Heart failure is a leading cause of hospitalization in those over 65. The family physician plays an important role in prevention through risk factor assessment, lifestyle counseling, and monitoring for signs and symptoms. When detected early, heart failure has a better prognosis than many cancers. Treatment involves medications like ACE inhibitors, ARBs, diuretics and beta-blockers to reduce symptoms and disease progression.

1. HEART FAILURE
WHAT A FAMILY PHYSICIAN NEED TO KNOW
Prepared by : Dr. Ahmed Ibrahim Eldesouky Abouelela
Family Medicine Registrar
MBBch, Msc, MRCGP.int

2. What a Family Physician need to
know
 Terrifying informations.
 Basic informations.
 Role of family physician.

3. Terrifying Informations
 Heart failure is the leading cause of
hospitalization of patients
> 65 years in age.
 > 15million new cases of HF estimated
each year worldwide.
 Approximately 50% of patients with HF
die within 5 years of diagnosis.
 Symptomatic HF has worse prognosis
than majority of cancers.
 The most common cause of complications of
heart failure is poor compliance to treatment.

4. Basic Definition
Failure of the heart to provide the
body tissue by its need of blood
and subsequently oxygen and
nutrients

5. Heart Failure Classification
 Acute vs. Chronic
 Systolic vs. Diastolic
 Right sided vs. Left sided
 Right ventricular vs.
Left ventricular vs.
Biventricular
 Preload vs. Afterload
 Low cardiac output vs. High cardiac out put
 Low ejection fraction vs. Normal ejection
fraction

6. Acute versus Chronic
Acute heart failure
 develops rapidly
 can be immediately life
threatening due to lack of time
to undergo compensatory
adaptations.
 may result from
cardiopulmonary by-pass
surgery, acute infection
(sepsis), acute myocardial
infarction, valve dysfunction,
severe arrhythmias, etc.
 can often be managed
successfully by
pharmacological or surgical
interventions.
Chronic heart failure
 a long-term condition
(months/years) that is
associated with the heart
undergoing adaptive
responses (e.g., dilation,
hypertrophy) to a
precipitating cause.
 These adaptive responses,
however, can be deleterious
in the long-term and lead to a
worsening condition.

7. 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

8. Left versus Right Failure
Left Heart Failure
Dyspnea
Decrease exercise
tolerance
Cough
Orthopnea
Pink, frothy sputum
Right Heart Failure
Decrease exercise
tolerance
Edema
Hepatomegaly
Ascites

9. Functional classification

10. NYHA Classification of heart failure
 Class I: no limitation is experienced in any
activities; there are no symptoms from
ordinary activities.
 Class II: slight, mild limitation of activity; the
patient is comfortable at rest or with mild
exertion.
 Class III: marked limitation of any activity;
the patient is comfortable only at rest.
 Class IV: any physical activity brings on
discomfort and symptoms occur at rest.

11. New classification of heart failure
• Stage A: Asymptomatic with no heart
damage but have risk factors for heart
failure
• Stage B: Asymptomatic but have signs
of structural heart damage
• Stage C: Have symptoms and heart
damage
• Stage D: End stage disease
 ACC/AHA guidelines, 2001

12. Classification of HF: Comparison Between
ACC/AHAHF Stage and NYHA Functional
Class
1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
B Structural heart disease but without
symptoms of heart failure
C Structural heart disease with prior or
current symptoms of heart failure
D Refractory heart failure requiring
specialized interventions
I Asymptomatic
II Symptomatic with moderate exertion
IV Symptomatic at rest
III Symptomatic with minimal exertion
None

13. Causes
 Hypertension
 Congenital heart defects
 Valvular heart diseases
 Heart attack
 Severe lung disease
 Diabetes
 Severe anemia
 Overactive thyroid gland
(hyperthyroidism)
 Abnormal heart rhythms(Arrhythmias)

14. Pathophysiology

15. Symptoms and Signs
• Fatigue, effort intolerance
• Dyspnea on exertion or at rest
• Difficulty breathing when lying flat (Orthopnea)
• Swelling in feet, ankles, legs or abdomen
• hepatomegaly
• Weight gain
• Heart palpitations
• May feel like the heart is racing or throbbing
• Coughing that produces white or pink blood-tinged sputum
• Feeling of being full or sick to your stomach
• Memory loss or feeling of disorientation
• Relative or caregiver may notice this first

16. Symptoms and Signs

17. Complication
 Kidney damage or failure.
 Heart valve problems.
 Heart rhythm problems.
 Liver damage.

18. Diagnosis
 Brain Natriuretic Peptide
( BNP test )
 Echo
 Chest X ray
 ECG
 Lab

19. BNP(Brain Natriuretic Peptide) Test
 BNP(Brain Natriuretic Peptide) Test
 Used in ER departments
 Good negative correlation
 Need baseline for positivity
 Diagnostic of CHF with
 Sensitivity 90%
 Specificity 76%
 Predictive accuracy 83%
 BNP < 100 pg/L – 98% negative predictive
accuracy

20. Treatment
• ACE Inhibitors
• ARBs
• Diuretics
• Aldosterone blockade
• Potassium
• Beta-blockers
• Vasodilators
• Digitalis preparations
• Device therapy ( Biventricular (BiV) pacers /
Intracardiac defibrillators (ICD’s)
• Surgery and other Medical Procedures

21. Heart Failure Treatments:
Medication Types
•ACE inhibitor
(angiotensin-converting
enzyme)
•ARB (angiotensin receptor
blockers)
•Beta-blocker
•Digoxin
•Diuretic
•Aldosterone
blockade
Type What it does
•Expands blood vessels which lowers
blood pressure, neurohormonal
blockade
•Similar to ACE inhibitor—lowers
blood pressure
•Reduces the action of stress
hormones and slows the heart rate
•Slows the heart rate and improves the
heart’s pumping function (EF)
•Filters sodium and excess fluid from the
blood to reduce the heart’s workload
•Blocks neurohormal activation and controls
volume

22. Heart Failure Treatments:
Types and Mechanisms
 Diuretics
and ACEi
Reduce load
 B blockers
Limit speed and
Thus save energy

23. Heart Failure Treatments:
Types and Mechanisms
 Digitalis
Motivate heart
 Devices
Increase efficiency

24. Role of Family Physician
Prevention

25. New classification of heart failure
• Stage A: Asymptomatic with
no heart damage but have
risk factors for heart failure
• Stage B: Asymptomatic but have signs of
structural heart damage
• Stage C: Have symptoms and heart damage
• Stage D: End stage disease
 ACC/AHA guidelines, 2001

26. Prevention
 1ry prevention
 2ry prevention
 3ry prevention

27. 1ry prevention
 Heart failure can’t be primarily prevented
but still life style modification is
recommended to those who has more
than one risk factor

28. Risk factors
 High blood pressure.
 Coronary artery disease.
 Heart attack.
 Diabetes and Some diabetes medications.
 COPD.
 Sleep apnea.
 Obesity.
 Alcohol use.
 Tobacco use.
 Congenital heart defects.
 Valvular heart disease.
 Irregular heartbeats.

29. Life style modification
 Stop smoking.
 Stop alcohol.
 Check legs, ankles and feet for
swelling daily.
 Eat a healthy diet, Restrict salt in diet.
 Maintain a healthy weight.
 Consider getting vaccinations.
 Control fats and cholesterol.
 Be active.
 Reduce stress.
 Sleep well.

30. 2ry prevention
 Assessing risk factors
 Applying Modified Framingham Criteria for
Heart Failure diagnosis
 Go to specific diagnosis investigation
(BNP or echo ) for definite diagnosis.

31. Risk factors
 High blood pressure.
 Coronary artery disease.
 Heart attack.
 Diabetes and Some diabetes medications.
 COPD.
 Sleep apnea.
 Congenital heart defects.
 Valvular heart disease.
 Alcohol use.
 Tobacco use.
 Obesity.
 Irregular heartbeats.

32. Modified Framingham Criteria
Diagnosis for Heart Failure
Major criteria Minor criteria
 Neck vein distension
 PND or Orthopnea
 Cardiomegaly on CXR
 Acute pulmonary edema
 Pulmonary rales
 Positive abdominojugular
test (Hepatojugular
reflux)
 Third heart sound (S3
Gallop rhythm)
 Bilateral ankle edema
 Night cough
 Dyspnea on exertion
 Hepatomegaly
 Pleural effusion
 Tachycardia (> 120
beats/min)

33. Modified Framingham Criteria
Diagnosis for Heart Failure
 Interpretation: heart failure diagnosis
requires 1 major criteria and 2 minor
criteria
 Efficacy: Sensitive but not specific
Test sensitivity: 97%
Test specificity: 79%

34. Life style modification
 Stop smoking.
 Stop alcohol.
 Check your legs, ankles and feet
for swelling daily.
 Eat a healthy diet, Restrict salt in your diet.
 Maintain a healthy weight.
 Consider getting vaccinations.
 Control fats and cholesterol.
 Be active.
 Reduce stress.
 Sleep well.

35. 3ry prevention
 Insure good compliance to
treatment.
 Life style modification.
 Appropriate timing of surgery or
angioplasty for ischemic or valvular heart
disease.

36. Home massages
 Heart failure is one of the professional killer
diseases.
 Heart failure is malignant than malignancy.
 The most common cause of heart failure
complication is poor compliance to treatment.
 Asymptomatic patient with no heart damage but
have risk factors for heart failure is consider to
be Stage A.
 Main role of family physician is prevention.

37. REFERENCES
 Up To Date
 Mayo Clinic
 J M 6th edition
 Medscape
 Pubmed

38. ‫اع‬‫م‬‫ت‬‫س‬‫اال‬‫سن‬‫ح‬‫لي‬‫ع‬‫ا‬‫ر‬‫ي‬‫خ‬‫هللا‬‫م‬‫ك‬‫ا‬‫ز‬‫ج‬‫و‬
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