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Heart Failure
Results from any
structural or functional
abnormality that
impairs the ability of
the ventricle to eject
blood (Systolic Heart
Failure) or to fill with
blood (Diastolic Heart
Failure).
Heart Failure
LV Dysfunction causes
Decreased cardiac output
Main causes
Ischemic heart disease, Cardiomyopathy, Hypertension
Other causes: Valvular heart disease, Congenital
heart
disease, Alcohol and drugs, Hyperdynamic circulation
(anaemia, thyrotoxicosis, haemochromatosis, Paget's
disease), Right heart failure (RV infarct, pulmonary
hypertension, pulmonary embolism, cor pulmonale
(COPD)), Arrhythmia and Pericardial disease.
Infections
Arrhythmias
Physical, Dietary, Fluid, Environmental, and Emotional
Excesses.
Myocardial infarction
Pulmonary embolism
Anemia
Thyrotoxicosis and pregnancy
Aggravation of hypertension
Rheumatic, Viral, and Other Forms of Myocarditis
Infective endocarditis
PATHOPHYSIOLOGICAL CHANGES
Ventricular dilatation
Myocyte hypertrophy
Increased collagen synthesis
Altered myosin gene expression
Altered sarcoplasmic Ca2+-ATPase density
Increased ANP secretion
Salt and water retention
Sympathetic stimulation
Peripheral vasoconstriction
Neurohormonal changes
N/H changes
Favorable effect
Unfavor. effect
HR , contractility,
vasoconst. V return,
filling
Arteriolar constriction
After load workload
O2 consumption
Renin-Angiotensin
Aldosterone
Vasoconstriction
after load
Vasopressin
Same effect
Same effect
interleukins &TNF
Apoptosis
Vasoconstriction VR
After load
Sympathetic activity
Endothelin
Right-Ventricular Failure
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy
(HCM)
Restrictive cardiomyopathy
18
21
Kerley B lines
Echocardiogram:
Coronary arteriography
Should be performed in patients presenting with heart failure
who have angina or significant ischemia
Reasonable in patients who have chest pain that may or
may not be cardiac in origin, in whom cardiac anatomy is not
known, and in patients with known or suspected coronary
artery disease who do not have angina.
Measure cardiac output, degree of left ventricular
dysfunction, and left ventricular end-diastolic pressure.
Ventricular remodeling
Heart Failure
Classification Systems
New York Heart Association Functional
Classification of HF
Classes I to IV
STAGE
DISABILITY
CLASS 1
MILD
CLASS 2
MILD
CLASS 3
MODERATE
CLASS 4 SEVERE
Thyroid dysfunction
Infections
Uncontrolled diabetes
Hypertension
Lifestyle modification
Lower salt intake
Alcohol cessation
Medication compliance
Maximize medications
Discontinue drugs that may contribute to heart failure (NSAIDS,
antiarrhythmics, calcium channel blockers)
Order of Therapy
1.
2.
3.
4.
5.
6.
Loop diuretics
ACE inhibitor (or ARB if not tolerated)
Beta blockers
Digoxin
Hydralazine, Nitrate
Potassium sparing diuretics
Diuretics
Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve symptoms
Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Shown to improve survival in CHF
ACE Inhibitor
Improve survival in patients with all
severities of heart failure.
Begin therapy low and titrate up as
possible:
Enalapril 2.5 mg po BID
Captopril 6.25 mg po TID
Lisinopril 5 mg po QDaily
Isosorbide dinitrate
Started at 40 mg po TID/QID
Digoxin
Given to patients with HF to control
symptoms such as fatigue, dyspnea,
exercise intolerance
Shown to significantly reduce
hospitalization for heart failure, but no
benefit in terms of overall mortality.
DIGOXIN cont.
Cardiac glycosides : Digoxin :
Inhibition of Na/K ATPase pump
increase intracellular sodium
concentration eventually increase
cytosolic calcium.
It restores the vagal tone and abolishes
the sympathetic over activity.
DIGOXIN cont.
Cardiac glycosides : Digoxin
Increase the refractoriness of AV node
thus decrease ventricular response to
atrial rate.
Digoxin is used as a first-line drug in
patients with congestive heart failure
who are in atrial fibrillation.
DIGOXIN cont.
Digoxin : Adverse effects / Precautions :
Nausea, vomiting, gynecomastia, visual
disturbances and psychosis.
Ventricular bigeminy, AV block and
bradycardia.
Amiodarone and verapamil can
increase the plasma concentration of
digoxin by inhibiting its excretion.
DIGOXIN cont.
Digoxin toxicity treatment:
Toxicity can be treated with higher than
normal doses of potassium.
Digoxin antibody (digibind) is used
specifically to treat life-threatening
digoxin overdose.
Thiazolidinediones
Include rosiglitazone (Avandia), and pioglitazone
(Actos)
Cause fluid retention that can exacerbate HF
Metformin
People with HF who take it are at increased risk of
potentially lethic lactic acidosis
Cardiac Transplantation
A history of multiple hospitalizations for HF
Escalation in the intensity of medical therapy
A reproducable peak oxygen consumption with
maximal exercise (VO2max) of < 14 mL/kg per min.
(normal is 20 mL/kg per min. or more) is relative
indication, while a VO2max < 10 mL/kg per min is a
stronger indication.
IABP Machine
Volume Overload
Transfusions, IV fluids
Non-compliance with diuretics, diet (high salt
intake)
Clinical Findings
Tachypnea
Tachycardia
Hypertension/Hypotension
Crackles on lung exam
Increased JVD
S3, S4 or new murmur
Labs/Studies in Acute
Decompensated Heart Failure
Chemistry, CBC
EKG
Chest X-ray
May consider cardiac enzymes
2D-Echo
Heart Failure
Complications
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 Failure
Complications
High risk of fatal dysrhythmias (e.g., sudden cardiac
death, ventricular tachycardia) with HF and an EF
<35%
Keys to understanding HF
All organs (liver, lungs, legs, etc.) return blood to heart
When heart begins to fail/ weaken> unable to pump blood forward-fluid backs up >
Inc. pressure within all organs.
Organ response
LUNGS: congested > stiffer , inc effort to breathe; fluid starts to escape into
alveoli; fluid interferes with O2 exchange, aggravates shortness of breath.
Shortness of breath during exertion, may be early symptoms > progresses > later
require extra pillows at night to breathe > experience "P.N.D." or paroxysmal
nocturnal dyspnea .
Pulmonary edema
Legs, ankles, feet- blood from feet and legs > back-up of fluid and pressure in these
areas, heart unable to pump blood as promptly as received > inc. fluid within feet
and legs causes fluid to "seep" out of blood vessels ; inc. weight
In God we trust,
everything else
should be
based on evidence
(Claude Organ)
THANK YOU
agbudhitresna@yahoo.com