2. DEFNITION
• 2013 ACC/ AHA DEFNITION-
– 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) ”
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 .
4. CLASSIFICATION BASED ON EJECTION
FRACTION
• Heart Failure with reserved Ejection Fraction
HFrEF – Ejection fraction ≤ 40% .
– These patients will have systolic dysfunction and
concomitant diastolic dysfunction. Coronary artery
disease is the major cause.
• Heart Failure with Preserved Ejection Fraction
HFpEF – Ejection Fraction 40 – 50%.
– These patients can be diagnosed by 1)clinical signs
and symptoms and 2)evidence of pEF or normal EF or
previously rEF 3)evidence of abnormal LV diastolic
dysfunction (echo / LV catheterisation)
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.
– Usually right sided failure occurs followed by left sided
failure with presence of shortened circulatory time.
• 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.
8. FORWARD AND BACKWARD HEART
FAILURE
• FORWARD HEART FAILURE-
– This results from inadequate discharge of blood
into arterial system leading to poor tissue
perfusion and excess Na+ reabsorption through
RAAS.
• 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. ACCF/AHA FUNCTIONAL
CLASSIFICATION
• Stage A – At high risk of HF but witout
structural hear disease.
• Stage B – Structural heart disease without
signs or symptoms of HF.
• Stage C – Structural heart disease with prior
HF or current HF.
• Stage D – Refractory HF requiring special
interventions.
10. NYHA FUNCTIONAL CLASSIFICATION
• Stage 1 – no limitation of ordinary physical
activity.
• Stage 2 – slight limitation of ordinary physical
activity.
• Stage 3 – marked limitation of ordinary
physical activity, but comfortable at rest.
• Stage 4 – unable to carry out physical activity,
symptomatic at rest.
11. RISK FACTORS
• Epidemiology –
– Worldwide 2 crore people are affected by heart
failure. Approximate 2 % prevalence in developed
countries. Women have better survival than men.
– Coronary artery disease is the major cause for
heart failure. (60 – 75%)
• Etiology and Risk Factors –
– Any condition that leads to alteration of LV
structure and function can lead to heart failure
14. Etiologies of Heart Failure
• High output states
– Thyrotoxicosis
– Nutritional – Beriberi
– Anemia
15. LV Remodeling
• DEFNITION – It refers to change in LV Mass ,
Volume or Shape or the Composition of the heart
after Cardiac injury or index event.
• Progress of HF associated with changes in
geometry of remodeled LV
• Changes that occur include –
– LV dilatation
– LV thinning
– Increase in LV end diastolic volume
– Decrease in stroke volume
16. LV Remodeling
– Subendocardial hypoperfusion
– Increased oxidative stress and free radical
generation
– Stress activated hypertrophic signaling pathways
– Incompitence of mitral valve apparatus and
functional MR
17. CLINICAL FEATURES
• Important symptoms –
– Fatigue
– Exertional Breathlessness
• Cause of breathlessness is multifactorial
– Pulmonary congestion due to LVF
– Accumulation of interstitial and intra alveolar fluid
, stimulating juxta capillary J receptors, causing
Rapid Shallow breathing
– Decreased pulmonary compliance
– Increased airway resistance
– Respiratory fatigue and Anemia
18. CLINICAL FEATURES
• Orthopnea –
– Dyspnea in recumbent position
– Occurs due to redistribution of fluid from
splanchnic circulation and lower extremities
– Causes increase in pulmonary capillary pressure.
– Nocturnal cough is usually asociated with this
symptom
– Relieved by sitting upright .
– This symtom is more common in patients with co
morbid obesity or ascites
19. CLINICAL FEATURES
• Paroxysmal Nocturnal Dyspnea-
– Defnition – it refers to acute episode of shortness of
breath and coughing that generally occur at night and
awken patient from sleep usually 1 – 3 hours after
recline.
– Associated with coughing or wheeze
– Mechanism – increased pressure in bronchial arteries
leading to airway compression (+) interstitial
pulmonary edema = increased airway resistance.
– Orthopnea symptoms resolve after upright posture,
but symptoms of PND persist even after upright
posture.
20. CLINICAL FEATURES
• Cheyne stokes respiration
– Also called periodic / cyclic respiration
– It is present in nearly 40 % cases of HF
– It is caused by decreased sensitivity of
RESPIRATORY CENTRE to PaCO2.
– Due to transient fall in PaO2 , rise in PaCO2 there
is an apneustic phase. PaCO2 rises steadily till it
stimulates depressed respiratory centre and
causes hyperventilation and hypocapnia (low
PaCO2).
21. CLINICAL FEATURES
• Other symptoms like
– Anorexia
– Nausea
– Early satiety
– Abdominal pain
– Abdominal fullness
– Congestive hepatomegaly
– Confusion , disorientation, sleep disturbances,
– Nocturia
22. 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.
23. PHYSICAL EXAMINATION
• Jugular venous pressure –
– Indicates right atrial pressure
– It is measured in terms of (cm of H2O)
– Normal < 8 cm of H2O
– Method – measure highest point of JVP vertically
from sternal angle and add 5 cm of H2O
– Positive Abdomino- Jugular reflex
24. 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)
25. PHYSICAL EXAMINATION
• Cardiovascular system
– Apical impulse may shift inferiorly / laterally.
– Sustained apical impulse is felt in severe LVH.
– S3 gallop (protodiastolic gallop) can be heard.
– Left parasternal impulse in cases if severe RVH
– S4 gallop is usually present in diastolic dysfunction.
– MR or TR may be present additionally.
26. PHYSICAL EXAMINATION
• Per abdomen
– Hepatomegaly is present (tender / pulsatile)
– Pulsations in liver indicate tricuspid regurgitation
– 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
27. Other Important Comorbidities in HF
• Atrial Fibrillation
• Anemia
• Depression
• Others
– Diabetes
– Arthritis
– CKD
– COPD
