation

Decrease morbidity and mortality

Slow and/or reverse disease progression Identify and treat reversible causes of LV dysfunction

Treatment of Heart failure

Non pharmacological Pharmacological

Surgical
Device therapy Transplant

Non pharmacological
Avoid alcohol,smoking Bed rest Counseling Diet low in salt Exercise Fluid restriction

How Do We Make Heart Failure Patients Feel Better?

Diuretics Vasodilators Nitrates, ACEI Positive inotropic agents Mechanical interventions that improve hemodynamics (e.g., CRT, LVADs) Oxygen

How Do We Make Heart Failure Patients Live Longer?

Angiotensin II
(Renin-Angiotensin System [RAS])

Norepinephrine
(Sympathetic Nervous System [SNS])

RAS Inhibition

-Blockade

Disease Progression

Triple therapy + Device therapy

ACE Inhibitors in HF
Improve survival & symptoms First line therapy

Titrate to effective dosage

ARBs for patients who dont tolerate ACEIs

Drug Treatment of Heart Failure

Diuretic Vasodilator Beta blocker Anti arrythmic Anti coagulant
- Frusemide, metolazone, Spironolactone - ACEI , AT2 blockers - Carvedilol, metoprolol, bisoprolol

- Digoxin , Amiodarone - Warfarin ? aspirin

DEVICE THERAPY

ICD

LVAD

Biventricular pacing