1 Heart failure. 2 DEFINITION HEART FAILURE –the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirement.

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Heart failure

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DEFINITION

• HEART FAILURE – the pathophysiological state in which the heart is

unable to pump blood at a rate commensurate with the requirement of the metabolizing tissues or can do so only from an elevated filling pressure.

– Usually caused by a defect in myocardial contraction (myocardial failure).

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DEFINITION

• CONGESTIVE HEART FAILURE– Clinical manifested as

• Pulmonary congestion• Systemic congestion• Inadequate tissure blood perfusion

• HEMODYNAMICALLY heart failure (cardiac dysfunction) is diagnosed when – LVEDP>18mmHg or– RVEDP>10mmHg

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UNDERLYING CAUSES

• Primary myocardial dysfunction (systolic and/or diastolic)– Cardiomyopathy

– Primary or secondary metabolic disturbances of myocardium

• Overloading of heart – Pressure overloading

– Volume overloading

– limited diastolic function

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UNDERLYING CAUSES

Age Age 70.3±10.1 yr.70.3±10.1 yr.

Causes CHDCauses CHD 65.8% 65.8%

Hypertension 36.0%Hypertension 36.0%

Dila. Cardiomy. 11.9%Dila. Cardiomy. 11.9%

With 2°DM 14.9%With 2°DM 14.9%

Shanghai OPD, Shanghai OPD, Chin J Cardiol 2001;29:6442001;29:644

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Precipitating factors

• infection

• arrhythmias

• Pulmonary embolism

• overfatigue

• Pregnancy and delivery

• Anemia and hemorrhage

• others

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Pathophysiology

• Frank-Starling mechanism

• Activation of neurohormonal pathway (SAS and RAS)

• Myocardial damage and remodeling

• Diasatolic heart failure

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CLINICAL CLASSIFICATION

• A cute vs. chronic heart failure

• Right-sided vs. left-sided Heart failure

• Low-output vs high-output heart failure

• Systolic vs diastolic heart failure

• Asymptomatic vs congestive heart failure

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Chronic left-sided HF ：symptoms

Respiratory distress Exertional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Acute pumnonary edema Cough (nonproductive), and hemoptysis

Reduced exercise capacityFatigue and weaknessUrinary symptoms

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Chron. left-sided HF ： Physi. findings

General appearance

Dyspnetic

Cyanosis, icterus, malar flush, diminished pulse pressure, reduced SBP, rapid, weak and thready pulse in severe HF

Evidence of ↑adrenergic activity

Peripheral vasoconstriction (pallor, coldness of extremities and cyanosis of the digits ).

Diaphoresis with sinus tachycardia

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Chron. left-sided HF ： Physi. finding

Cardiac findings

Cardiomegaly

S3 gallops

Accentuation of P2

Systolic murmur

Pulsus alternans

Pulmonary rales

Moist rales over

the lung bases

Rhonchi wheezes

↓BS

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Chron. right-sided HF ： symptoms

•Gastrointestinal symptoms •Symtoms of urinary system •Dull ache in right upper quadrant. •dyspnea

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Chron. right-sided HF ： Physi. finding

• Cardiac findings

• Hepatojugular reflux

• Congetive hepatomegaly or tenderness

• Edema

• Hydrothorax and ascites• Others (cyanosis, and etc.)

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Chronic HF ： labolaroty findings

• Routine lab. And serum electrolytes & liver function tests

• ECG • Echocardiography • Chest Roentgenogram

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ECG

• Suggesting basic presence of basic heart diseases

• Atrial and ventricular hypertrophy, myocardial ischemia or infarction , arrhythmia

• V1ptf ＜－ 0.03mm ／ s ， indicating left atrial overloading.

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Echocardiogram

• M mode, 2D echo and Dopler technique for systolic and diastolic function of LV

– LVDd and LVDs （ Dd and Ds ）– LV fraction of shortening （△ D ％ ＝（ Dd - Ds ）／ Dd × 100 ％）– mVCF ＝（ Dd - Ds ）／ Dd × LVET – SV– LVEF

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Chest X ray

Left-sided heart failure cardiomegaly (cardiothorax ratio ＞ 50%) dilated pulmonary vein

pulmonary infiltrates.

prominent bronchovascular markings

Interstitial edema, Kerley.s B line, alveolar edema, pleural effusion when PCWP ＞ 25 ～ 30mmHg.

Right-sided HFCardiomegaly

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Invasive hemodynamic monitoring

•Using Swan-Ganz cather and thermodilution method for measurement of– Intracardiac and vascular pre

ssure–Cardiac output

to asses cardiac function

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Invasive hemodynamic monitoring

• CVP （中心静脉压） 6 ～ 12cmH2O

• PAP （肺动脉压） 12 ～ 30/4 ～ l3mmHg

• PCWP （肺毛细血管楔嵌压） 6 ～ 12mmHg

• SV （心搏量） 60 ～ 70ml

• SI （心搏指数） 4l ～ 51ml/m2

• CO （心排血量） 5 ～ 6L/min

• CI （心排指数） 2.6 ～ 4.0L/min.m2

• EF （射血分数） 0.5 ～ 0.6

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Chronic HF ： diagnosis

•causes•anatomy•pathology•arrhythmia•Functional classification

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Functional classification（ NYHA)

• Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation

• Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.

• Class III-marked limitation of physical activity: 　 although patients are comfortable at rest, less than ordinary activity will lead to symptoms.

• Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.

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Chronic HF ： diff. diagnosis

Left-sided HF

With pulmonary dyspnea: COPD,asthma Metabolic acidosisCardiac neurosis

Right-sided HFPricarditis

Hepatic, renal edema.

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Functional classification（ NYHA)

• Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation

• Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.

• Class III-marked limitation of physical activity: 　 although patients are comfortable at rest, less than ordinary activity will lead to symptoms.

• Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.

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Chronic HF ： diff. diagnosis

Left-sided HF

With pulmonary dyspnea: COPD, asthma Metabolic acidosis Cardiac neurosis

Right-sided HF Pricarditis Hepatic, renal edema.

Survival

Morbidity

Exercise capacity

Quality of life

Neurohormonal changes

Progression of CHF

Symptoms

TREATMENT OBJECTIVES

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Chronic HF: treatment

Reducing loadRest and tranquilizer

Control salt intake

Water intake

diuretics

Vasodilators

Improve CO digitalis non-digitalis posit

ive inotropic agents aldost. antagonist β-bloker

correcting PF and cause of HF

diastolic HF dificult HF cases

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Diuretics

ThiazidesHydrochlorothiazide

Potassium-sparing diureticsSpironolactone

amiloride

Loop diureticsFrusemide

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Vasodilators

Nitrates

Nitroglycerine

Isosorbide dinitrate

Mononitrates

Nitroprusside

ACE inhibitor

ARB (Angiotensin receptor blocker)

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Acute heart failure

• Definition

• Etioloogy and mechanism

• Clinical picture

• Diagnosis

• treatment

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