Heart Failure

Case History

Name : Fred Field Gender : MaleAge : 63 yearsDetails :- Manufacture Kitchen

Equipments- Work long hours under

pressure, esp. in Trade Fair Weeks

- Heavy breakfast @ 8 am (egg, bacon, sausage, bread)

- Medication Taken : Antacid

Symptoms:

- Angina

- Nausea

- Edema in ankles &

joints

Diagnosis:-No MI

- Cardiomegaly

What tests could be performed to show

whether Myocardial Infarction (MI) has

occurred?

Question 1.

Test Results [indicating MI]Tests done for MI

Laboratory TestsEnzymes :

- CK MB

- Lactate Dehydrogenase (LDH)

Proteins : Myoglobin

Cardiac Troponins (T & I subtypes)

Physical Tests - X-rays

- ECG

- Angiogram

- MRI (Magnetic Resonance Imaging)

- Radionuclide Imaging

- Elevation of

- CKMB

- Cardiac Troponins

- LDH (*not specific)

- Myoglobin Protein (*not specific)

- Abnormal Chest X-Ray showing

cardiomegaly

- Abnormal ECG waves

- Coronary Blockage (Angiograms)

- Abnormal pictures of Heart in MRI

Chest X-Rays

1. Superior Vena Cava2. Right Atrium3. Right Ventricle4. Aortic Knuckle5. Pulmonary Artery6. Left Ventricle7. Apex

Normal Chest X-Ray(4)

Chest X-Rays

(fig a. Front View) (fig b. Side View)

Chest X-rays Showing Enlargement of Heart(3)

ECG: Electro Cardiogram

ECG: Electro Cardiogram

(Figure : ECG showing Abnormal Waves)

12-lead electrocardiogram showing ST-segment elevation (orange) in I, aVL and V1-V5 with reciprocal changes (blue) in the inferior leads, indicative

of an anterior wall myocardial infarction

Arteriogram/Angiogram(2)

• Coronary Angiography + Cardiac Catheterization• Tested for chances of MI, when there’s–

• Unstable Angina• Atypical Chest Pain• Unexplained Heart Failure

• Uses X-rays and a special dye injected into the blood flow; the blood flow is screened for blocks

• Risks – • Arrhythmias, Heart Attacks, • Allergies to the dye,• Bleeding & infection at the injection site, • Blood clots, Stroke, • Blood vessel damage, • Hemorrhage, Hematoma• Kidney damage due to the dye Fig. Angiogram

Arteriogram/Angiogram(2)

Figure a.Arteriogram OR

Coronary Angiogram

Figure b.Cardiac Catheterization

Magnetic Resonance Imaging (1)

• Cardiac Nuclear Magnetic Imaging, when ECG is unclear• Avoid dangers of Angiogram, repeated exposure to radiation,

&/or use of Ionic-based dye• Used to diagnose - heart muscle damage after MI - Birth defects of the heart - Heart tumors and growths• Show - Amount of dead heart cells after MI - Heart Valve Disorders

- Pericardial Effusions - Fibrosis of Heart - Congenital Heart Abnormalities

• NO RADIATION: Radio-magnetic waves • Special dye given as IV in special tests (commonly

Gadolinium)• **Metals must be removed before the test (Magnetic Waves)

Magnetic Resonance Imaging (6)

Panels A–D: MRI study at baseline demonstrates slight apical hypokinesis in end-systolic phase (arrows in D, C = end-diastolic phase).

In A and B, short-axis delayed-enhanced MR images show multiple foci in the sub-epicardium and the midwall (arrows in A and B) and the acute ECG shows ST-elevation (arrows).

At 3-months follow-up (E–H), systolic function normalized (G and H) and delayed-enhancement demonstrates resolution of inflammatory foci (E and F, identical location as in A and B) with ECG normalization (F/u).

Radionuclide Imaging(7)

• To evaluate :

– coronary artery disease (CAD),

– valvular or congenital cardiac disorders,

– cardiomyopathy, and other cardiac disorders

• 3D images of the Heart

• Use Single Photon Emitting Computerized Tomography (SPECT)

• Radioisotopes Injected IntraVenously

• A gamma camera is used to capture the photon particles emitted from the

radioisotopes (same as Computerized Tomography)

• Camera is revolved around the patient, in an elliptical fashion, to capture

images from different angles and create a 3D image

Radionuclide Imaging(7)

(Fig.) Stress and rest images from single-photon emission computed tomography (SPECT) of a 52-yr-old man with recent-onset angina. Images obtained during stress show a large area of ischemia in the territory fed by the left anterior descending (LAD) artery that is absent at rest. Angiography confirmed a 95 to 99% occlusion involving the bifurcation of the LAD at the first diagonal branch.[Source: http://www.merck.com/mmpe/multimedia/Photo1sec07ch070.html?Ref=t&ItemId=Photo1sec07ch070&RefId=sec07/ch070/ch070i]

Laboratory Testing

• NOT much sensitive or specific – critical timing• Cardiac Markers Tested –

1. Troponin (I & T) : Structural components of cardiac muscles - Released into blood stream after MI- Elevate within 3 to 12 hours, - Uptill 5-9days (I) & 2 weeks (T)

2. Creatinine Kinase : MB fraction is more specific for MI - 15-40% of CK in Cardiac Muscle- CK MB has 2 isoforms (1&2)- Ratio of CKMB isoform 2 to 1 indicates MI (>= 1.5)

3. Myoglobin : Present in skeletal & cardiac muscles- Elevate before CKMB- Rise in Myoglobin: Size of MI, - Negative Myoglobin: No MI

4. LDH : MUST be supplemented by other tests- 5 isoenzymes (1 to 5)- Elevates within 12-24 hrs, Dissipates in 5-14 days- Peaks at 2-3 days- Isoenzyme 2 > 1 (normal); Isoenzyme 1 > 2 (MI)

Laboratory Testing

To Diagnose MI

• No laboratory tests are specific to diagnose MI • Must combine with physical examination and

various scanning tests • Physical Symptoms of MI (all or some*) :– Restlessness, Severe Distress, Increased

Respiratory Rate, Perspiration, Low-grade Fever, BP Changes, Arrhythmia, Cold & Pale Complexion

..Fred Field had NO myocardial infarction..

Question 2.

How are swollen ankles and cardiac

enlargement related to heart failure?

EDEMA in CHF

Impaired Pumping Action of Ventricles

Blood backing up in the venous side of the circulatory system

High hydrostatic pressure in the venous end of capillary beds

Water loss from plasma into interstitial spaces between cells

Edema in body & extremities (Eg. Pulmonary Edema, Edema in ankles & eyelids, etc. )

EDEMA in CHF

Fig A. Pulmonary Edema

Fig B. Edema in Extremities Fig C. Edema in Congestive Heart Failure

Cardiomegaly in CHF

Damaged Cardiac Fibers (due to MI, Cardio Myopathy, etc.)

Inefficient Cardiac Contractibility

The Need to improve Cardiac Contractibility

Inability of Cardiac cells to differentiate into Myocardium

Enlargement or Hypertrophy of the Myocardium

Increased stiffness of Heart Walls

Decreased ability of relaxation ,after contraction

Enlargement of Heart or Cardiomegaly

Cardiomegaly in CHF

Fig a. Cardiomegaly

Fig b. Cardiomyopathy

Fig c. Cardiac Hypertrophy

Question 3.

How is tissue fluid normally formed, and

how is this changed in congestive heart

failure?

Formation of Tissue Fluid

Fig A.Normal Formation of Tissue Fluid

Fig B. Fluid Retention in Congestive Heart Failure

Formation of Tissue Fluid(9) .. In Normal Condition & Congestive Heart Failure ..

Question 4.

What is the mechanism of action of

thiazide diuretics, and how may they

help patients with heart failure?

Thiazide Diuretics

????

Diuretics

Thiazide Diuretic• Derived from Benzothiadiazine

• Inhibit Na+,Cl- reabsorption (thiazidie-sensitive

symporters)

• K+ , Serum Uric Acid

• Risks of MI, CHF, stroke

• Cheap & affordable for general public

• First choice of Hypertension treatment

Thiazides

Thiazides

ThiazidesMechanism of Action of Thiazides

Thiazide

• Lowers the Blood

Pressure

• Decreases the workload

• Prevents overload of

blood in veins

• Prevents inefficient

pumping

• Prevents overwork of

heart muscles

ThiazidesMechanism of Action of Thiazides

• The Laboratory tests and Physical tests such as X-Rays, ECG, Angiogram, MRI and Radionuclide Imaging proved that Fred Field have no myocardial infarction.

• Impaired pumping action of ventricles, damaged cardiac fibres and decreased oncotic pressure at the venous end cause oedema and thus results in swollen ankles and cardiac enlargement.

• Whenever hydrostatic pressure is greater than oncotic pressure, fluid will leave the capillaries into the tissue and whenever the oncotic pressure is greater than the hydrostatic pressure fluid will enter the capillaries. If not the fluid will accumulate in the tissue and cause oedema.

• Thiazide diuretics inhibit Cl binding & transport, inhibit Na+ transport, lowers ˉ

blood pressure, decrease workload, decrease K+, increase serum uric acid and thus it decrease the risks of MI, CHF and Stroke.

SUMMARY

References1. Taylor's Cardiovascular Diseases: A Handbook by Robert B. Taylor, M.D. Editor; 2005 Springer; ISBN

0-387-22351-72. Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th Ed.; 2001 W.B. Saunders;

ISBN 0-8089-2258-03. The Physics of Coronary Blood Flow by M. Zamir; 2005 Springer; ISBN 0-387-26019-64. European Heart Journal - http://eurheartj.oxfordjournals.org/content/vol26/issue14/cover.dtl5. Medline Plus Medical Encyclopedia

- http://www.nlm.nih.gov/medlineplus/ency/article/003795.htm- http://www.nlm.nih.gov/medlineplus/ency/article/003327.htm

6. Medic Zone - http://www.mediczone.co.za/index.php?7. Chest X-ray - http://www.geocities.com/balachandiran_xray/home.htm8. Methodist Hospital System - http://www.methodisthealth.com/tmhs/mdhvc.do?channelId=-

92272&contentId=235402&contentType=SERVICE_CONTENT_TYPE9. National Library of Medicine - http://www.nlm.nih.gov/cgi/mesh/2009/MB_cgi?

mode=&term=SPECT10. Merck Manuals Online Medical Library - http://www.merck.com/mmpe/sec07/ch070/ch070i.html11. Animation on Capillary Pressure : Nursing Review – http://www.youtube.com/watch?

v=aq1pDMzYXOI12. Mayo Clinic - http://www.mayoclinic.com/health/medical/IM0210613. Experimental & Clinical Research Central Berlin –

http://www.fvk-berlin.de/kfo192/index.php?id=29