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HEART FAILURE SYMPTOMS AND DIAGNOSIS
- 2. Table of content Physiology of heart and defenition of HF 03 Classification of HF Etiology, risk factor, patohysiology of HF Diagnosis and Clinical Manifestation
- 3. Table of content Treatment of HF 07 Diffrential diagnosis of HF Defenition, etiology, pathophysiology RHD Diagnosis for RHD
- 4. Table of content Treatment of CHD 11 Complication, prognosis of RHD Education
- 5. Physiology of heart and defenition of HF 01
- 6. ANATOMY - Mediastinum Mediastinum is central, midline thoracic cavity, which is surrounded anteriorly by sternum, posteriorly by 12 thoracic vertebrae & laterally by pleural cavity. Mediastinum is divided into superior mediastinum & inferior mediastinum. • Superior mediastinum • Above the plane of sternal angle (above 2 nd rib) • Contains superior vena cava, aortic arch & its branches, trachea, oesophagus, thoracic duct, vagus and phrenic nerve. • Inferior mediastinum • Below the plane of sternal angle • Further divided into 3 parts - anterior, middle & posterior mediastinum. • Anterior mediastinum is anterior to the heart • Middle mediastinum contains the heart and great vessels • Posterior mediastinum contains everything that is below the posterior margin of heart i.e. thoracic aorta
- 7. INTERNAL STRUCTURES Image Courtesy - Sylvia S. Mader, Inquiry into Life, 8 th Edition
- 8. EXTERNAL STRUCTURES Image Courtesy: www.droualb.faculty.mjc.edu
- 9. CARDIAC TERRITORIES FRONTAL VIEW • Right border is formed by right atrium. • Laterally to right atrium on left side is right ventricle (covers most of the anterior surface of heart) • Left border - Mainly formed by left ventricle • Posterior border is where most part of left atrium is located. • The apex of heart is formed by left ventricle Image courtesy - University of Auckland
- 10. CONDUCTION PATHWAY • Speed of conduction - Purkinje > Atria > Ventricles > AV node • Pacemakers rhythm generation - SA (60- 100/min) > AV (40- 60/min) > bundle of His/Purkinje (20-40/min). • Pacemaker - Uses calcium to generate action potential. Atrial and ventricular muscle depolarization is sodium dependent Image courtesy : Hole’s human anatomy and physiology , 7 th edition by Shier
- 11. CORONARY ARTERIES • The left coronary artery is further divided into left circumflex artery and left anterior descending artery aka anterior interventricular branch • The right coronary artery is further divided into marginal arteries, nodal arteries & posterior interventricular branch.
- 12. CONCEPTS OF PRELOAD, EJECTION FRACTION & CARDIAC OUTPUT PRELOAD • Preload is the load on ventricular muscles at the end of diastole. It is determined mainly by left ventricular end diastolic volume & left ventricular end diastolic pressure, in other words - by venous return. • Increase in preload results in increase in contractility that in turn increases stroke volume & thus increase in ejection fraction • Chronic increase in preload is responsible for dilated cardiomyopathy
- 13. CONCEPTS OF PRELOAD, EJECTION FRACTION & CARDIAC OUTPUT STROKE VOLUME • Stroke volume is the amount of blood that heart pump out with each beat. It is affected by contractility, afterload & preload • SV = EDV (End Diastolic Volume) – ESV (End Systolic Volume) EJECTION FRACTION • Is the fraction of blood that heart pump out during 1 contraction which is usually 60- 70% in healthy normal adult • Ejection Fraction = Stroke volume/End diastolic volume; therefore, EF = EDV – ESV/EDV CARDIAC OUTPUT • Is the amount of blood that heart pump out during 1 minute • Cardiac output is calculated as: CO = Heart rate * Stroke volume.
- 14. CONCEPTS OF PRELOAD, EJECTION FRACTION & CARDIAC OUTPUT AFTERLOAD • Afterload is the pressure against which heart will work. It is determined by peripheral arterial resistance • Chronic increase in afterload (e.g. hypertension, increasing age) will lead to left ventricular hypertrophy • Peripheral resistance is calculated as - Blood flow = Pressure / Resistance (Q=P/R), therefore R = P/Q
- 15. CONCEPTS OF VELOCITY, AREA, RESISTANCE AND FLOW
- 16. HEART FAILURE
- 17. Defenition
- 19. HEART FAILURE Basically classified into 3 types • Left Heart Failure • Systolic Heart Failure (SHF) • Diastolic Heart Failure (DHF) • Right Heart Failure • Due to increase in resistance to blood flow out of the right ventricle. • High Output Heart Failure • Failure of heart due to persistent high cardiac output (high stroke volume)
- 20. Etiology, risk factor, patohysiology of HF 03
- 21. Etiology
- 22. LEFT HEART FAILURE Systolic Heart Failure (SHF) • Etiology • Ischemic heart disease (most common) • Chronic hypertension • Dilated cardiomyopathy • Viral myocarditis • Idiopathic myopathies in younger patients • Peripartum cardiomyopathy Diastolic Heart Failure (DHF) • Etiology • Hypertension with left ventricular hypertrophy (most common) • Hypertrophic cardiomyopathy • Restrictive cardiomyopathy (amyloidosis, sarcoidosis, • hemochromatosis)
- 23. RIGHT HEART FAILURE Due to increase in resistance to blood flow out of the right ventricle. Etiology • Left heart failure (is most common cause). • Idiopathic pulmonary hypertension (BMPR2 mutation leading to pulmonary vasoconstriction) • Pulmonary stenosis or embolization (give thrombolytic to break embolus in hemodynamically unstable patient) • Right ventricular infarction (clear lungs, hypotension, JVD elevation) • Restrictive cardiomyopathy, Tricuspid or Pulmonary regurgitation
- 24. HIGH OUTPUT HEART FAILURE Failure of heart due to persistent high cardiac output (high stroke volume) Etiology • Hyperthyroidism • Severe anemia • Thiamine deficiency (wet beri beri) • Septic shock • Arteriovenous fistula (trauma, shunt, Paget disease of bone) • Obesity
- 25. Risk Factor
- 26. What raises my risk for heart failure? • Aging can weaken and stiffen your heart. People 65 years or older have a higher risk of heart failure. Older adults are also more likely to have other health conditions that cause heart failure. • Family history of heart failure makes your risk of heart failure higher. Genetics may also play a role. Certain changes, or mutations, to genes can make your heart tissue weaker or less flexible. • Unhealthy lifestyle habits, such as an unhealthy diet, smoking, using cocaine or other illegal drugs, heavy alcohol use, and lack of physical activity, increase your risk of heart failure.
- 27. What raises my risk for heart failure? • Heart or blood vessel conditions, serious lung disease, or infections such as HIV or SARS-CoV-2 raise your risk. This is also true for long-term health conditions such as obesity, high blood pressure, diabetes, sleep apnea, chronic kidney disease, anemia, thyroid disease, or iron overload. • Black and African American people are more likely to have heart failure than people of other races, often have more serious cases of heart failure and experience heart failure at a younger age
- 28. pathopysiology
- 29. Pathopysiology
- 32. Diagnosis HF
- 33. LEFT HEART FAILURE Symptoms • Poor exercise tolerance, easy fatigability • Jugulovenous distension, Peripheral swelling (ankle) • Inspiratory rales, Shortness of breath, Dyspnea - because fluid in interstitium prevents expansion of lung. edema can narrow the airways, which produces wheezes during expiration; this phenomenon is called as Cardiac Asthma. • Paroxysmal Nocturnal Dyspnea – Difficulty in breathing on laying down due to increase in venous return. Usually patient complains of using 2-3 pillows for sleeping. Standing up relieves symptoms. • Confusion
- 34. LEFT HEART FAILURE Findings • Cardiomegaly, Jugular venous distension, S3 in SHF (rapid filling of ventricles), S4 in DHF (atrial contract against stiffened ventricles). • Congested lungs, Pulmonary edema (transudate fluid due to increase in pulmonary capillary hydrostatic pressure). • If pulmonary capillary rupture then heart failure cells in alveoli (alveolar macrophage containing hemosiderin)
- 35. New York Heart Association functional classification based on severity of symptoms and physical activity
- 36. INVESTIGATIONS • BNP level – Use in emergent situation when you are not clear about CHF. • BNP level – Use in emergent situation when you are not clear about CHF. • High level cannot differentiate SHF versus DHF and so do transthoracic echocardiography • If the BNP levels remain high after treatment – sign of bad prognosis. • If BNP is < 100 pg/mL – Heart failure is highly unlikely. • If BNP is 100-500 pg/mL - Results are uncertain but suspicious • If BNP is > 500 pg/ml - Heart failure is highly likely.
- 37. INVESTIGATIONS • On X-Ray: Cardiomegaly, Kerley B lines (septal edema), pulmonary vasculature congestion, air bronchogram • On ECG - Left ventricular hypertrophy (S wave in V1 + R in V5 or V6 > 35 mm, > 7 large squares). • ECG might show ischemic heart disease, arrhythmias and ventricular hypertrophy.
- 38. RIGHT HEART FAILURE PHYSICAL FINDINGS • Jugulovenous distension, Peripheral edema (in ankle) • Tricuspid valve regurgitation +/-, S3-S4 sound on right side • No crackles (if RHF is not due to LHF) • Hepatosplenomegaly (zone 3 – central zone is affected most, ascites) • Cyanosis due to decrease in oxygen saturation
- 39. HIGH OUTPUT HEART FAILURE SIGNS AND SYMPTOMS • Breathlessness at rest or on exertion • Exercise intolerance • Fatigue • The signs of typical heart failure may be present including tachycardia, tachypnea, raised jugular venous pressure, pulmonary rales, pleural effusion and peripheral edema • In high output heart failure, patients are likely to have warm rather than cold peripheries due to low systemic vascular resistance and peripheral vasodilatation.
- 42. Diagnosis RHD
- 48. LAB. FINDINGS • Positive throat culture for group a beta hemolitic streptococci • Elevated acute pahse reactants • Erythrocyte sedimentation rate • C- reactive protein • Leukocytosis • Prolong P-R interval
- 49. IMAGING
- 50. Laki-laki usia 61 tahun datang ke poli dengan Riwayat DM lama. Minum glibenclamid fan metformin. Tidak ada obat lain. Sudah seminggu ini sesak napas saat aktifitas sehari- hari. Tidur harus setengah duduk 3 hari ini. Kaki pernah bengkak. Diberi furosemide dan berkurang. Ronki minimal di basal. Td 100/60
- 54. Classification • Positive throat culture for group a beta hemolitic streptococci • Elevated acute pahse reactants • Erythrocyte sedimentation rate • C- reactive protein • Leukocytosis • Prolong P-R interval
- 57. Recommen dations (Class 1 and 2a) for Patients at Risk of HF
- 58. Stage c and d
- 60. Drugs Commonly Used for HFrEF (Stage C HF)
- 61. Drugs Commonly Used for HFrEF (Stage C HF)
- 62. Recommendations for Patients With Mildly Reduced LVEF (41%– 49%)
- 63. Recommendations for Patients With Preserved LVEF (≥50%).
- 64. RHD
- 65. Progression of rheumatic heart disease (RHD)
- 67. • Low-grade fever does not require specific treatment • Fever alone, or fever with mild arthralgia or arthritis, may not require NSAIDs but can instead be treated with paracetamol
- 68. • Salicylates (aspirin) have traditionally been recommended as first-line treatment
- 69. Laki-laki usia 61 tahun datang ke poli dengan Riwayat DM lama. Minum glibenclamid fan metformin. Tidak ada obat lain. Sudah seminggu ini sesak napas saat aktifitas sehari- hari. Tidur harus setengah duduk 3 hari ini. Kaki pernah bengkak. Diberi furosemide dan berkurang. Ronki minimal di basal. Td 100/60
- 70. RAWAT JALAN • Furosemide 1x 20mg • Spironolakton 1 x 25mg • Ramipril 1x 1,25 mg • Ivabradine 2x 2.5mg • Digoxin 1x1/2 tab • Glimepiride 1x 2mg • Atrovastatin
- 72. Heart failure should be distinguished from other conditions that cause dyspnea, fatigue and edema
- 73. Classification Cardiac Pulmonary High output status
- 74. • HFpEF (Heart Failure with preserved Ejection Fraction • HFrEF (Heart Failure with reduced Ejection Fraction) • Pericardial disease • Arrhythmia
- 77. • Chronic airway disease • Pulmonary hypertension
- 81. THANK YOU!
- 82. References
- 83. References