2 heart failure

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2 heart failure

  1. 1. INTERNAL MEDICINE<br />
  2. 2. Heart failure<br />Definition <br />‘Failure of the heart to maintain a cardiac output sufficient to meet the metabolic demands of the body’<br />Physiology Cardiac Output = Heart Rate X Stroke Volume - Latter is dependent on:<br />Preload = Left ventricular end diastolic volume i.e. amount of stretch of left ventricle = volume overload<br />Afterload = Total peripheral resistance = pressure overload <br />Contractility = Capacity of myocardium to 'respond to' preload and afterload<br />
  3. 3. Heart failure<br />A)Classification:New York Heart Association Functional Classification<br />Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.<br />Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.<br />Class III: marked limitation of any activity; the patient is comfortable only at rest.<br />Class IV: any physical activity brings on discomfort and symptoms occur at rest.<br />
  4. 4. Heart failure<br />B)Classification of heart failure:<br />1.Right heart failure<br />2.Left heart failure<br />3.Biventricular failure<br />C) Classification of heart failure:<br />1.Acute heart failure<br />2.Chronic heart failure<br />
  5. 5. Heart failure<br />D) Heart failure is often classified as either systolic or diastolic.<br />1.Systolic heart failure means,heart muscle cannot pump, or eject, the blood out of the heart very well.<br />2.Diastolic heart failure means, heart's pumping chamber does not fill up with blood.<br />
  6. 6. Heart failure<br />Causes:<br />Valve heart disease - approximately 10% of cases.Aorticstenosis can cause left ventricular hypertrophy due to chronic excessive afterload.<br />Aortic or mitral regurgitation, ASD, VSD and tricuspid incompetencecause excessive preload.<br />
  7. 7. Heart failure<br />Causes:<br />Heart failure secondary to myocardial disease:Coronary heart disease (myocardial infarction (MI) and ischaemia, arrhythmias, e.g. atrial fibrillation, heart block)<br />Hypertension (increased vascular resistance, often with left ventricular hypertrophy )<br />Cardiomyopathies<br />
  8. 8. Heart failure<br />Causes: Other’s <br />Drugs (e.g. beta-blockers, cytotoxics) <br />Toxins (e.g.alcohol) <br />Endocrine (diabetes)<br />
  9. 9. Heart failure<br />Causes: Other’s <br />Nutritional (e.g. deficiencies )<br />Infiltrative (e.g. connective tissue disease) <br />Infective (e.g. HIV)<br />
  10. 10. Heart failure<br />Causes: Other’s <br />Anaemia<br />Pregnancy<br />Arteriovenous malformations<br />
  11. 11. Heart failure<br />Local change in heart:<br />Chamber enlargement<br />Myocardial hypertrophy<br />Increased heart rate<br />
  12. 12. Heart failure<br />Clinical feature:<br />Dyspnoea and fatigue (may limit exercise tolerance).<br /> Fluid retention (may cause pulmonary or peripheral oedema). <br />Patients do not necessarily have both, and either may dominate at any one time. In addition, patients may be depressed or complain of drug-related side-effects.<br />
  13. 13. Heart failure<br />Clinical feature:<br />When the left ventricle is failing (LVF): dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea (PND), nocturnal cough or wheeze. <br />Right ventricular failure: (RVF) peripheral oedema (up to thighs, sacrum, abdominal wall), abdominal distension (ascites), nausea, anorexia, facial engorgement, pulsation in neck and face (tricuspid regurgitation), epistaxis.<br />
  14. 14. Heart failure<br />Clinical feature:<br />The patient may look ill and exhausted, with tachypnoea, cool peripheries, peripheral ± central cyanosis. <br />There may be a tachycardia at rest, low systolic BP, a displaced apex (LV dilatation) or RV heave (pulmonary hypertension)and a raised JVP.<br />
  15. 15. Heart failure<br />Clinical feature:<br />On auscultation there may be a gallop rhythm or murmurs of mitral or aortic valve disease; wheeze , pleural effusions, tender hepatomegaly – pulsatile in tricuspid regurgitation, with ascites and often extensive peripheral oedema.<br />The peak expiratory flow rate may be reduced but, if it is < 150 litres/min, suspect COPD or asthma.<br />
  16. 16. Right Heart Failure<br />Causes:<br />Secondary to LVF<br />LD-CB<br />VHD- MS<br />Congenital heart disease- ASD,VSD<br />Pulmonary embolism<br />Myocarditis<br />MI<br />
  17. 17. Left Heart Failure<br />Causes:<br />Pressure overload- systolic hypertension, aortic stenosis<br />Volume overload- mitral regurgitation, aortic regurgitation<br />Ventricular inflow obstruction- mitral stenosis<br />Reduced ventricular hypertrophy- MI, myocarditis<br />
  18. 18. RHF/LHF<br />Clinical feature of RHF and LHF:<br />See previous slide<br />
  19. 19. Right Heart Failure<br />Investigation: RHF<br />CXR P/A view<br />ECG<br />Echocardiography<br />
  20. 20. Left Heart Failure<br />Investigation:LHF<br />CBC<br />RFT<br />CXR P/A view<br />ECG<br />Cardiac enzymes<br />Echocardiography<br />Cardiac MRI<br />Angiogram <br />
  21. 21. Heart failure<br />Management of heart failure:<br />A)General management-<br />Diet<br />Restricted alcohol<br />Restricted smoking<br />Exercise <br />
  22. 22. Heart failure<br />Management of heart failure:<br />B)Drug management-<br />1.Diuretics- frusemide, potassium spirolactone<br />2.Vasodilators- ACE inhibitors<br />3.Inotropic agent- digoxin, dubutamines<br />
  23. 23. Heart failure<br />Management in acute case:LVF/PE<br />Bed rest in propped up position<br />O2 inhalation<br />Inj:morphine 10 mg iv<br />Frusemide 40-80 mg iv<br />Glyceryltrinitrate<br />Dubutamine 2.5-10 μg/kg/min<br />Aminophylline 250-500 mg infused over 10 mins<br />

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