Heart Failure

Case History
Name : Fred Field
Gender : Male
Age : 63 years
Details :
Manufacture Kitchen Equipments
Work long hours under pressure, esp. in Trade Fair Weeks
Heavy breakfast @ 8 am (egg, bacon, sausage, bread)
Medication Taken : Antacid
Symptoms :
Angina
Nausea
Edema in ankles & joints
Diagnosis:
No MI
Cardiomegaly

What tests could be performed to show whether Myocardial Infarction (MI) has occurred?
Question 1.

Test Results [indicating MI]
Tests done for MI
Laboratory Tests
Enzymes :
- CK MB
- Lactate Dehydrogenase (LDH)
Proteins : Myoglobin
Cardiac Troponins (T & I subtypes)
Physical Tests
- X-rays
- ECG
- Angiogram
- MRI (Magnetic Resonance Imaging)
- Radionuclide Imaging
Elevation of
CKMB
Cardiac Troponins
LDH (*not specific)
Myoglobin Protein (*not specific)
Abnormal Chest X-Ray showing
cardiomegaly
- Abnormal ECG waves
Coronary Blockage (Angiograms)
Abnormal pictures of Heart in MRI

Chest X-Rays
Superior Vena Cava
Right Atrium
Right Ventricle
Aortic Knuckle
Pulmonary Artery
Left Ventricle
Apex
Normal Chest X-Ray (4)

Chest X-Rays (fig a. Front View) (fig b. Side View) Chest X-rays Showing Enlargement of Heart (3)

ECG: Electro Cardiogram

ECG: Electro Cardiogram
(Figure : ECG showing Abnormal Waves)
12-lead electrocardiogram showing ST-segment elevation (orange) in I, aVL and V1-V5 with reciprocal changes (blue) in the inferior leads, indicative of an anterior wall myocardial infarction

Arteriogram/Angiogram (2)
Coronary Angiography + Cardiac Catheterization
Tested for chances of MI, when there’s–
Unstable Angina
Atypical Chest Pain
Unexplained Heart Failure
Uses X-rays and a special dye injected into the blood flow; the blood flow is screened for blocks
Risks –
Arrhythmias, Heart Attacks,
Allergies to the dye,
Bleeding & infection at the injection site,
Blood clots, Stroke,
Blood vessel damage,
Hemorrhage, Hematoma
Kidney damage due to the dye
Fig. Angiogram

Arteriogram/Angiogram (2) Figure a. Arteriogram OR Coronary Angiogram Figure b. Cardiac Catheterization

Magnetic Resonance Imaging (1)
Cardiac Nuclear Magnetic Imaging, when ECG is unclear
Avoid dangers of Angiogram, repeated exposure to radiation, &/or use of Ionic-based dye
Used to diagnose - heart muscle damage after MI
- Birth defects of the heart
- Heart tumors and growths
Show - Amount of dead heart cells after MI
- Heart Valve Disorders
- Pericardial Effusions
- Fibrosis of Heart
- Congenital Heart Abnormalities
NO RADIATION: Radio-magnetic waves
Special dye given as IV in special tests (commonly Gadolinium)
**Metals must be removed before the test (Magnetic Waves)

Magnetic Resonance Imaging (6) Panels A–D: MRI study at baseline demonstrates slight apical hypokinesis in end-systolic phase (arrows in D, C = end-diastolic phase). In A and B, short-axis delayed-enhanced MR images show multiple foci in the sub-epicardium and the midwall (arrows in A and B) and the acute ECG shows ST-elevation (arrows). At 3-months follow-up (E–H), systolic function normalized (G and H) and delayed-enhancement demonstrates resolution of inflammatory foci (E and F, identical location as in A and B) with ECG normalization (F/u).

Radionuclide Imaging (7)
To evaluate :
coronary artery disease (CAD),
valvular or congenital cardiac disorders,
cardiomyopathy, and other cardiac disorders
3D images of the Heart
Use Single Photon Emitting Computerized Tomography (SPECT)
Radioisotopes Injected IntraVenously
A gamma camera is used to capture the photon particles emitted from the radioisotopes (same as Computerized Tomography)
Camera is revolved around the patient, in an elliptical fashion, to capture images from different angles and create a 3D image

Radionuclide Imaging (7) (Fig.) Stress and rest images from single-photon emission computed tomography (SPECT) of a 52-yr-old man with recent-onset angina. Images obtained during stress show a large area of ischemia in the territory fed by the left anterior descending (LAD) artery that is absent at rest. Angiography confirmed a 95 to 99% occlusion involving the bifurcation of the LAD at the first diagonal branch. [Source: http://www.merck.com/mmpe/multimedia/Photo1sec07ch070.html?Ref=t&ItemId=Photo1sec07ch070&RefId=sec07/ch070/ch070i]

Laboratory Testing
NOT much sensitive or specific – critical timing
Cardiac Markers Tested –
1. Troponin (I & T) : Structural components of cardiac muscles
- Released into blood stream after MI
- Elevate within 3 to 12 hours,
- Uptill 5-9days (I) & 2 weeks (T)
2. Creatinine Kinase : MB fraction is more specific for MI
- 15-40% of CK in Cardiac Muscle
- CK MB has 2 isoforms (1&2)
- Ratio of CKMB isoform 2 to 1 indicates MI (>= 1.5)

3. Myoglobin : Present in skeletal & cardiac muscles
- Elevate before CKMB
- Rise in Myoglobin: Size of MI,
- Negative Myoglobin: No MI
4. LDH : MUST be supplemented by other tests
- 5 isoenzymes (1 to 5)
- Elevates within 12-24 hrs, Dissipates in 5-14 days
- Peaks at 2-3 days
- Isoenzyme 2 > 1 (normal); Isoenzyme 1 > 2 (MI)
Laboratory Testing

To Diagnose MI
No laboratory tests are specific to diagnose MI
Must combine with physical examination and various scanning tests
Physical Symptoms of MI (all or some*) :
Restlessness, Severe Distress, Increased Respiratory Rate, Perspiration, Low-grade Fever, BP Changes, Arrhythmia, Cold & Pale Complexion
..Fred Field had NO myocardial infarction..

Question 2.
How are swollen ankles and cardiac enlargement related to heart failure?

EDEMA in CHF
Impaired Pumping Action of Ventricles
Blood backing up in the venous side of the circulatory system
High hydrostatic pressure in the venous end of capillary beds
Water loss from plasma into interstitial spaces between cells
Edema in body & extremities
(Eg. Pulmonary Edema, Edema in ankles & eyelids, etc. )

EDEMA in CHF Fig A. Pulmonary Edema Fig B. Edema in Extremities Fig C. Edema in Congestive Heart Failure

Cardiomegaly in CHF
Damaged Cardiac Fibers (due to MI, Cardio Myopathy, etc.)
Inefficient Cardiac Contractibility
The Need to improve Cardiac Contractibility
Inability of Cardiac cells to differentiate into Myocardium
Enlargement or Hypertrophy of the Myocardium
Increased stiffness of Heart Walls
Decreased ability of relaxation ,after contraction
Enlargement of Heart or Cardiomegaly

Cardiomegaly in CHF Fig a. Cardiomegaly Fig b. Cardiomyopathy Fig c. Cardiac Hypertrophy

Question 3. How is tissue fluid normally formed, and how is this changed in congestive heart failure?

Formation of Tissue Fluid Fig A. Normal Formation of Tissue Fluid Fig B. Fluid Retention in Congestive Heart Failure

Formation of Tissue Fluid (9)
.. In Normal Condition & Congestive Heart Failure ..

Question 4. What is the mechanism of action of thiazide diuretics, and how may they help patients with heart failure?

Thiazide Diuretics ?? ??

Diuretics

Thiazide Diuretic
Derived from Benzothiadiazine
Inhibit Na + ,Cl - reabsorption (thiazidie-sensitive symporters)
K + , Serum Uric Acid
Risks of MI, CHF, stroke
Cheap & affordable for general public
First choice of Hypertension treatment

Thiazides

Thiazides Mechanism of Action of Thiazides
Thiazide
Lowers the Blood Pressure
Decreases the workload
Prevents overload of blood in veins
Prevents inefficient pumping
Prevents overwork of heart muscles

Thiazides Mechanism of Action of Thiazides

The Laboratory tests and Physical tests such as X-Rays, ECG, Angiogram, MRI and Radionuclide Imaging proved that Fred Field have no myocardial infarction.
Impaired pumping action of ventricles, damaged cardiac fibres and decreased oncotic pressure at the venous end cause oedema and thus results in swollen ankles and cardiac enlargement.
Whenever hydrostatic pressure is greater than oncotic pressure, fluid will leave the capillaries into the tissue and whenever the oncotic pressure is greater than the hydrostatic pressure fluid will enter the capillaries. If not the fluid will accumulate in the tissue and cause oedema.

Thiazide diuretics inhibit Clˉ binding & transport, inhibit Na+ transport, lowers blood pressure, decrease workload, decrease K+, increase serum uric acid and thus it decrease the risks of MI, CHF and Stroke.
SUMMARY

References
Taylor's Cardiovascular Diseases: A Handbook by Robert B. Taylor, M.D. Editor; 2005 Springer; ISBN 0-387-22351-7
Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6 th Ed.; 2001 W.B. Saunders; ISBN 0-8089-2258-0
The Physics of Coronary Blood Flow by M. Zamir; 2005 Springer; ISBN 0-387-26019-6
European Heart Journal - http://eurheartj.oxfordjournals.org/content/vol26/issue14/cover.dtl
Medline Plus Medical Encyclopedia
- http://www.nlm.nih.gov/medlineplus/ency/article/003795.htm
- http://www.nlm.nih.gov/medlineplus/ency/article/003327.htm
Medic Zone - http://www.mediczone.co.za/index.php?
Chest X-ray - http://www.geocities.com/balachandiran_xray/home.htm
Methodist Hospital System - http://www.methodisthealth.com/tmhs/mdhvc.do?channelId=-92272&contentId=235402&contentType=SERVICE_CONTENT_TYPE
National Library of Medicine - http://www.nlm.nih.gov/cgi/mesh/2009/MB_cgi?mode=&term=SPECT
Merck Manuals Online Medical Library - http://www.merck.com/mmpe/sec07/ch070/ch070i.html
Animation on Capillary Pressure : Nursing Review – http://www.youtube.com/watch?v=aq1pDMzYXOI
Mayo Clinic - http://www.mayoclinic.com/health/medical/IM02106
Experimental & Clinical Research Central Berlin –
http://www.fvk-berlin.de/kfo192/index.php?id=29

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Heart Failure

by ionsis on Sep 14, 2009

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Heart Failure — Presentation Transcript