Presentaions of Heart Faliure

1. Heart Failure
Noha Khalil , MD

2. Definition
 Heart failure is a clinical syndrome usually due
to left ventricular dysfunction, resulting in acute
or chronic symptoms of cardiac pump failure.

3. Aetiology
 The most common causes of heart failure are
coronary heart disease, hypertension, alcohol
abuse, and idiopathic dilated cardiomyopathy
 Other causes are valvular and pericardial
disease; or non-cardiac diseases causing high-output
cardiac failure, such as anaemia,
thyrotoxicosis, septicaemia, Paget's disease of
bone, and arteriovenous fistulae.

4. Symptoms
 DYSPNEA
 CHEST PAIN
 SYNCOPE
 PALPITATION
 EDEMA
 COUGH
 HEMOPTYSIS
 FATIGUE
 CYANOSIS

5. DYSPNEA
 Abnormally uncomfortable awareness of breathing
 Dyspnea after strenous activity- Normal Individual
 Dyspnea after moderate activity – Deconditioned
Individual
 Dyspnea becomes abnormal only if it occurs at rest
or at a level of activity not expected to cause dyspnea

6. DIFFERENTIAL DIAGNOSIS OF
DYSPNEA
 PULMONARY
- Reactive airways disease
- COPD
- Pulmoary edema
- Pulmonary hypertension
- Infection
- Pulmonary embolism
- Pleural diseases
- Interstitial lung disease

7. DIFFERENTIAL DIAGNOSIS OF
DYSPNEA
 CARDIAC
-Ischemic heart dsease
- Right sided heart failure
- Arrhythmias
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy
- Valve stenosis and regurgitation

8. ACUTE DYSPNEA
 Sudden development of dyspnea
- Pulmonary embolism
- Pneumonia
- Airway obstruction

9. CHRONIC DYSPNEA
 Symptom progress slowly or gradual
- HEART FAILURE
- COPD ( chronic obstructive pulmonary
disease )

10. PAROXYSMAL NOCTURNAL
DYSPNEA
 Interstitial or interalveolar pulmonary edema
 Secondary to ventricular failure
 Symptom starts 2-4 hours after sleeping, patient
arise from sleep feeling short of breath
 Symptom ameliorated by sitting on the side of
bed and take about 15-30 min

11. ORTHOPNEA
 Inability to breath comfortably when lying
 Severe pulmonary venous congestion is the cause
of orthopnea
 Usually seen in advanced heart failure were
resting pulmonary venous pressure is elevated

12. CHEST PAIN
 Cardinal manifestation of coronary heart disease
 There are other structures that can casue chest
pain- Intrathoracic structures like aorta,
pulmonary airway, pleura and mediastinum;
tissue of the neck; thoracic wall and
subdiaphragmatic structures

13. DIFFERENTIAL DIAGNOSIS OF
CHEST PAIN
 PULMONARY
- pulmonary embolism
- pneumothorax
- pneumonia

14.  NEUROMUSCULAR
- Degenerative joint disease of cervical area
- Costochondritis
- Herpes zoster

15.  PSYCHOGENIC
- Anxiety
- Depression

16.  GASTROINTESTINAL
- Cholecystitis
- Esophageal spasm
- GERD

17. QUALITY OF PAIN
 Angina means tightening
 Unpleasant sensation which is describe as either
heaviness, pressing, squeezing or constricting

18. LOCATION
 Anginal pain is substrenal in location
 Pain at times radiates to the jaw, left arm, or neck

19. DURATION
 The pain of angina pectoris is usually brief and
last between 2-10 minutes
 Chest pain lasting for more than 15 minutes
would fall into either UNSTABLE ANGINA OR
MYOCARDIAL INFARCTION

20. COUGH
 Cough due to left ventricular failure is dry,
irritating , spasmodic and nocturnal
 It is due to pulmonary venous congention
 Cough of pulmonary disease is usually productive
 Cough follwed by dyspnea is usally pulmonary in
nature while dyspnea follwed by cough is cardiac
in nature

21. HEMOPTYSIS
 Expectoration of blood in sputum
 RBC escapes into aleveoli
 Rupture of bronchial vessel
 Necrosis and hemorrahge into the alveoli

22. FATIGUE
 Patient with impaired cardiovascular function
 Decrease peripheral perfusion
Muscle weakness

23. Chronic Heart Failure
 The most specific signs are:
 Laterally displaced apex beat
 Elevated jugular venous pressure
 Third heart sound
 Less specific signs include:
 Tachycardia
 Lung crepitations
 Hepatic engorgement (tender hepatomegaly)
 Peripheral oedema

24. Investigations
 Electrocardiogram (ECG) may show acute ischaemia, arrhythmias,
left ventricular hypertrophy, left bundle branch block, or prior MI.
 Heart failure is unlikely if the ECG is normal, and the diagnosis
should be reconsidered in this situation.
 Chest X-ray (CXR)
 pulmonary vascular congestion (upper lobe diversion),
 pulmonary oedema
 effusions
 cardiomegaly

25. Chronic Heart Failure
 B-type natriuretic peptide (BNP) and its N-terminal
fragment (NTproBNP)
 New diagnostic test
 A raised concentration of either has been shown to have a
sensitivity of greater than 90% and a specificity of 80-
90% for the diagnosis of heart failure.
 Heart failure is unlikely if the level of BNP or NTproBNP
is normal, especially if the ECG is also normal, and the
diagnosis should be reconsidered in this situation.

26. Medication
 Drug treatments should be initiated in the
following order:
 ACE inhibitor - with diuretic if needed - for
NYHA Grades I-IV.
 Angiotensin-II receptor antagonist - if intolerant
of ACE inhibitor.
 Beta-blocker - for NYHA Grades I-IV.
 Spironolactone - for NYHA Grades III-IV.
 Digoxin - for NYHA Grades II-IV.

27. Thank you