Heart failure is a common condition where the heart muscle is unable to pump sufficiently. It affects around 2% of developed countries' adult populations and risk increases with age. Heart failure can be systolic, with reduced ejection fraction below 40%, or diastolic, with preserved ejection fraction above 40-50%. Common causes include coronary artery disease, hypertension, valvular diseases, cardiomyopathies, and arrhythmias. Treatment focuses on managing symptoms, slowing disease progression, and reducing mortality risk through lifestyle changes, medications like diuretics, ACE inhibitors, beta-blockers, and aldosterone antagonists, and devices or procedures for advanced cases.

3. • Overall prevalence of HF is 2% in adult
population of developed countries with
prevalence rising with age .
• Heart failure is broadly classified into -
Systolic dysfunction :
depressed EF (< 40%)
Diastolic dysfunction:
preserved EF (>40-
50%)

4. • Any condition leading to alteration in LV structure
/function.
Causes for systolic dysfunction -
 Coronary artery disease – myocardial ischemia and
infarction .
 Chr. Pressure overload – hypertension .
 Chr. Volume overload – (i)regurgitating valvular
diseases (ii)intracardiac shunting .
 Dilated cardiomyopathies .
 Dysarrhythmias –chr . Brady and tachy
arrhythmias.
 Toxic induced

5. Causes of diastolic failure –
 Hypertrophic cardiomyopathy .
 Hypertension .
 Aging .
 Restrictive cardiomyopathy –(i)infiltrative
disorders.
 Fibrosis
Other causes –
 Pulmonary heart disease –cor pulmonale ,pul.
Vasular disorders .
 High output states –thyrotoxicosis,beriberi
,anaemia ,AV shunting .

7. • Heart failure is a progressive disorder initiated after
an index event (damage to heart muscles with loss
of functioning cardiac myocytes /disrupts the
ability of myocardium to generate force ) .
Spectrum of disease ranges from -
ASYMPTOMATIC SYMPTOMATIC
(compensated) (decompensated)

10. • SYMPTOMS –
1. Fatigue .
2. Dyspnoea (rapid, shallow breathing )
3. Orthopnoea .
4. Paroxysmal nocturnal dyspnoea .
5. Cheyn –stroke breathing .
Other symptoms –
› GI symptoms –anorexia , nausea ,early satiety .
› Right upper quadrant pain .
› Cerebral symptoms –sleep & mood disturbances
,confusion ,disorientation .
› Nocturia .

11. • General appearance and vitals –
• Decreased systolic blood pressure , decreased pulse
pressure .
• Sinus tachycardia .
• Cool peripheries with cyanosis of lips and nail beds .
• Raised JVP
Pulmonary examination –
• Pulmonary crackles are heard widely over both lung fields
.
• Pleural effusion occurs in biventricular failure .

12. • Cardiac examination –
• Apex -is displaced below the 5th ICS lateral to mid-clavicular
line ,palpated in two ICS and sustained .
• left Parasternal heave –in case of RV hypertrophy .
• S3 in cases with volume overload .
Per abdomen –
• Tender hepatomegaly .
• Ascitis and jaundice .
• Peripheral edema (dependent ,pitting type ) .
Cardiac cachexia .

14. • Routine laboratory tests –CBP ,serum
electrolytes ,serum creatinine ,liver function test
,urinanalysis .
• ECG – for cardiac rhythm , LV hypertrophy
,prior MI .
• Chest x-ray –cardiac size and state of
pulmonary vasculature .
• Assesment of LV function –
• 2d echo/doppler –LV size and function ,regional wall
motion abnormalities ,valvular abnormalities .
• Ejection fraction(EF) –stroke vol /end diastolic vol .

15. • MRI – it is the gold standard investigation for
assesing left ventricular mass and volume . And is
also emerging useful to determine the cause of HF .
• Biomarkers –
1. B type natriuretic peptide & N –terminal pro-BNP are
released from failing heart and are elevated in heart
failure .
2. Troponine T and I
3. C reactive protein .

19. STAGES
A HIGH RISK PATIENTS WITH NO STRUCTURAL
DISEASE /SYMPTOMS OF HEART FAILURE .
B STRUCTURAL DISEASE BUT NO SYMPTOMS
ARE PRESENT
C STRUCTURAL DISEASE WITH SYMPTOMS OF
HEART FAILURE
D REFRACTORY HEART FAILURE

22.  Correction of systemic factors(thyroid dysfunction
uncontrolled dm, infections )and other co morbidities
like COPD and sleep apnea .
 Lifestyle modifications –
 Cessation of smoking .
 Restriction of alcohol consumption .
 Salt restriction (~2 to 3 g/day )
 Fluid restriction (<2 L/day ) .
 Weight reduction .
 Moderate exercise .
 Pneumococcal and influenza vaccination annually
 Treatment of cause of heart disease .
 Pharmacological therapy
 ICD and CRT .
 Cardiac transplantation .

23. Goals of therapy include to –
• Improve symptoms
• Slow or reverse deterioration in myocardial
functions .
• Reduce mortality .

24. Heart failure
Fluid retention
diuretics
No fluid
retention
ACE inhibitors
Beta blockers
ARB
Aldosteron antagonists
Isosorbide
digoxin

25. Goal is relief of signs and symptoms of dyspnea and
peripheral edema .
Symptoms relieve within hours to days .
• Loop diuretics –furosemide (20 -40 mg/qd ) ,torsemide
(10-20 mg /qd ) initial dose .
• Subsequent doses are dependent on diuretic response
(wt loss of 1 kg /day ) or until the dry weight of the
patient is reached .
• Thiazide diuretics may be added along with loop
diuretics if fluid retention persists even after high doses
of loop diuretics (25 mg /od or bd )

26. These improve the survival in pts with left ventricular
systolic dysfunction .all pts with asymptomatic or
symptomatic LV systolic dysfunction should be started
on ACE inhibitors .
Beginning therapy with low doses and tittering it upwards
to target doses at an interval of 1-2 wks .
• Captopril -6.25 mg/tid ----50mg /tid
• Enalapril – 2.5 mg/bd ----- 20mg/bd
• Lisopril -5 mg/od -----40 mg /day

27. Given in concert with ACE inhibitors beta blockers reverse
the process of LV remodeling , improve patients
symptoms, prevent hospitalization and prolong life .
These antagonize the deleterious effect of adrenergic
nervous system and are to be used in asymptomatic and
symptomatic HF with depressed EF .
These are to be started only when the fluid overload in the
pt has been stabalised
Starting with low doses these are titrated upwards but at a
interval of 2 wks or more –
• Carvedilol -3.125 mg/bd -----25 to 50 mg /bd
• Metoprolol -12.5 mg (III &IV) or 25mg/day(II) -----
200mg/day
• Bisprolol -1.25 mg/day ----5 to 10 mg/day .

28. • Heart rate <60 bpm
• Symptomatic hypotension .
• Fluid retention .
• Peripheral hypoperfusion .
• PR interval >0.24 sec
• Second or third degree AV block .
• h/o asthma .
• Peripheral artery disease .

29.  These are recommended in pts with NYHA class III or
IV and LVEF <35% who are on standard therapy with
diuretics, ACE inhibitors and beta blockers .
 Serum potassium and renal function should be
monitored with the sr potassium <5.0 mEq/ L and GFR
should be >30 ml/min/1.73 sq.m
 Serum k+and creatinine have to be monitored every 1-2
wks .
 Dosages –
› Spironolactone -25 to 50 mg /day
› Eplerenone -25mg/day and after 4 wks 50 mg/day

30.  These are used in patients who cannot tolerate ACE
inhibitors
 These are slightly less efficacious than ACE inhibitors .
Hydralizine pluse nitrate –
This combination is suggested in patients who are unable
to take ACE inhibitors and ARB due to intolerance
,hypotension or renal insufficiencies .
 Dosage –
› Hydralizine -25 mg/tid +isosorbide dinitrate – 20 mg/tid
› Target dose -75 mg/tid for hydralizine and 40 mg /tid for
isosorbide .up titration to be done every 2 to 4 wks .

31. Given to pts with HF and systolic dysfunction to control
symptoms like fatigue ,dyspnea ,exercise intolerance
and in pts with AF .
Dosage is to be adjusted so that the serum digoxin
concentration is in the range of 0.5 -0.8 ng/mL .
It is not recommended as primary therapy for stabilization
of patient but is used after initial treatment for HF is
given and pt is stabilized .

32.  Statins –no benefit from statins has been demonstrated
in moderate to severe HF due to systolic dysfunction
with or without CAD but statins may be useful in cases
of HF with diastolic dysfunction.
 Calcium channel blockers –these have no direct role in
treatment of HF. But can be used in pts with other
indications like angina or hypertension .(amlodipine )

33. Some pts do not improve or have rapid recurrence with the
standard treatment for heart failure .
These pts are to be managed with specialized strategies
including –
• Continuous I.V positive inotropic therapy
• Cardiac resynchronization therapy .
• Extracorporeal ultrafiltration via heamofiltration .
• Mechanical circulatory support .
• Cardiac transplantation .