Describes heart failure, types ,manifestations and management

1. Heart Failure

2. • Heart Failure is defined as “ a complex clinical
syndrome that results from any structural or
functional impairment of ventricular
filling(diastole) or ejection of blood. (systole)
”It is the pathophysiological process in which the heart as a
pump is unable to meet the metabolic requirements of the tissue
for oxygen and substrates despite the venous return to heart is
either normal or increased.

3. CLASSIFICATION BY DEFNITION
• SYSTOLIC HEART FAILURE
– Characterized by reduced ejection fraction and
enlarged ventricle size. Clinically present with left
ventricular failure and marked cardiomegaly.
• DIASTOLIC HEART FAILURE
– Characterized by increased resistance to filling due
to increased filling pressures. Clinically present
with pulmonary congestion with normal or slightly
enlarged ventricles .

5. CLASSIFICATION BASED ON
CARDIAC OUTPUT
• HIGH OUTPUT FAILURE-
– The normal heart fails to maintain normal or
increased output in conditions like anemia,
hyperthyroidism, pregnancy.
• LOW OUTPUT FAILURE-
– Heart fails to generate adequate output in conditions
like cardiomyopathy, valvular heart disease, tamponade
and bradycardia.

6. RIGHT AND LEFT SIDED HEART FAILURE
• Right sided heart failure is characterised by the
presence of peripheral edema, raised JVP and
hypotension and congestive hepatomegaly.
• Left sided heart failure – pulmonary edema is the
striking feature. Other signs are tachypnea,
tachycardia, third heart sound, pulsus alternans,
cardiomegaly.
• Congestive Cardiac Failure – Characterised by
combination of both left and right sided heart
failure.

7. FORWARD AND BACKWARD HEART
FAILURE
• FORWARD HEART FAILURE-
– This results from inadequate discharge of blood
into arterial system leading to poor tissue
perfusion
• BACKWARD HEART FAILURE-
– This results from failure of one or both ventricles
to fill normally and discharge its contents, causing
back pressure on the atria and venous system.

9. Risk factors
• Primary risk factors
– Coronary artery disease (CAD)
– Advancing age
• Contributing risk factors
– Hypertension
– Diabetes
– Tobacco use
– Obesity
– High serum cholesterol
– African American descent
– Valvular heart disease
– Hypervolemia

10. Causes
1. Impaired cardiac function
• Coronary heart disease
• Cardiomyopathies
• Rheumatic fever
• Endocarditis
2. Increased cardiac workload
• Hypertension
• Valvular disorders
• Anemias
• Congenital heart defects
3. Acute non-cardiac conditions
• Volume overload
• Hyperthyroid, Fever,infection

15. Increased demand for oxygen/ Decreased supply
Failure of cardiac reserve
Activation of compensatory
mechanism
Ventricular Dilation Increased
Sympathetic
stimulation
Activation of RAAS
Over stretching of
Muscles and Hypoxia
Arteriolar constriction
Looses
contractility
Increased after load and
myocardial contractility
Increased preload and
after load
Worsening of cardiac
function - Heart Failure
Retention of Fluid

16. PHYSICAL
EXAMINATION• Patient will present with laboured breathing in
an acute LVF. He/she may not be able to
finish the sentence due to shortness of
breath. He / she may have difficulty to talk
due to shortness of breath.
• Blood pressure may be normal or high in
early HF may decrease consequently and is
usually low.
• Low pulse pressure (reduced stroke volume)
• Sinus tachycardia (increased sympathetic
activity) cool peripheries, cyanosis of tips of
fingers and nail bed.

17. PHYSICAL
EXAMINATION
• Jugular venous pressure –
– Indicates right atrial pressure
– It is measured in terms of (cm of H2O)
– Normal < 8 cm of H2O

18. PHYSICAL
EXAMINATION
• Respiratory system
– Bilateral rales/crepitations may be present
as a result of transudate of fluid from
intravascular space to intraalveolar space.
– May be accompanied by expiratory
wheeze (cardiac asthma).
– Pleural effusion may/may not be
present. (common in CCF)

19. PHYSICAL
EXAMINATION
• Cardiovascular system
– Apical impulse may shift inferiorly / laterally.
– S3 gallop can be heard.
– S4 gallop is usually present in diastolic
dysfunction.
– MR or TR may be present additionally.

20. PHYSICAL
EXAMINATION• Per abdomen
– Hepatomegaly is present (tender / pulsatile)
– Ascites , Jaundice , raised liver enzymes
– Peripheral edema can be pre tibial or pre
sacral edema
• Cardiac cachexia
– Cause for cachexia is multifactorial
• Elevation of BMR
• Elevated circulating cytokines like TNF
• Congestion of intestinal veins

21. Medical Management
Objectives of management
1. Reduce preload and after
load
2. Reduce symptoms
3. Stabilization of patient
condition
4. Delay the progression of HF

22. Pharmacological Therapy
•ACE Inhibitors: Decreases
afterload and BP
•Angiotensin receptors blockers:
Decreases afterload and BP
•Hydralazine and isosorbide
dinitrate: Dilates blood vessels,
Decreases afterload and BP
•Beta Blockers: Dilates blood
vessels, Decreases afterload and BP
•Diuretics: Decreases fluid overload

23. Surgical management of Heart
Failure

24. Cardiac Resynchronization
therapy
Use of Biventricular
pace maker to treat
electrical conduction
defects

25. Ultrafiltration
Used for patients with fluid over load , advanced HF, resistant to Diuretics

26. Ventricular assist devices
Ventricular assist device (VAD) is a mechanical
pump that's used to support heart function and
blood flow in people who have weakened hearts.
The device takes blood from a lower chamber of
the heart and helps pump it to the body and vital
organs, just as a healthy heart would.

28. IABP
The Intra-aortic balloon pump
(IABP) is a mechanical device that
increases myocardial oxygen perfusion
while at the same time increasing
cardiac output.
It consists of a cylindrical polyethylene
balloon that sits in the aorta,
approximately 2 centimeters from the
left subclavian artery

29. It actively deflates in systole,
increasing forward blood flow by
reducing afterload. It actively inflates in
diastole, increasing blood flow to the
coronary arteries. These actions
combine to decrease myocardial oxygen
demand and increase myocardial
oxygen supply.

32. External counterpulsation
ECP increases coronary perfusion
pressure and blood flow, thereby
reducing heart workload and
improving cardiac output. It is
absolutely painless, safe treatment,
which requires no hospitalisation.

33. Procedure
The patient has to lie down on a padded
table
Three sets of rubber cuffs more than four
inches wide, are tied around three points of
the body- thighs, legs and hips.
These connect to air hoses, which in turn
are connected to valves of the machine.

35. Cont…
When the heart contracts the cuffs are
deflated and when it relaxes the cuffs are
inflated with a predetermined amount of
pressure, which pushes the blood from the
lower extremities in a timed and sequential
manner, towards the heart.
Duration of the Treatment
patient has to undergo the procedure
several times, usually 35 days of treatment,
six days a week for six weeks.

36. Heart Transplantation
Heart transplantation is the
procedure by which the failing heart
is replaced with another heart from
a suitable donor.

37. Procedure : Orthotopic
•General anesthesia is given
•Patient is kept on Cardio pulmonary bypass
machine
•Recipient's heart is removed except the posterior
right and left atrial wall and their venous
connection
•Recipient’s heart is then replaced with doner’s
heart

39. Heterotopic

40. Artificial Heart

41. Cardiomyoplasty
Cardiomyoplasty is a surgical procedure in
which healthy muscle from another part of the
body is wrapped around the heart to provide
support for the failing heart.
Most often the latissimus dorsi muscle is used
for this purpose. A special pacemaker is
implanted to make the skeletal muscle contract.