Heart Failure
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Heart Failure Heart Failure Presentation Transcript

  • CARDIAC FAILURE 03/17/11
  • Group members:
    • Karjome Lama
    • Alok Chandra Thakur
    • Namita Gyawali
    • Nanayakkara Sattambi R.D.Thanuga Dilhani
    03/17/11
  • NORMAL HEART HEART FAILURE 03/17/11
  • INTRODUCTION
    • One of the most common ailments treated by the physicians.
    • In simple words, “cardiac failure” means failure of the heart to pump the blood to satisfy the bodily needs but it doesn’t mean that the heart has completely stopped like in cardiac arrest .
    • It is not considered as a disease. Rather, it is the result from any heart condition that reduces the ability of the heart to pump the blood due to decreased contractility of myocardium.
    03/17/11
    • Heart failure may occur suddenly, or it may develop gradually. When heart function deteriorates over years, one or more conditions may exist. The strength of muscle contractions may be reduced, and the ability of the heart chambers to fill with blood may be limited by mechanical problems, resulting in less blood to pump out to tissues in the body. Conversely, the pumping chambers may enlarge and fill with too much blood when the heart muscle is not strong enough to pump out all the blood it receives.
    • In addition, as the architecture of the heart changes as it enlarges, regurgitation of the mitral valve may develop, making the heart failure even worse.
    03/17/11
  • Cardiac Physiology (remember this?)
    • CO = SV x HR
    • HR: parasympathetic and sympathetic tone
    • SV: preload, afterload, contractility
    Preload Contractility Afterload Stroke Volume Heart Rate Cardiac Output 03/17/11
  • Preload
    • Def: Passive stretch of muscle prior to contraction
    • Measurement: Swan-Ganz
      • LVEDP(Left Ventricular End-Diastolic Volume)
    • Really a function of LVEDV
    • Affected by compliance
      • Low compliance = higher LVEDP @ lower LVEDV
      • False high estimate of preload
    03/17/11
  • Afterload
    • Def: Force opposing/stretching muscle after contraction begins
    • Measurement: SVR(Systemic Vascular Resistance)
    • Really a function of:
      • SVR
      • Chamber radius (dilated cardiomyopathies)
      • Wall thickness (hypertrophy)
    03/17/11
  • Contractility
    • Def: Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces
    • In other words:
      • How healthy is your heart muscle?
    • Ischemia, Hypertrophy, Muscle loss
    03/17/11
    • What Causes Heart Failure?
      • Health conditions that either damage the heart or make it work too hard
        • Coronary artery disease
        • Heart attack
        • High blood pressure & Hypertension
        • Abnormal heart valves
        • Heart muscle diseases (cardiomyopathy)
        • Heart inflammation (myocarditis & pericarditis)
    03/17/11
  • ENDOCARDITIS PERICARDITIS 03/17/11
  • NORMAL HEART HYPERTROPHIED HEART 03/17/11
    • What Causes Heart Failure?
        • Congenital heart defects
        • Severe lung disease
        • Diabetes
        • Severe anemia
        • Overactive thyroid gland (hyperthyroidism)
        • Abnormal heart rhythms(Arrhythmias)
    03/17/11
    • What Causes Heart Failure?
      • Coronary artery disease
        • Cholesterol and fatty deposits build up in the heart’s arteries
        • Less blood and oxygen reach the heart muscle
        • This causes the heart to work harder and occasionally damages the heart muscle
    03/17/11                             
    • What Causes Heart Failure?
      • Heart attack
        • An artery supplying blood to the heart becomes blocked
        • Loss of oxygen and nutrients damages heart muscle tissue causing it to die
        • Remaining healthy heart muscle must pump harder to keep up
    03/17/11                             
    • What Causes Heart Failure?
      • High blood pressure & Hypertension
        • Uncontrolled high blood pressure and hypertension doubles a persons risk of developing heart failure
        • Heart must pump harder to keep blood circulating
        • Over time, chamber first thickens, then gets larger and weaker
    03/17/11                             
    • What Causes Heart Failure?
      • Abnormal heart valves
      • Heart muscle disease
        • Damage to heart muscle due to drugs, alcohol or infections
      • Congenital heart disease
      • Severe lung disease
        • Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.
    03/17/11
    • What Causes Heart Failure?
      • Diabetes
        • Tend to have other conditions that make the heart work harder
        • Obesity
        • Hypertension
        • High cholesterol
    03/17/11                             
    • What Causes Heart Failure?
      • Severe anemia
        • Not enough red blood cells to carry oxygen
        • Heart beats faster and can become overtaxed with the effort
      • Hyperthyroidism
        • Body metabolism is increased and overworks the heart
      • Abnormal Heart Rhythm
        • If the heart beats too fast, too slow or irregular it may not be able to pump enough blood to the body
    03/17/11                              
  • TYPES OF HEART FAILURE
    • Anatomically
      • Left versus Right
    • Physiologically
      • Systolic versus Diastolic
    • Functionally
      • How symptomatic is your patient?
    03/17/11
  • Left versus Right Failure
    • Left Heart Failure
      • Dyspnea
      • Decrease exercise tolerance
      • Cough
        • Orthopnea
        • Pink, frothy sputum
    • Right Heart Failure
      • Decrease exercise tolerance
      • Edema
      • Hepatomegaly
      • Ascites
    03/17/11
  • Bilateral pulmonary effusion in right heart failure Pitting edema of the ankle. 03/17/11
  • The renin–angiotensin–aldosterone system
    • Reduction of renal blood flow and glomerular filtration rate.
    • The renin–angiotensin–aldosterone system is activated.
    • Increase in peripheral vascular resistance.
    • Increase in sodium and water retention.
    03/17/11
  • THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM ACE ACE INHIBITORS JGA RENIN ADRENAL ALDOSTERONE ANGIOTENSINOGEN ANGIOTENSIN 1 ANGIOTENSIN 2 VASOCONSTRICTS Na RETENTION INCREASED BP 03/17/11
  • Systolic versus Diastolic
    • Systolic– “can’t pump”
      • Aortic Stenosis
      • HTN
      • Aortic Insufficiency
      • Mitral Regurgitation
      • Muscle Loss
        • Ischemia
        • Fibrosis
        • Infiltration
    • Diastolic- “can’t fill”
      • Mitral Stenosis
      • Tamponade
      • Hypertrophy
      • Infiltration
      • Fibrosis
    03/17/11
  • DIASTOLIC HEART FAILURE SYSTOLIC HEART FAILURE 03/17/11
  • ACUTE MITRAL REGURGITATION CHRONIC MITRAL REGURGITATION 03/17/11
  • Acute versus Chronic
    • Acute heart failure
      • develops rapidly
      • can be immediately life threatening due to lack of time to undergo compensatory adaptations.
      • may result from cardiopulmonary by-pass surgery, acute infection (sepsis), acute myocardial infarction, valve dysfunction, severe arrhythmias, etc.
      • can often be managed successfully by pharmacological or surgical interventions. 
    • Chronic heart failure
      • a long-term condition (months/years) that is associated with the heart undergoing adaptive responses (e.g., dilation, hypertrophy) to a precipitating cause.
      • These adaptive responses, however, can be deleterious in the long-term and lead to a worsening condition.
    03/17/11
  • Functional classification of Heart Failure by New York Heart Association 03/17/11                              Class % of patients Symptoms I 35% No symptoms or limitations in ordinary physical activity II 35% Mild symptoms and slight limitation during ordinary activity III 25% Marked limitation in activity even during minimal activity. Comfortable only at rest IV 5% Severe limitation. Experiences symptoms even at rest
  • Pathophysiology of the Heart Failure
    • Decreased stroke volume
    • Raised end-diastolic volume and pressure
    • Ventricular dilation will occur.
    • Chronic elevation of diastolic pressures.
    • Increased capillary pressure.
    • Increased peripheral vascular resistance.
    • Transudation of fluid with resulting pulmonary or systemic edema.
    03/17/11
    • Activation of neural and humoral systems.
    • Frank –starling mechanism
    • Increased LV afterload, so that excessive sympathetic activity may further depress cardiac function.
    • Increased activity of the sympathetic nervous system(mainly adrenergic activity) but reduced vagal activity to heart.
    • Increased myocardial contractility, heart rate, and venous tone.
    Pathophysiology of the Heart Failure 03/17/11
  • Frank-starling Mechanism
    • The Frank-Starling law of the heart states that as the ventricular volume increases and stretches the myocardial muscle fibers, the stroke volume increases, up to its maximum capacity. After that point, increasing volume increases pulmonary capillary pressure (and pulmonary congestion), without increasing the stroke volume or cardiac output. The mechanism is the length-force relationships of muscle contraction.
    Stroke volume End-Diastolic volume Maximum capacity to produce stroke volume Normal range: stroke volume increases with end-diastolic volume 03/17/11
  • An overall view of Heart Failure 03/17/11
      • Shortness of Breath (Dyspnea)
        • WHY?
          • Blood “backs up” in the pulmonary veins because the heart can’t keep up with the supply an fluid leaks into the lungs
        • SYMPTOMS
          • Dyspnea on exertion or at rest
          • Difficulty breathing when lying flat (Orthopnea)
          • Waking up short of breath
    Signs and Symptoms of Heart Failure 03/17/11
      • Persistent Cough or Wheezing
        • WHY?
          • Fluid “backs up” in the lungs
        • SYMPTOMS
          • Coughing that produces white or pink blood-tinged sputum
    Signs and Symptoms of Heart Failure 03/17/11                             
      • Edema
        • WHY?
          • Decreased blood flow out of the weak heart
          • Blood returning to the heart from the veins “backs up” causing fluid to build up in tissues
        • SYMPTOMS
          • Swelling in feet, ankles, legs or abdomen
          • Weight gain
    Signs and Symptoms of Heart Failure 03/17/11                             
      • Tiredness, fatigue
        • WHY?
          • Heart can’t pump enough blood to meet needs of bodies tissues
          • Body diverts blood away from less vital organs (muscles in limbs) and sends it to the heart and brain
        • SYMPTOMS
          • Constant tired feeling
          • Difficulty with everyday activities
    Signs and Symptoms of Heart Failure 03/17/11
      • Lack of appetite/ Nausea
        • WHY?
          • The digestive system receives less blood causing problems with digestion
        • SYMPTOMS
          • Feeling of being full or sick to your stomach
    Signs and Symptoms of Heart Failure 03/17/11                             
      • Confusion/ Impaired thinking
        • WHY?
          • Changing levels of substances in the blood ( sodium) can cause confusion
        • SYMPTOMS
          • Memory loss or feeling of disorientation
          • Relative or caregiver may notice this first
    Signs and Symptoms of Heart Failure 03/17/11                             
      • Increased heart rate
        • WHY?
          • The heart beats faster to “make up for” the loss in pumping function
        • SYMPTOMS
          • Heart palpitations
          • May feel like the heart is racing or throbbing
    Signs and Symptoms of Heart Failure 03/17/11                             
  • Clinical Data
    • CXR(Chest X-Ray)
      • Kerley’s lines : A and B
      • Pulmonary Edema
      • Cephalization
      • Pleural Effusions (bilateral)
    • EKG(Electrocardiogram)
      • Left atrial enlargement
      • Arrhythmias
      • Hypertrophy (left or right)
    03/17/11
  • Cardiomyopathy Pulmonary Edema 03/17/11
  • Clinical Data
    • HEART SOUNDS!!!
    • Systolic Murmurs
      • Mitral Regurgitation
      • Aortic Stenosis
    • Diastolic Murmurs
      • Mitral Stenosis
      • Aortic Insufficiency
    • S3 : Rapid filling of a diseased ventricle
    Mitral Stenosis 03/17/11
  • Clinical Data
    • Laboratory Data
    • Chemistry
      • Renal Function: Be Wary
    • BNP(Brain Natriuretic Peptide) Test
      • Used in ER departments the world over
      • Good negative correlation
      • Need baseline for positivity
      • Pulmonary versus cardiac dyspnea
    03/17/11
  • Modified Framingham Criteria Diagnosis for Heart Failure
    • Major criteria
    • Neck vein distension
    • Orthopnea
    • Cardiomegaly on CXR
    • CVP > 12 mm Hg
    • Left Ventricular dysfunction on EKG
    • Weight loss
    • Acute pulmonary edema
    • Minor criteria
    • Bilateral ankle edema
    • Night cough
    • Dyspnea on exertion
    • Hepatomegaly
    • Pleural effusion
    • Tachycardia (> 120 beats/min)
    03/17/11
      • The more common forms of heart failure cannot be cured, but can be treated
        • Lifestyle changes
        • Medications
        • Surgery
    Treatment Options 03/17/11                             
      • Stop smoking
      • Avoid alcohol
      • Avoid or limit caffeine
      • Eat a low-fat, low-sodium diet
      • Exercise
      • Reduce stress
    Lifestyle Changes 03/17/11                             
      • Lose weight
      • Keep track of symptoms and weight and report any changes or concern to the doctor
      • Limit fluid intake
      • See the doctor more frequently
    Lifestyle Changes 03/17/11                             
      • ACE Inhibitors
        • Cornerstone of heart failure therapy
        • Proven to slow the progression of heart failure
        • Vasodilator – cause blood vessels to expand lowering blood pressure and the hearts work load
    Medications used to treat Heart Failure 03/17/11                             
      • Diuretics (water pills)
        • Prescribed for fluid build up, swelling or edema
        • Cause kidneys to remove more sodium and water from the bloodstream
        • Decreases workload of the heart and edema
        • Fine balance – removing too much fluid can strain kidneys or cause low blood pressure
    Medications used to treat Heart Failure 03/17/11
      • Potassium
        • Most diuretics remove potassium from the body
        • Potassium pills compensate for the amount lost in the urine
        • Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles
    Medications used to treat Heart Failure 03/17/11
      • Vasodilators
        • Cause blood vessel walls to relax
        • Occasionally used if patient cannot tolerate ACE
        • Decrease workload of the heart
    Medications used to treat Heart Failure 03/17/11                             
      • Digitalis preparations
        • Increases the force of the hearts contractions
        • Relieves symptoms
        • Slows heart rate and certain irregular heart beats
    Medications used to treat Heart Failure 03/17/11                             
      • Beta-blockers
        • Lower the heart rate and blood pressure
        • Decrease the workload of the heart
      • Blood-thinners (coumadin)
        • Used in patients at risk for developing blood clots in the blood vessels, legs, lung and heart
        • Used in irregular heart rhythms due to risk of stroke
    Medications used to treat Heart Failure 03/17/11                             
  • 03/17/11
      • Surgery and other Medical Procedures
        • Not often used in heart failure unless there is a correctable problem
        • Coronary artery bypass
        • Angioplasty
        • Valve replacement
        • Defibrillator implantation
        • Heart transplantation
        • Left ventricular assist device(LVAD)
    Treatment Options 03/17/11                             
  • Incidence of Heart Failure and its Prognosis
    • Heart failure is the leading cause of hospitalization of patients over 65 years in age.
    • > 15million new cases of Heart failure estimated each year worldwide.
    • Rapidly increasing number because of the aging population.
    • Despite many new advances in drug therapy and cardiac assist devices, the prognosis for chronic heart failure remains very poor.
    • One year mortality figures are
      • 50-60% for patients diagnosed with severe failure,
      • 15-30% in mild to moderate failure, and
      • about 10% in mild or asymptomatic failure.
    03/17/11
  • Thank you for listening!!!
    • Questions?????
    03/17/11