Heart failure is a clinical syndrome defined as the heart's inability to maintain adequate output to meet the body's metabolic demands, affecting 1-2% of the population and causing significant hospital admissions, especially in those over 65. It can be categorized into various types such as acute vs. chronic, left sided vs. right sided, and systolic vs. diastolic heart failure, with common causes including ischemic heart disease and dilated cardiomyopathy. Treatment involves addressing reversible causes, pharmacological options like diuretics and ACE inhibitors, as well as non-pharmacological interventions and potential surgical options.

1. Heart Failure
Mohammad Shafiq, MD, FESC, FSCAI
Associate professor of cardiology
Defenition
• Heart failure is a clinical syndrome not an investigation disease.
• Clinically defined as the inability of the heart at the normal filling
pressures to maintain an output adequate to meet the metabolic
demands of the body.

2. Pathophysiology
• Nearly all compensatory mechanisms are harmful:
COP = SV x HR
- Heart dilatation (Cardiomegaly)
-Renin angiotensin system actication (↑ Na retension)
-Increased HR (Sympathetic actication)
Epidemiology:
• 1-2% of the general population
• U S A : 20% of hospital admissions among persons > 65
• 45% annual mortality in severe symptomatic heart failure
• More dollars are spent for diagnosis and treatment of heart
failure than for any other single diagnosis.
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3. Aetiology:
1. Dilated Cardiomyopathy (about 50% of cases are familial)
2. Hypertrophic Cardiomyopathy (1:500)
3. Restrictive Cardiomyopathy (myocardial infiltrating diseases)
4. Arrhythmogenic Right Ventricular Cardiomyopathy
5. Unclassifiable Cardiomyopathies
6. Specific (Terminal fate) Cardiomyopathies (ischemic, hypertensive, valvular
obstruction/insufficiency, myocarditis).
7. Metabolic (thyrotoxicosis, hypothyroidism, pheochromocytoma)
8. General system disease (alcohol, anthracyclines, radiation, SLE, PAN, scleroderma,
sarcoidosis, muscular dystrophies, peripartum cardiomyopathy, etc.)
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4. The most common causes of CHF
• Ischemic heart disease ~ 40 % .
• Dilated cardiomyopathy ~ 30 % .
• Primary valvular heart disease ~ 15 % .
• Hypertensive heart disease ~ 10 % .
• Other ~ 5 %.
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5. 5

6. Classifications of HF
1) Acute or chronic HF:
Acute: acutely symptomatic patient with dyspnea/hypotension
mand needs admission
chronic: ambulatory due to medical treatment.
Causes for acute HF decompensation:
1) Iatrogenic:
- non-compliance to treatment or Inappropriate reduction of ttt.
- Admministration of cardiac depressants (e.g. alcohol) or durgs causing salt
& water retension (NSAIDs)
- Exceess salt in diet.
2) Acute valvular lesion (infective endocarditis).
3) C hest infection .
4) Myocardial ischemia (ACS, MI, its complications).
5) Arrhythmias : Tachy arrhythmias ( A F ) .

7. 6) Physical, emotional, environmental stress.
2) Left Sided Heart Failure, Right Sided Heart Failure:
according to which circulation affected more: forward failure in
both ---> Low CO symptoms :
- Cerebral: Confusion , headache.
- Heart: Angina.
- Kidney: Oliguria and renal failure.
- Skletal muscles: Fatigue and muscle wasting.
- Skin: Pallor, peripheral cyanosis and cold extremities.

8. Backward:
If Left Sided Heart Failure shows Pulmonary congestion
symptoms:
- Dyspnea.
- Orthopnea
- Paroxysmal nocturnal dyspnea (PND)
- Cough (dry, excertional)
- Acute pulmonary edema.
Right Sided Heart Failure shows Systemic venous congestion
symptoms:
- Dull aching pain in right hypochondrium: due to hepatic
congestion.
- Anorexia, Nausea ,Vomiting: due to gastric wall congestion. -
Abdominal distension: due to ascites.

9. - Bilateral lower Limb swelling (edema) : due to subcutaneous
edema.
NB: left & right side HF almost coexcist and left
sided can be complicated with right side heart
failure by time.

10. 3) Systolic or diastolic HF: not all cases has weak myocardium
Ejection fraction: % of ejected blood from LV cavity (Normally
>50%)
According to contractility (Ejection fraction: assessed by
Echocardiography) of the left ventricle. It is either:
• Systolic HF if the EF% is < 40% also called Heart Failure with
reduced EF, HFrEF).
• Diastolic heart failure or heart failure with preserved EF
if EF% is > 50% (HFpEF) .
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11. New York heart association classification
(NYHA) for dyspnea
• Class 1:
• Class II:
Dyspnea on more than ordinary effort.
Dyspnea on ordinary effort.
• Class III:
• Class 1V:
asthma.
Dyspnea on less than ordinary effort.
Dyspnea at rest including orthopnea, PND, cardiac
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12. 15

13. • Chest X-Ray: Cardiomegaly (Heart shadow >50% of
chest width) & pulmonary congestion.

14. • Echocardiography: Gold standard for diagnosis,
detect cause and degree of Left Ventricular systolic
fucntion (Ejection Fraction %, EF%).
https://youtube.com/clip/UgkxP7lJQk48jTelNlSD0M2dX
d0ChEdR7I3K?si=Z9-frkdQ7TDDRpqL

15. • Cardiac catheterization:
left heart catheter for coronary angiography to detect
Coronary Artery Disease (CAD) or right heart catheter to
take myocardial biopsy.
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16. Laboratory work up
• Electrolytes: Na, K, Ca, Mg
• Kidney functions: urea, creatinin and creatinin clearence
• CBC to exclude anemia
• For specific causes: eg: serum Iron and ferritin if suspected
haemochrmatosis or abdominal fat biopsy if suspected
cardiac amyloidosis
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17. Treatment of heart failure
1) General measures:
• Treatment of reversible causes (e.g. IHD or arrhytmias) & avoid preciptating factors
(e.g. chest infection and anemia)
• Salt restriction ( < 5 g/day) & bed rest.
• Oxygen therapy for acutely distressed patient.
2) Pharmacological ttt:
• Symptomatic ttt by Diuretics : Loop diuretics e.g: Furosemide (Lasix) or thiazide
diuretics e.g: Hydrochlorothaizides.
• Disease Modifying drugs:
1- Mineralocorticoids antagonists (MRAs) e.g: Spironolactone
2- Beta blockers (BB, e.g:bisoprolol)
3- Angiotensin Converting Enzyme (ACE) Inhibitors e.g: enalapril or Angiotensin

18. Receptor Blockers (ARBs) e.g: Valsartan.
• Other drugs: Ivabradine or Digoxin.
• Positive inotropic support for shocked patient : Dopamine , dobutamine or
norepinephrine.
3) Non-Pharmachological ttt:
• Mechanical ventilation for acute respiartory distress or acute pulmonary edema.
• Ultrafilteration by dialysis to releive volume overload in resistant cases.
• Device therapy by:
1- CRT (cardiac resynchronzation therapy if QRS complex in ECG is > 150msec) correct
delay between lateral wall and septum

19. 2- ICD (Implantable cardiovertor defibrillator) to give automatic DC
shock to restore contractions after cardiac arrest due to ventricular
arrhythmia
• Surgical ttt : by Heart or heart-lung transplantation.
Thanks for your attention
and good luck