definition of heart failure, classification of heart failure, risk factors for heart failure, clinical features, general physical examination findings in heart failure

1. HEART FAILURE
CLASSIFICATION, RISK FACTORS AND
CLINICAL FEATURES
GUIDE – Dr. L. S. PATIL
PRESENTER – Dr DEEPAK R. CHINAGI

2. DEFNITION
• 2013 ACC/ AHA DEFNITION-
– Heart Failure is defined as “ a complex clinical
syndrome that results from any structural or
functional impairment of ventricular
filling(diastole) or ejection of blood. (systole) ”

3. CLASSIFICATION BY DEFNITION
• SYSTOLIC HEART FAILURE
– Characterized by reduced ejection fraction and
enlarged ventricle size. Clinically present with left
ventricular failure and marked cardiomegaly.
• DIASTOLIC HEART FAILURE
– Characterized by increased resistance to filling due
to increased filling pressures. Clinically present
with pulmonary congestion with normal or slightly
enlarged ventricles .

4. CLASSIFICATION BASED ON EJECTION
FRACTION
• Heart Failure with reserved Ejection Fraction
HFrEF – Ejection fraction ≤ 40% .
– These patients will have systolic dysfunction and
concomitant diastolic dysfunction. Coronary artery
disease is the major cause.
• Heart Failure with Preserved Ejection Fraction
HFpEF – Ejection Fraction 40 – 50%.
– These patients can be diagnosed by 1)clinical signs
and symptoms and 2)evidence of pEF or normal EF or
previously rEF 3)evidence of abnormal LV diastolic
dysfunction (echo / LV catheterisation)

5. CLASSIFICATION BASED ON CARDIAC
OUTPUT
• HIGH OUTPUT FAILURE-
– The normal heart fails to maintain normal or
increased output in conditions like anemia,
hyperthyroidism, pregnancy.
– Usually right sided failure occurs followed by left sided
failure with presence of shortened circulatory time.
• LOW OUTPUT FAILURE-
– Heart fails to generate adequate output in conditions
like cardiomyopathy, valvular heart disease,
tamponade and bradycardia.

6. RIGHT AND LEFT SIDED HEART FAILURE
• Right sided heart failure is characterised by the
presence of peripheral edema, raised JVP and
hypotension and congestive hepatomegaly.
• Left sided heart failure – pulmonary edema is the
striking feature. Other signs are tachypnea,
tachycardia, third heart sound, pulsus alternans,
cardiomegaly.
• Congestive Cardiac Failure – Characterised by
combination of both left and right sided heart
failure.

8. FORWARD AND BACKWARD HEART
FAILURE
• FORWARD HEART FAILURE-
– This results from inadequate discharge of blood
into arterial system leading to poor tissue
perfusion and excess Na+ reabsorption through
RAAS.
• BACKWARD HEART FAILURE-
– This results from failure of one or both ventricles
to fill normally and discharge its contents, causing
back pressure on the atria and venous system.

9. ACCF/AHA FUNCTIONAL
CLASSIFICATION
• Stage A – At high risk of HF but witout
structural hear disease.
• Stage B – Structural heart disease without
signs or symptoms of HF.
• Stage C – Structural heart disease with prior
HF or current HF.
• Stage D – Refractory HF requiring special
interventions.

10. NYHA FUNCTIONAL CLASSIFICATION
• Stage 1 – no limitation of ordinary physical
activity.
• Stage 2 – slight limitation of ordinary physical
activity.
• Stage 3 – marked limitation of ordinary
physical activity, but comfortable at rest.
• Stage 4 – unable to carry out physical activity,
symptomatic at rest.

11. RISK FACTORS
• Epidemiology –
– Worldwide 2 crore people are affected by heart
failure. Approximate 2 % prevalence in developed
countries. Women have better survival than men.
– Coronary artery disease is the major cause for
heart failure. (60 – 75%)
• Etiology and Risk Factors –
– Any condition that leads to alteration of LV
structure and function can lead to heart failure

12. Etiologies of Heart Failure
• HFrEF (EF < 40%) –
– Coronary Artery Disease (Infarction/Ischemia)
– Chronic Pressure Overload (Hypertension/
Valvular Heart Disease - Stenotic)
– Chronic Volume Oveload(Valvular Heart Disease-
Regurgitant/ Intracardiac shunting)
– Non ischemic DCM (Familial/ Infiltrative/
Endocrine/ Toxic/ Inflammatory/ Peripartum/
Stress)

13. Etiologies of Heart Failure
• HFpEF (EF 40 – 50%)-
– Hypertrophic Cardiomyopathy
– Hypertensive heart disease
– Restrictive Cardiomyopathy(Amyloidosis /
Sarcoidosis / Hemochromatosis)
– Fibrosis / Endomyocardial Disorders / Aging
• Right Heart diseases-
– Cor pulmonale
– Pulmonary Vascular disorders

14. Etiologies of Heart Failure
• High output states
– Thyrotoxicosis
– Nutritional – Beriberi
– Anemia

15. LV Remodeling
• DEFNITION – It refers to change in LV Mass ,
Volume or Shape or the Composition of the heart
after Cardiac injury or index event.
• Progress of HF associated with changes in
geometry of remodeled LV
• Changes that occur include –
– LV dilatation
– LV thinning
– Increase in LV end diastolic volume
– Decrease in stroke volume

16. LV Remodeling
– Subendocardial hypoperfusion
– Increased oxidative stress and free radical
generation
– Stress activated hypertrophic signaling pathways
– Incompitence of mitral valve apparatus and
functional MR

17. CLINICAL FEATURES
• Important symptoms –
– Fatigue
– Exertional Breathlessness
• Cause of breathlessness is multifactorial
– Pulmonary congestion due to LVF
– Accumulation of interstitial and intra alveolar fluid
, stimulating juxta capillary J receptors, causing
Rapid Shallow breathing
– Decreased pulmonary compliance
– Increased airway resistance
– Respiratory fatigue and Anemia

18. CLINICAL FEATURES
• Orthopnea –
– Dyspnea in recumbent position
– Occurs due to redistribution of fluid from
splanchnic circulation and lower extremities
– Causes increase in pulmonary capillary pressure.
– Nocturnal cough is usually asociated with this
symptom
– Relieved by sitting upright .
– This symtom is more common in patients with co
morbid obesity or ascites

19. CLINICAL FEATURES
• Paroxysmal Nocturnal Dyspnea-
– Defnition – it refers to acute episode of shortness of
breath and coughing that generally occur at night and
awken patient from sleep usually 1 – 3 hours after
recline.
– Associated with coughing or wheeze
– Mechanism – increased pressure in bronchial arteries
leading to airway compression (+) interstitial
pulmonary edema = increased airway resistance.
– Orthopnea symptoms resolve after upright posture,
but symptoms of PND persist even after upright
posture.

20. CLINICAL FEATURES
• Cheyne stokes respiration
– Also called periodic / cyclic respiration
– It is present in nearly 40 % cases of HF
– It is caused by decreased sensitivity of
RESPIRATORY CENTRE to PaCO2.
– Due to transient fall in PaO2 , rise in PaCO2 there
is an apneustic phase. PaCO2 rises steadily till it
stimulates depressed respiratory centre and
causes hyperventilation and hypocapnia (low
PaCO2).

21. CLINICAL FEATURES
• Other symptoms like
– Anorexia
– Nausea
– Early satiety
– Abdominal pain
– Abdominal fullness
– Congestive hepatomegaly
– Confusion , disorientation, sleep disturbances,
– Nocturia

22. PHYSICAL EXAMINATION
• Patient will present with laboured breathing in an
acute LVF. He/she may not be able to finish the
sentence due to shortness of breath. He / she
may have difficulty to talk due to shortness of
breath.
• Blood pressure may be normal or high in early HF
, may decrease consequently and is usually low.
• Low pulse pressure (reduced stroke volume)
• Sinus tachycardia (increased sympathetic activity)
cool peripheries, cyanosis of tips of fingers and
nail bed.

23. PHYSICAL EXAMINATION
• Jugular venous pressure –
– Indicates right atrial pressure
– It is measured in terms of (cm of H2O)
– Normal < 8 cm of H2O
– Method – measure highest point of JVP vertically
from sternal angle and add 5 cm of H2O
– Positive Abdomino- Jugular reflex

24. PHYSICAL EXAMINATION
• Respiratory system
– Bilateral rales/crepitations may be present as a
result of transudate of fluid from intravascular
space to intraalveolar space.
– May be accompanied by expiratory wheeze
(cardiac asthma).
– Pleural effusion may/may not be present.
(common in CCF)

25. PHYSICAL EXAMINATION
• Cardiovascular system
– Apical impulse may shift inferiorly / laterally.
– Sustained apical impulse is felt in severe LVH.
– S3 gallop (protodiastolic gallop) can be heard.
– Left parasternal impulse in cases if severe RVH
– S4 gallop is usually present in diastolic dysfunction.
– MR or TR may be present additionally.

26. PHYSICAL EXAMINATION
• Per abdomen
– Hepatomegaly is present (tender / pulsatile)
– Pulsations in liver indicate tricuspid regurgitation
– Ascites , Jaundice , raised liver enzymes
– Peripheral edema can be pre tibial or pre sacral
edema
• Cardiac cachexia
– Cause for cachexia is multifactorial
• Elevation of BMR
• Elevated circulating cytokines like TNF
• Congestion of intestinal veins

27. Other Important Comorbidities in HF
• Atrial Fibrillation
• Anemia
• Depression
• Others
– Diabetes
– Arthritis
– CKD
– COPD

28. THANK YOU