Heart Failure Introduction

What is heart failure?

• congestive heart failure (CHF)
• Heart failure is caused by any condition which reduces the efficiency
of the heart muscle, through damage or overloading.
 Common causes
• include coronary artery disease including a previous myocardial
infarction , high blood pressure, atrial fibrillation, valvular heart
disease, excess alcohol use, infection, and cardiomyopathy of an
unknown cause.
• According to LVEF(left ventricular ejection fraction),HF is roughly
divided into two 2 groups;

1. HFrEF(heart failure with reduced ejection fraction )

2. HFpEF(heart failure with preserved ejection fraction)
 Symptoms and Signs
• commonly include shortness of breath, excessive tiredness, and leg
swelling

1. Left-sided failure
2. Right-sided failure
3. Biventricular failure
 Left-sided failure
• Failure of the left side of the heart causes blood to back up (be
congested) into the lungs, causing respiratory symptoms as well as
fatigue due to insufficient supply of oxygenated blood.
• Common respiratory signs are increased rate of breathing and
increased work of breathing (non-specific signs of respiratory distress)
• Rales or crackles, heard initially in the lung bases, and when severe,
throughout the lung fields suggest the development of pulmonary
edema
• Cyanosis which suggests severe low blood oxygen, is a late sign of
extremely severe pulmonary edema.
• Additional signs indicating left ventricular failure include a laterally
displaced apex beat(which occurs if the heart is enlarged) and a gallop
rhythm (additional heart sounds) may be heard as a marker of
increased blood flow or increased in
• Heart murmurs may indicate the presence of valvular heart disease,
either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral
regurgitation) of the heart failure.tra-cardiac pressure.
• Backward failure of the left ventricle causes congestion of the lungs'
blood vessels:
1. Dyspnea(in severe cases, dyspnea at rest. )
2. Increasing breathlessness on lying flat, called orthopnea. →It is
often measured in the number of pillows required to lie
comfortably, and in orthopnea, the patient may resort to sleeping
while sitting up.
• paroxysmal nocturnal dyspnea→ a sudden nighttime attack of severe
breathlessness, usually several hours after going to sleep.
• Easy fatigability and exercise intolerance are also common complaints
related to respiratory compromise.
• "Cardiac asthma" or wheezing may occur.
• Compromise of left ventricular forward function may result in
symptoms of poor systemic circulation such
as dizziness, confusion and cool extremities at rest.
 Right-sided failure
• Right-sided heart failure is often caused by pulmonary heart
disease ,which is typically caused by difficulties of the pulmonary
circulation, such as pulmonary hypertension or pulmonic stenosis.
• Physical examination may reveal pitting peripheral edema, ascites,
and liver enlargement.
• Jugular venous pressure is frequently assessed as a marker of fluid
status, which can be accentuated by eliciting hepatojugular reflux.
 Diagnosis
• No system of diagnostic criteria has been agreed on as the gold
standard for heart failure.
• Usually HF is diagnosed based on the history of the symptoms and a
physical examination with confirmation by echocardiography. Blood
tests, electrocardiography, and chest radiography may be useful to
determine the underlying cause.
 Modified Framingham clinical criteria for the diagnosis of heart failure
Major Minor

Paroxysmal nocturnal dyspnea Bilateral leg edema

Nocturnal cough
Orthopnea
Dyspnea on ordinary exertion
Elevated jugular venous pressure
Hepatomegaly
Pulmonary rales Pleural effusion
Third heart sound Tachycardia (heart rate ≥120 beats/min)
Cardiomegaly on chest x-ray Weight loss ≥4.5 kg in five days
Diagnosis
Pulmonary edema on chest x-ray
The diagnosis of heart failure requires that two major
Weight loss ≥4.5 kg in five days in response to treatment or one major and two minor criteria cannot be
of presumed heart failure* attributed to another medical condition.
 Classification
• The New York Heart Association (NYHA) Functional
Classification provides a simple way of classifying the extent of heart
failure.
NYHA Class Symptoms

No symptoms and no limitation in ordinary physical activity, e.g. no

I
shortness of breath when walking, climbing stairs etc.

Mild symptoms (mild shortness of breath and/or angina) and slight

II
limitation during ordinary activity.

Marked limitation in activity due to symptoms, even during less-than-

III ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.

Severe limitations. Experiences symptoms even while at rest. Mostly

IV
bedbound patients.
 REFERENCE

• https://www.uptodate.com/contents/epidemiology-and-causes-of-
heart-
failure?search=heart%20failure&source=search_result&selectedTitle=
3~150&usage_type=default&display_rank=3
• https://www.uptodate.com/contents/clinical-manifestations-and-
diagnosis-of-advanced-heart-
failure?search=heart%20failure&source=search_result&selectedTitle=
2~150&usage_type=default&display_rank=2