Basics of heart failure for rehab students internal medicine course

1. Congestive Heart Failure
Hanna Al-Makhamreh, MD FACC
Interventional cardiology

2. Heart Failure
 Results from any structural or
functional abnormality that impairs
the ability of the ventricle to eject
blood (Systolic Heart Failure) or
to fill with blood (Diastolic Heart
Failure).

3. The Vicious Cycle of Congestive Heart
Failure
Decreased Blood Pressure and
Decreased Renal perfusion
Stimulates the Release
of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure
LV Dysfunction causes
Decreased cardiac output

4. Types of Heart Failure
 Systolic Heart Failure:
 decreased cardiac output
 Decreased Left ventricular ejection fraction
 Diastolic Heart Failure:
 Elevated Left and Right ventricular end-diastolic
pressures
 May have normal LVEF
 .

5. Causes of Low-Output Heart Failure
 Systolic Dysfunction
 Coronary Artery Disease
 Idiopathic dilated cardiomyopathy (DCM)
 50% idiopathic (at least 25% familial)
 9 % mycoarditis (viral)
 peripartum, HIV, connective tissue disease,
substance abuse, doxorubicin
 Hypertension
 Valvular Heart Disease(MR,AR)
 Diastolic Dysfunction
 Hypertension
 Hypertrophic obstructive cardiomyopathy (HCM)
 Restrictive cardiomyopathy
 AS

6. Clinical Presentation of Heart Failure
 Due to excess fluid accumulation:
 Dyspnea (most sensitive symptom)
 Edema
 Hepatic congestion
 Ascites
 Orthopnea, Paroxysmal Nocturnal Dyspnea
(PND)
 Due to reduction in cardiac ouput:
 Fatigue
 Weakness

7. Physical Examination in Heart Failure
 S3 gallop
 Low sensitivity, but highly specific
 Cool, pale, cyanotic extremities
 Have sinus tachycardia, diaphoresis and peripheral
vasoconstriction
 Crackles or decreased breath sounds at bases
(effusions) on lung exam
 Elevated jugular venous pressure
 Lower extremity edema
 Ascites
 Hepatomegaly
 Splenomegaly
 Displaced PMI
 Apical impulse that is laterally displaced past the
midclavicular line is usually indicative of left ventricular
enlargement>

8. Lab Analysis in Heart Failure
 CBC
 Since anemia can exacerbate heart failure
 Serum electrolytes and creatinine
 before starting high dose diuretics
 Fasting Blood glucose
 To evaluate for possible diabetes mellitus
 Thyroid function tests
 Since thyrotoxicosis can result in A. Fib,
and hypothyroidism can results in HF.
 Iron studies
 To screen for hereditary hemochromatosis as cause of heart
failure.
 ANA
 To evaluate for possible lupus
 Viral studies
 If viral mycocarditis suspected

9. Laboratory Analysis (cont.)
 BNP
 With chronic heart failure, atrial mycotes
secrete increase amounts of atrial natriuretic
peptide (ANP) and brain natriuretic pepetide
(BNP) in response to high atrial and
ventricular filling pressures
 Usually is > 400 pg/mL in patients with
dyspnea due to heart failure.

10. Chest X-ray in Heart Failure
 Cardiomegaly
 Cephalization of the pulmonary
vessels
 Kerley B-lines
 Pleural effusions

11. Cardiomegaly

12. Pulmonary vessel congestion

13. Pulmonary Edema due to Heart Failure

14. Cardiac Testing in Heart Failure
 Electrocardiogram:
 May show specific cause of heart
failure:
 Ischemic heart disease
 Dilated cardiomyopathy: first degree AV
block, LBBB, Left anterior fascicular block
 Amyloidosis: pseudo-infarction pattern
 Idiopathic dilated cardiomyopathy: LVH
 Echocardiogram:
 Left ventricular ejection fraction
 Structural/valvular abnormalities

15. Further Cardiac Testing in Heart
Failure
 Coronary arteriography
 Should be performed in patients presenting with
heart failure who have angina or significant
ischemia
 Reasonable in patients who have chest pain that
may or may not be cardiac in origin, in whom
cardiac anatomy is not known, and in patients with
known or suspected coronary artery disease who do
not have angina.
 Measure cardiac output, degree of left ventricular
dysfunction, and left ventricular end-diastolic
pressure.

16. Classification of Heart Failure
 New York Heart Association (NYHA)
 Class I – symptoms of HF only at
levels that would limit normal
individuals.
 Class II – symptoms of HF with
ordinary exertion
 Class III – symptoms of HF on less
than ordinary exertion
 Class IV – symptoms of HF at rest

17. Classification of Heart Failure (cont.)
 ACC/AHA Guidelines
 Stage A – High risk of HF, without
structural heart disease or symptoms
 Stage B – Heart disease with
asymptomatic left ventricular
dysfunction
 Stage C – Prior or current symptoms
of HF
 Stage D – Advanced heart disease and
severely symptomatic or refractory HF

18. Chronic Treatment of Systolic Heart
Failure
 Correction of systemic factors
 Thyroid dysfunction
 Infections
 Uncontrolled diabetes
 Hypertension
 Lifestyle modification
 Lower salt intake
 Alcohol cessation
 Medication compliance
 Maximize medications
 Discontinue drugs that may contribute to heart
failure (NSAIDS, antiarrhythmics, calcium channel
blockers)

19. Order of Therapy
1. Loop diuretics
2. ACE inhibitor (or ARB if not
tolerated)
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs

20. Diuretics
 Loop diuretics
 Furosemide, buteminide
 For Fluid control, and to help relieve
symptoms
 Potassium-sparing diuretics
 Spironolactone, eplerenone
 Help enhance diuresis
 Maintain potassium
 Shown to improve survival in CHF

21. ACE Inhibitor
 Improve survival in patients with all
severities of heart failure.
 Begin therapy low and titrate up as
possible:
 Enalapril – 2.5 mg po BID
 Captopril – 6.25 mg po TID
 Lisinopril – 5 mg po QDaily
 If cannot tolerate, may try ARB

22. Beta Blocker therapy
 Certain Beta blockers (carvedilol,
metoprolol, bisoprolol) can improve
overall and event free survival in NYHA
class II to III HF, probably in class IV.
 Contraindicated:
 Heart rate <60 bpm
 Symptomatic bradycardia
 Signs of peripheral hypoperfusion
 COPD, asthma
 Heart block

23. Management of Refractory Heart
Failure
 Inotropic drugs:
 Dobutamine, dopamine, milrinone,
nitroprusside, nitroglycerin
 Mechanical circulatory support:
 Intraaortic balloon pump
 Left ventricular assist device (LVAD)
 Cardiac Transplantation
 A history of multiple hospitalizations for HF
 Escalation in the intensity of medical therapy
 A reproducable peak oxygen consumption with
maximal exercise (VO2max) of < 14 mL/kg
per min. (normal is 20 mL/kg per min. or more)
is relative indication, while a VO2max < 10
mL/kg per min is a stronger indication.