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Congestive Cardiac Failure presentation and diagnosis
This document provides an overview of congestive heart failure (CHF), including its definition, causes, pathophysiology, clinical manifestations, diagnostic evaluation, and management. CHF is defined as a clinical syndrome where the heart cannot pump enough blood to meet the body's needs. It is most commonly caused by conditions that overload or damage the heart such as hypertension, heart attacks, and cardiomyopathy. Clinically, it presents with symptoms of fluid backup like dyspnea, edema, and fatigue. Diagnostic tests include chest x-rays, EKGs, blood tests like BNP, and echocardiography. Treatment focuses on managing symptoms, addressing the underlying cause, and preventing complications through medications, lifestyle changes, and potentially devices
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Congestive Cardiac Failure presentation and diagnosis
- 1. Nothing can happenunless you first dream Carl Sandburg
- 2. Congestive heart failure Presentation and Diagnosis The most common reason for hospitalization in adults >65 years old Dr Shahid Abbas Consultant Interventional Cardiologist
- 3. Road Map –Definition – Causes and pathophysiology – Types of heart failure – Compensatory mechanism of heart failure – Clinical manifestations – Classification of heart failure – Diagnostic evaluation – Management
- 4. Definition A clinicalsyndrome that develops when the heart cannot maintain an adequate cardiac output The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs Leading to Other changes that may further weaken the heart
- 5. 5 Etiology •A syndrome of Pulmonary and/ or Systemic congestion due to C.O • Heart is unable to pump enough blood to meet tissues O2 requirements Pulmonary pressure fluid in alveoli (PULMONARY EDEMA) Systemic pressure fluid in tissues (PERIPHERAL EDEMA)
- 6. 6 Etiology •Heart failure is caused by systemic hypertension in 75% of cases • About one third of clients experiencing myocardial infarction also develop heart failure • Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart
- 7. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases – Aortic Stenosis – Mitral Stenosis – Mitral Regurgitation
- 8. Causes of congestiveheart failure (cont…) • Severe lung disease (pulmonary hypertension) • Severe anemia • Overactive thyroid gland (hyperthyroidism) • Underactive thyroid gland (hypothyroidism) • Abnormal heart rhythms ( atrial fibrillation) • Kidney failure
- 9. Cardiac Physiology (rememberthis?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility
- 10. Preload • Passivestretch of muscle prior to contraction • Measurement: Swan-Ganz – LVEDP • Really a function of LVEDV • Affected by compliance – Low compliance = higher LVEDP @ lower LVEDV – False high estimate of preload • Frank-Starling right?
- 11. Afterload • Forceopposing/stretching muscle after contraction begins • Measurement: SVR • Really a function of: – SVR – Chamber radius (dilated cardiomyopathies) – Wall thickness (hypertrophy)
- 12. Contractility • Normalability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces • In other words: – How healthy is your heart muscle? • Ischemia, Hypertrophy (?), Muscle loss
- 13. CHF: the heartmuscle March 2013 ghennersdorf DGK ESC SES
- 14. CHF: the heartmuscle sarcomere March 2013 ghennersdorf DGK ESC SES
- 15. Pathophysiology Renin +Angiotensinogen Angiotensin I Angiotensin II Peripheral Vasoconstriction Afterload Cardiac Output Heart Failure Salt & Water Retention Plasma Volume Preload Cardiac Workload Edema Aldosterone Secretion Renin-angiotensin system
- 16. Heart Failure •Pathophysiology • A. Cardiac compensatory mechanisms – 1.tachycardia – 2.ventricular dilation-Starling’s law – 3.myocardial hypertrophy • Hypoxia leads to dec. contractility
- 17. Acute decompensated heartfailure Pulmonary edema, often life-threatening • Early –Increase in the respiratory rate –Decrease in PaO2 • Later –Tachypnea –Respiratory acidemia
- 18. Acute Decompensated HeartFailure (ADHF) Pulmonary Edema Pulmonary edema begins with an increased filtration through the loose junctions of the pulmonary capillaries. As the intracapillary pressure increases, normally impermeable (tight) junctions between the alveolar cells open, permitting alveolar flooding to occur.
- 19. END RESULT FLUIDOVERLOAD > Acute Decompensated Heart Failure (ADHF)/Pulmonary Edema Medical Emergency!
- 20. Person literally drowningin secretions Immediate Action Needed
- 21. MMildild Heart Failure (progression) Drugs Diet Fluid Restriction Cardiogenic shock Cardiomyopathy CDHF(Pulmonary Edema) Severe End Stage Irreversible Needs new ventricle VAD IABP VAD IABP Heart Transplant Control With Emergency-Upright, O2, morphine, etc
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- 24. Classifying Heart Failure • Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
- 25. Congestive heart failure Types • Left-sided heart failure There are two types of left-sided heart failure Systolic dysfunction Diastolic dysfunction • Right-sided heart failure
- 26. Left versus RightFailure Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - HJR / JVD - Hepatomegaly - Ascites
- 27. Systolic versus Diastolic Systolic– “can’t pump” – Aortic Stenosis – HTN – Aortic Insufficiency – Mitral Regurgitation – Muscle Loss • Ischemia • Fibrosis • Infiltration Diastolic- “can’t fill” – Mitral Stenosis – Tamponade – Hypertrophy – Infiltration – Fibrosis
- 30. Classification of heartfailure New York Heart Association (NYHA) Functional Classification Class % of patients Symptoms No symptoms or limitations in ordinary physical activity I 35% Mild symptoms and slight limitation during ordinary activity II 35% Marked limitation in activity even during minimal activity. Comfortable only at rest III 25% Severe limitation. Experiences symptoms even at rest IV 5%
- 31. Heart Failure ClinicalManifestations • Acute decompensated heart failure (ADHF) • Physical findings • Orthopnea • Dyspnea, tachypnea • Use of accessory muscles • Cyanosis • Cool and clammy skin •Physical findings •*Cough with frothy, blood-tinged sputum •Breath sounds: Crackles, wheezes, rhonchi •Tachycardia •Hypotension or hypertension
- 32. ADHF/Pulmonary Edema (advancedL side HF) When PA WEDGE pressure is approx 30mmHg – Signs and symptoms • wheezing • pallor, cyanosis • Inc. HR and BP • S3 gallop • Rales,copious pink, frothy sputum
- 33. Congestive heart failure Clinical manifestations – Symptoms (back up of blood and fluid) – Dyspnea – Orthopnea – Reduced exercise tolerance, lethargy, fatigue – Nocturnal cough –Wheeze – Ankle swelling – Anorexia
- 34. Congestive heart failure Clinical manifestations ( cont…) –Signs – Cachexia and muscle wasting – Tachycardia – Pulsus alternans – Elevated jugular venous pressure – Crepitations or wheeze – Third heart sound – Oedema – Hepatomegaly (tender) – Ascites
- 35. Clinical Data •HEART SOUNDS!!! • Systolic Murmurs – Mitral Regurg – Aortic Stenosis • Diastolic Murmurs – Mitral Stenosis – Aortic Insufficiency • S3: Rapid filling of a diseased ventricle
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- 38. 38 PULMONARY EDEMA Rapid fluid accumulation in lung spaces that has leaked from engorged pulmonary capillaries Etiology – most common cause is sudden deterioration of LV function
- 39. 39 Cardiogenic Shock Significant reduction in SV & CO causes drop in pressure & poor tissue perfusion a/r/o LV MI • Clinical signs: – BP, pulse, peripheral pulses – confusion/ agitation (cerebral hypoxia) – cold/ clammy skin – urine output – Resp distress – Chest pain
- 41. 41 (R) SIDEDHF Blood “BACKS UP” into venous circulation. High oncotic pressure pushes fluids into tissues. CLINICAL SIGNS: CVP SUDDEN WT. GAIN JVD DEPENDENT EDEMA FATIGUE LIVER CONGESTION LETHARGY ASCITES ORTHOPNEA ANOREXIA
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- 43. What does this show?
- 44. Can You HaveRVF Without LVF? • What is this called? COR PULMONALE
- 45. What is presentin this extremity, common to right sided HF?
- 46. Heart Failure Complications • Pleural effusion • Atrial fibrillation (most common dysrhythmia) – Loss of atrial contraction (kick) -reduce CO by 10% to 20% – Promotes thrombus/embolus formation inc. risk for stroke – Treatment may include cardioversion, antidysrhythmics, and/or anticoagulants
- 47. Heart Failure Complications • **High risk of fatal dysrhythmias (e.g., sudden cardiac death, ventricular tachycardia) with HF and an EF <35% – HF lead to severe hepatomegaly, especially with RV failure • Fibrosis and cirrhosis - develop over time – Renal insufficiency or failure
- 48. Heart Failure DiagnosticStudies • Primary goal- determine underlying cause – History and physical examination( dyspnea) – Chest x-ray – ECG – Lab studies (e.g., cardiac enzymes, BNP- (beta natriuretic peptide- normal value less than 100) electrolytes – EF
- 49. Clinical Data •CXR – Kerley’s lines : A and B – Pulmonary Edema – Cephalization – Pleural Effusions (bilateral) • EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
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- 51. Cardiomegaly/ventricular remodeling occursas heart overworked> changes in size, shape, and function of heart after injury to left ventricle. Injury due to acute myocardial infarction or due to causes that inc. pressure or volume overload as in Heart failure
- 52. Clinical Data •Laboratory Data • Chemistry – Renal Function: Be Wary • BNP – Used in ER departments the world over – Good negative correlation – Need baseline for positivity – Pulmonary versus cardiac dyspnea
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- 57. Goals of Treatment-ADHF/PulmonaryEdema) MAD DOG • Improve gas exchange – Start O2/elevate HOB/intubate – Morphine –dec anxiety/afterload – A- (airway/head up/legs down) – D- (Drugs) Dig not first now- but drugs as • IV nitroglycerin; IV Nipride, Natrecor – D- Diuretics – O- oxygen /measure sats; • Hemodynamics, careful observation – G- blood gases – Think physiology