Heart failure

1. HEART FAILURE

2. What is Heart Failure?
 The clinical syndrome where the cardiac is not sufficient
enough to fulfill the body’s requirement.
 Even if it does, it is at the expense of elevated ventricular
filling pressure.

3. Systolic versus diastolic heart failure
Systolic failure: Inability of the ventricles to contract that results
in decreased cardiac oitput. Ejection fraction is less than 40
percent.
 Causes: IHD, MI, Cardiomyopathy
Diastolic failure: Inability of the ventricles to relax and fill
normally causing filling pressures. Ejection fraction more than 50
percent.
 Causes: constrictive pericarditis, cardiac tamponade,
restrictive cardiomyopathy.

5. Left sided versus Right versus failure
 May occur independently or together. (Known as congestive
cardiac failure)
 Left ventricular failure symptoms: Patient looks restless,
agitated and has cold, clammy skin. Dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, nocturnal cough(pink frothy
sputum), wheeze, pulmonary edema
 Right ventricular failure symptoms: Pitting edema (From
thighs, sacrum, abdominal wall), ascites, hepatomegaly
 Raised JVP in both.

8. Other causes of heart failure:
 Ventricular outflow obstruction: HTN, Aortic stenosis,
Pulmonary HTN
 Ventricular inflow obstruction: Mitral stenosis,
Tricuspid stenosis
 Ventricular volume overload: Ventricular septal defect,
Mitral regurgitation, aortic regurgitation
 Arrythmias: Atrial fibrillation, Tachycardi

9. Conditions that aggravate or
precipitate heart failure
 MI
 Arrythmias
 Inappropriate reduction of drug
 Administration of a drug
 Pulmonary embolism

10. Complications
 Renal failure
 Hypokalemia
 Hyperkalemia
 Impaired liver function
 Arrythmias

11. Investigations:
 Chest Xray: May show abnormal distension of pulmonary
veins, vasculature of lung fields becomes more prominent.
Interstitial edema causes thickened interlobular septa
and dilated lymphatics. (Kerley B lines)
Pleural effusion can be observed in lungs.

13.  Echo: To rule out any valvular diseases.
 Urea, Creatinine and electrolytes
 Complete blood picture
 Brain Natriuretic peptide is elevated in heart disease. More than
500 pg/ml confirms HF with dyspnea
 ECG

15. Management
 Risk factor management
 Patient education
 Treatment: Non Pharmacological
 Treatment: Pharmacological
 When to refer?

16. Risk factor management
 Manage blood pressure or any other vascular
disease
 Manage diabetes

17. Patient education
 Very important for successful management
 Emphasis of being compliant as far as
medications are concerned

18. Non Pharmacological treatment
 Lifestyle modifications
 Encourage exercise
 Salt and fluid restriction

19. Pharmacological treatment
Diuretic:
 Loop diuretic: Furosemide 5-10 mg/hr
 Potassium sparing diuretic: Spironolactone or eplerenone
ACE Inhibitors:
 Enalapril 2.5 mg daily starting dose
ARBs:
 Losartan: 25mg daily dose

20. Neprilysin Inhibitors:
 Sacubitril. Can be used in combination with ARB Valsartan
Vasodilators:
 Venodilators such as nitrates
 Arteriodilators such as hydralazine
Betablockers:
 Bisoprolol 1.25 mg daily starting dose
Digoxin to provide rate control in patients with atrial fibrillation

21. Surgical intervention:
 Defibrillators in arrythmic patients
 Resynchronization devices in patients with
Coronary Artery Diseases
 Cardiac transplantation in patients with
cardiomyopathies
 Coronary revascularization in patients with
CAD