heart Failure

Cardiac failureCardiac failureBy Dr. Osman BukhariBy Dr. Osman Bukhari

Cardiac failureCardiac failure: : - Occurs when the heart is unable - Occurs when the heart is unable to maintain sufficient cardiac to maintain sufficient cardiac output to meet the demands of output to meet the demands of the bodythe body..

- - Incidence Incidence increases with ageincreases with age..

- - Many pts. are Many pts. are admitted repeatedlyadmitted repeatedly..

- - Despite improvement in Despite improvement in management management mortality is still mortality is still highhigh

PathophysiologyPathophysiology.…….……

Manifestations of cardiac failureManifestations of cardiac failure::

11 - -Left cardiac failureLeft cardiac failure::

- - SymptomsSymptoms include: fatigue, exertional include: fatigue, exertional dyspnoea, orthopnoea & dyspnoea, orthopnoea & paroxysmal nocturnal dyspnoeaparoxysmal nocturnal dyspnoea..

- - SignsSigns include: Cardiomegaly with include: Cardiomegaly with displaced & often sustained apical displaced & often sustained apical impulse, triple & gallop rhythm, impulse, triple & gallop rhythm, basal lung crackles, pulsus basal lung crackles, pulsus alternans, functional MR & alternans, functional MR & pulmonary edemapulmonary edema..

Cardiomegaly

LVF & pulmonary oedema

CausesCauses-:-: 11 - -HTHT..

22 - -Ischemic heart diseaseIschemic heart disease..

33 - -Ao stenosis & regurgitationAo stenosis & regurgitation..

44 - -Mitral regurgitationMitral regurgitation..

55 - -CardiomyopathyCardiomyopathy..

66 - -Myocarditis. Myocarditis. 7- arrhythmias 7- arrhythmias..

88 - -High output states (anemia , A-V High output states (anemia , A-V fistula, thyrotoxicosis, PDA, pagets fistula, thyrotoxicosis, PDA, pagets disease of bone, beri-beri & disease of bone, beri-beri & gram negative septicemia.)gram negative septicemia.)

22 - -Right cardiac failureRight cardiac failure:: - - Symptoms Symptoms include: include:

- fatigue, anorexia and nausea - fatigue, anorexia and nausea related to distension and fluid related to distension and fluid accumulation in areas drained accumulation in areas drained by systemic veinsby systemic veins..

- - Rt hypochondrial painRt hypochondrial pain

- - swelling of of the LLsswelling of of the LLs

- -Signs:Signs: include: include: - - increased JVP increased JVP - tender smooth hepatomegaly - tender smooth hepatomegaly - dependent pitting edema - dependent pitting edema - ascites & pleural - ascites & pleural transudates - tachycardia. transudates - tachycardia. - LPH, TR, - LPH, TR, Rt. S3Rt. S3

Pitting oedema of the LL

CausesCauses 11 - -Lt heart failureLt heart failure

22 - -Chronic lung disease (core Chronic lung disease (core pulmonale)pulmonale)

33 - -Pulm embolismPulm embolism

44 - -Pulm HTPulm HT

55 - -Tricuspid valve disTricuspid valve dis..

66 - -Pulm valve disPulm valve dis

77 - -Lt to Rt shunts ( ASD , VSD)Lt to Rt shunts ( ASD , VSD) 8- isolated Rt. Vent. 8- isolated Rt. Vent. CardiomyopathyCardiomyopathy

99 - -IHDIHD..

1010 - -Constrictive pericarditis & cardiac Constrictive pericarditis & cardiac tamponade tamponade..

1111 - -High output statesHigh output states..

33 - -CCF: CCCF: Combines both Lt & Rt HFombines both Lt & Rt HF..

Acute heart failureAcute heart failure 11 - -Extensive acute MIExtensive acute MI..

22 - -Rupture of IVS producing VSDRupture of IVS producing VSD..

33 - -Papillary or chordal rupture in Papillary or chordal rupture in endocarditis producing MR endocarditis producing MR 4- Sudden Ao valve rupture in 4- Sudden Ao valve rupture in endocarditis endocarditis 5- Acute pulmonary 5- Acute pulmonary embolism & cardiac tamponadeembolism & cardiac tamponade..

In all these conditions the heart In all these conditions the heart size size is is relatively normalrelatively normal..

High output statesHigh output states are associated are associated with with tachycardia, gallop rhythmtachycardia, gallop rhythm & & patients are often patients are often warm with warm with distended veinsdistended veins..

Factors precipitating HF in Factors precipitating HF in controlled patientscontrolled patients..

11 - -Increased salt intakeIncreased salt intake . .

22 - -Uncontrolled HTUncontrolled HT..

33 - -Anaemia & pregnancyAnaemia & pregnancy..

44 - -Fluid overloadFluid overload..

55 - -MIMI..

66 - -Arrhythmias specially AFArrhythmias specially AF..

77 - -Pulm. EmbolismPulm. Embolism..

88 - -Infections sp. chest infections Infections sp. chest infections causing hyperdynamic causing hyperdynamic circulation. 9-circulation. 9-ThyrotoxicosisThyrotoxicosis..

1010 - -Drug non complianceDrug non compliance..

1111 - -Renal failureRenal failure secondary to diuretic secondary to diuretic induced volium depletion or induced volium depletion or due to intrinsic renal diseasedue to intrinsic renal disease..

Investigations in HFInvestigations in HFThis is to confirm HF & to establish the This is to confirm HF & to establish the underlying cause underlying cause..

11 - -CXRCXR: Shows cardiac size & evidence : Shows cardiac size & evidence of pulmonary congestion (upper of pulmonary congestion (upper lobe venous diversion; bat win lobe venous diversion; bat win appearanceappearance

in pulm oedemain pulm oedema(( 22 - -ECGECG: Shows arrhythmias, ischemia , : Shows arrhythmias, ischemia ,

chamber hypertrophy etc chamber hypertrophy etc . . 33 - -EchoEcho: (2- dimentional & doppler : (2- dimentional & doppler

echo) show valves, chambers echo) show valves, chambers size, ejection fraction, intracardiac size, ejection fraction, intracardiac

thrombithrombi . .

CXR with right apical fibrosis

Electrocardiogram

Echocardiography

44 - -CBC, LFT & blood urea & CBC, LFT & blood urea & electrolyteselectrolytes..

55 - -Cardiac enzymesCardiac enzymes in acute MI in acute MI

66 - -Cardiac catherizationCardiac catherization..

77 - -Ambulatory ECGAmbulatory ECG monitoring in monitoring in suspected arrhythmias suspected arrhythmias..

88 - -Stress ECGStress ECG . .

Coronary angiography

Treatment of HFTreatment of HF Preventive measures in HFPreventive measures in HF include include: :

- Cessation of smoking - Cessation of smoking - Control of DM - Control of DM - Effective treatment of HT - Effective treatment of HT - TR of - TR of hypercholesterolemia - hypercholesterolemia - pharmacological TR following MIpharmacological TR following MI..

TR of chronic HF aims atTR of chronic HF aims at: : - - Relieving symptoms, Relieving symptoms, - Retarding disease - Retarding disease progression, - Correction of progression, - Correction of the cause , -TR of the cause , -TR of aggravating factors, - aggravating factors, - Compliance with drug therapy. Compliance with drug therapy. - Improving survival - Improving survival , ,

11 - -General TRGeneral TR:: - - Physical activityPhysical activity: ranges from bed : ranges from bed

rest in severe HF to low level rest in severe HF to low level exercise in compensated HF . exercise in compensated HF . Avoid strenuous exerciseAvoid strenuous exercise..

- - Dietary modificationsDietary modifications: WT : WT reduction, salt restriction, reduction, salt restriction, alcohol abstinence & fluid alcohol abstinence & fluid restriction in severe HF restriction in severe HF and dilutional hyponatraemiaand dilutional hyponatraemia..

- - EducationEducation..

22 - -Drug TR Of Drug TR Of HF( Pharmacotherapy)HF( Pharmacotherapy)

- - DiureticsDiuretics

- - VasodilatorsVasodilators

- - DigoxinDigoxin

- -AntiarrhythicsAntiarrhythics

- - AnticoagulantsAnticoagulants

- - Inotropic drugsInotropic drugs

- - B BB B

- - StatinsStatins

22 - -Drug TR Of HF( Pharmacotherapy)Drug TR Of HF( Pharmacotherapy)

11 - -DiureticsDiuretics:: Act by promoting renal excretion of Act by promoting renal excretion of

salt and water reducing preload & salt and water reducing preload & rapidly improves dyspnoea & rapidly improves dyspnoea & systemic congestion. They systemic congestion. They also cause arteriolar vasodilatation also cause arteriolar vasodilatation

reducing after loadreducing after load . .

- -Loop diureticsLoop diuretics: e.g. frusemide (lasix) : e.g. frusemide (lasix) have a rapid onset of action & short have a rapid onset of action & short duration of action.They cause duration of action.They cause hypokalaemia ( hypokalaemia ( add slow-Kadd slow-K))

bb-Thiazide diuretics-Thiazide diuretics: e.g. : e.g. hydrochlorothiazidehydrochlorothiazide and and ChlorthalidoneChlorthalidone have mild diuretic have mild diuretic effect, but act synergistically effect, but act synergistically when combined with loop when combined with loop diuretics. Not effective in renal diuretics. Not effective in renal impairment. impairment. MetolazoneMetolazone is a powerful thiazide & is is a powerful thiazide & is combined with loop diuretics in combined with loop diuretics in

severe and resistant HFsevere and resistant HF . .

* *Loop & thiazide diuretics have no Loop & thiazide diuretics have no proven survival benefit. They give proven survival benefit. They give symptomaticsymptomatic relieve relieve

cc- Potassium sparing diuretics- Potassium sparing diuretics: : Care with ACE-I & avoided in Care with ACE-I & avoided in renal impairment . renal impairment . SpironolactoneSpironolactone reduces reduces mortality in doses of up to 25 mortality in doses of up to 25 mg when added to conventional mg when added to conventional therapy in moderate to severe therapy in moderate to severe HF. Risk of hyperkalaemia is HF. Risk of hyperkalaemia is high with doses of > 50 mghigh with doses of > 50 mg....

Ameloride & triamtereneAmeloride & triamterene are weak are weak but useful when combined with but useful when combined with

loop diureticsloop diuretics....

22 - -Vasodilater therapyVasodilater therapy::

a- ACE-Isa- ACE-Is

- - reduce after load & pre load reduce after load & pre load - reduce circulating levels of - reduce circulating levels of catecholamines, catecholamines, - reduce BP - reduce BP - reduce cardiac dilatation - reduce cardiac dilatation & CCF after extensive MI & CCF after extensive MI - improve exercise - improve exercise tolerance & survival in pts. with tolerance & survival in pts. with

severe HFsevere HF . .

- - ACE-I should be carefully introduced ACE-I should be carefully introduced in pts. on high doses diuretics & in pts. on high doses diuretics & in the presence of in the presence of hyponatraemia. - Care hyponatraemia. - Care with K- sparing diureticswith K- sparing diuretics..

b- ARBsb- ARBs have similar effects to ACE-I but have similar effects to ACE-I but do not affect bradykinin metabolism do not affect bradykinin metabolism . .

c- c- Alpha blockersAlpha blockers (prazocin) & direct (prazocin) & direct smooth muscle relaxantssmooth muscle relaxants (hydralazine) (hydralazine) are not very effective in HF. are not very effective in HF. CCBsCCBs reduce after load but have no reduce after load but have no prognostic benefit in HF. Diltiazem and prognostic benefit in HF. Diltiazem and verapamil are CI in HFverapamil are CI in HF..

d-d- NitratesNitrates (glyceride trinitrates and (glyceride trinitrates and isosorbide mononitrates) reduce isosorbide mononitrates) reduce preload and reduce pulm edema.Only preload and reduce pulm edema.Only

combination with hydralazine have combination with hydralazine have proven prognostic value proven prognostic value..

33 - -BBBB used in pts. with chronic stable used in pts. with chronic stable HF (e.g. metoprolol, bisoprolol, HF (e.g. metoprolol, bisoprolol, atenolol and carvedilol), atenolol and carvedilol), improve symptoms, improve symptoms, exercise tolerance, LV exercise tolerance, LV function and mortality in pts. with function and mortality in pts. with HF. Initial doses should be lowHF. Initial doses should be low..

44 - -Inotropic drugsInotropic drugs:: - -Digoxin - SympathomimeticDigoxin - Sympathomimetic

DigoxinDigoxin : : - cardiac glycoside, It blocks AV - cardiac glycoside, It blocks AV node and increases myocardial node and increases myocardial contractility. - used in severe HF contractility. - used in severe HF with conventional therapy, AF, with conventional therapy, AF, atrial flutter & SVT. - 90% is atrial flutter & SVT. - 90% is excreted unchanged in urine and excreted unchanged in urine and accumulation can occur in renal accumulation can occur in renal failure. Digitoxin is used In renal failure. Digitoxin is used In renal failure. failure. - Usual dose is 0.125-0.25 mg/d. with - Usual dose is 0.125-0.25 mg/d. with dose of 1mg in emergency dose of 1mg in emergency

Dose is reduced inDose is reduced in::

11 - -elderly elderly 2- renal failure 2- renal failure

33 - -hyperthyroidism hyperthyroidism 4- quinine therapy 4- quinine therapy

55 - -electrolyte disturbance e.g. electrolyte disturbance e.g. Hypokal & hypo Mg. Hypokal & hypo Mg. IV Ca is dangerous in IV Ca is dangerous in digitalized ptsdigitalized pts..

- - SE of DigoxinSE of Digoxin include: include: HA, fatigue, muscle weakness, abd. HA, fatigue, muscle weakness, abd. Pain, N, V, Wt. loss & gynaecomastia Pain, N, V, Wt. loss & gynaecomastia..

- - Digoxin toxicityDigoxin toxicity include: include: anorexia, N, V, coloured vision with anorexia, N, V, coloured vision with halo around objects (xanopsia), halo around objects (xanopsia), arrhythmias & fits. arrhythmias & fits. - - TR of digoxin toxicityTR of digoxin toxicity: : By stopping the drug, restoration of By stopping the drug, restoration of ser. K and management of ser. K and management of arrhythmias. Digoxin abs. in life arrhythmias. Digoxin abs. in life threatening toxicity threatening toxicity..

Adr., dobutamine, dopexopamine & Adr., dobutamine, dopexopamine & dopaminedopamine are IV adrenergic agonist. are IV adrenergic agonist. They increase CO & improve perfusion They increase CO & improve perfusion but increase myocardial O2 requirements but increase myocardial O2 requirements & aggravate cardiac ischemia. Volume & aggravate cardiac ischemia. Volume depletion should be corrected before depletion should be corrected before their use. Main use in pts. with acute LVF, their use. Main use in pts. with acute LVF, following cardiac surgery & in pts. with following cardiac surgery & in pts. with end stage HF as a bridge to end stage HF as a bridge to transplantationtransplantation..

Dobutamine is a B2 agonist increasing is a B2 agonist increasing cardiac contraction & has vasodil. cardiac contraction & has vasodil. effect by alpha blocker effect. Dose effect by alpha blocker effect. Dose 2.5-10 mcg/kg/minute2.5-10 mcg/kg/minute..

DopexamineDopexamine is B2 agonist with is B2 agonist with additional action on peripheral additional action on peripheral dopamine receptors improving renal dopamine receptors improving renal perfusionperfusion..

DopamineDopamine in low dose (2-4 in low dose (2-4 mcg/kg/min.) improves renal mcg/kg/min.) improves renal perfusion. In dose of 4- 10 perfusion. In dose of 4- 10 mcg/kg/min. increases HR & cardiac mcg/kg/min. increases HR & cardiac contractility. Higher doses increase BP contractility. Higher doses increase BP

at the expense of tissue perfusionat the expense of tissue perfusion . .

NoradrNoradr. Raise BP by peripheral . Raise BP by peripheral vasoconstriction vasoconstriction..

55 - -AnticoagulantsAnticoagulants to prevent to prevent thromboembolism in pts. with AF , thromboembolism in pts. with AF , endocardial thrombus & PH of endocardial thrombus & PH of thromboembolism thromboembolism..

66 - -Antiarrhythmic agentsAntiarrhythmic agents:: - - Drugs - DC shockDrugs - DC shock

- - Implantable cardiovertor - Implantable cardiovertor - defibrillatordefibrillator

) ) ICDICD(( 77 - -StatinsStatins

BB, ACE-I, statins & spironolactone may BB, ACE-I, statins & spironolactone may reduce sudden death in pts. with MI and reduce sudden death in pts. with MI and

HFHF..

Non-pharmacological Tr. of Non-pharmacological Tr. of HFHF: : 1- Revascularization1- Revascularization..

22 - -Pacemaker or ICDPacemaker or ICD..

33 - -Valvular surgeryValvular surgery & correction of & correction of other causes of HFother causes of HF..

44 - -Cardiac transplantationCardiac transplantation..

55 - -Ultra-filtrationUltra-filtration..

66 - -Intra-aortic balloon pumpIntra-aortic balloon pump..

Pace maker

In In summarysummary: : 1- All pts. with clinical HF 1- All pts. with clinical HF should receive diuretics & should receive diuretics & ACE-I. 2- Patients with AF ACE-I. 2- Patients with AF should be digitalizedshould be digitalized..

33 - -Pts. in SR improve with addition Pts. in SR improve with addition of Digoxin or BBof Digoxin or BB . .

44 - -Pts. with asymptomatic LV Pts. with asymptomatic LV dysfunction benefit from dysfunction benefit from prophylactic ACE- I prophylactic ACE- I therapy ortherapy or ARBARB

55 - -Pts. with ischemic HF & Pts. with ischemic HF & intolerant to ACE-I or in whom intolerant to ACE-I or in whom it is CI may benefit from it is CI may benefit from

nitrate/ hydralazine therapynitrate/ hydralazine therapy . .

66 - -Spironolactone should be Spironolactone should be addedadded..

Pulmonary edemaPulmonary edema - - Life-threatening emergencyLife-threatening emergency..

- - Usually preceded by PNDUsually preceded by PND..

- - Interstitial edema usually occurs Interstitial edema usually occurs with capillary pressure of 20 with capillary pressure of 20

mmHgmmHg . .

- - Alveolar edema occurs with Alveolar edema occurs with pressure of 25-30 mmHgpressure of 25-30 mmHg..

- - Causes are those of LVF, MS & Causes are those of LVF, MS & increased pulmonary capillary increased pulmonary capillary permeability (Adult RDS)permeability (Adult RDS)..

Pulmonary oedema

Clinical featuresClinical features include include:: - - Extreme SOB Extreme SOB

- Wheezing - Wheezing.. - - Anxiety & sweatingAnxiety & sweating..

- - Cough with frothy blood tinged Cough with frothy blood tinged sputumsputum..

- - Tachypnea, cyanosis, tachycardia Tachypnea, cyanosis, tachycardia andand

gallop rhythmgallop rhythm . . - - Crackles & wheeze in z chestCrackles & wheeze in z chest..

- - Low arterial PO2Low arterial PO2.. - - CXR shows diffuse haziness & bat CXR shows diffuse haziness & bat

wing appearancewing appearance..

TreatmentTreatment Include Include:: - - Admission in CCU. Admission in CCU.

- Cardiac bed - Cardiac bed.. - - Continuous flow high O2 conc and inContinuous flow high O2 conc and in

severe cases pt. is ventilatedsevere cases pt. is ventilated.. - - IV morphine 10-15 mg( + antemetic)IV morphine 10-15 mg( + antemetic) . .

Avoided if SBP < 90Avoided if SBP < 90 - - IV loop diuretic which produces IV loop diuretic which produces

immediate vasodilt. In addition to immediate vasodilt. In addition to more delayed diuresis more delayed diuresis . .

- - Venodilt. & arterial vasodilators to Venodilt. & arterial vasodilators to decrease pre-load & after load decrease pre-load & after load..

- -Aminophylline 5 mg/kg IV ( 250-Aminophylline 5 mg/kg IV ( 250-500) slowly to avoid the risk of 500) slowly to avoid the risk of precipitating ventricular precipitating ventricular arrhythmias. It is arrhythmias. It is bronchodilator., vasodilt. & increases bronchodilator., vasodilt. & increases cardiac contractility. Usually used cardiac contractility. Usually used when bronchospasm is presentwhen bronchospasm is present..

- - Monitor rhythm, O2 saturationMonitor rhythm, O2 saturation.. - - Venesection & mechanical methods Venesection & mechanical methods

of reducing venous return are of reducing venous return are ineffective and rarely usedineffective and rarely used..

- - Treat precipitating factors Treat precipitating factors (arrhythmias, chest infection, etc.)(arrhythmias, chest infection, etc.)

- - Correct the underlying cause of Correct the underlying cause of increased pulmonary increased pulmonary capillary permeability capillary permeability (toxins, hypoxia, (toxins, hypoxia, infections, DIC, etc.)infections, DIC, etc.) . .