Heart Failure

Heart Failure Acute and Chronic: 

DR. S. ASWINI KUMAR. MD., Professor of Internal Medicine Government Medical college Hospital Thiruvananthapuram, Kerala, INDIA Heart Failure Acute and Chronic 1

Thing’s to learn: 

Thing’s to learn Definition Review of Physiology Classification Symptoms Signs Diagnosis Investigations Drug treatment Other advances in the management 2

Definition: 

Definition Heart Failure is a pathophysiological state in which the heart is unable to pump blood at a rate to commensurate with the requirements of the metabolizing tissues (systolic failure) or can do so only with elevated filling pressures (diastolic failure ) Eugene Braunwald 3

Another definition: 

Another definition “ Congestive heart failure (CHF) represents a complex clinical syndrome characterized by abnormalities of left ventricular function and neuro -hormonal regulation, which are accompanied by effort intolerance, fluid retention and reduced longevity” Milton Packer 4

Incidence: 

Incidence 1 % of below 50 5 % between 51-80 and 10 % above 80 years 5

Cardiac Muscle Anatomy: 

Cardiac Muscle Anatomy A syncitium of myofibrils Consists of myocytes Actin and myocin filaments Interlocking with each other Sarcoplasmic reticulum Mitochondria 6

Cardiac contraction: 

Cardiac contraction 7

Events of cardiac cycle: 

Events of cardiac cycle 8

LV pressure changes: 

LV pressure changes 9

Frank Starling’s law: 

Frank Starling’s law 10

The downhill course: 

The downhill course Heart Failure End Stage Heart Disease Congestive Heart Failure Ventricular Dilation Ventricular Remodeling Loss of Cardiac Muscle Cardiac Arrhythmias Myocardial Infarction Myocardial Ischemia Coronary Artery Disease Endothelial Dysfunction Genetic Predisposition Valvular Heart Disease 11

Vicious cycle of CHF: 

Vicious cycle of CHF 12

Neurohumeral Mechanisms: 

Neurohumeral Mechanisms Volume receptors in the heart and large vessels Stimulate cardio-respiratory centers Act via sympathetic system to stimulate ADH 13

Slide 14: 

Primary Heart Injury Ventricular Dysfunction Primary Pump Failure Heart Remodeling Neuro -endocrine response Death Growth Factors Symptoms 14

Slide 15: 

Aortic valve disease Elevated LVEDP Mitral valve disease Elevated LA Pressure Elevated PV Pressure Passive transmission Pulmonary Edema PA Vasoconstriction Pulmonary vascular changes Pulmonary Arterial Hypertension RVH followed by RVE TR RAE and CHF Pathophysiology 15

Pathology of Heart failure Hypertrophic Cardiomyopathy: 

Pathology of Heart failure Hypertrophic Cardiomyopathy 16

Pathology of Heart failure Dilated Cardiomyopathy: 

Pathology of Heart failure Dilated Cardiomyopathy 17

Terms to learn: 

Terms to learn 18

Preload - definition: 

Preload - definition Preload is the maximum stretching force exerted on the ventricular muscle at the end of diastole caused by the end-diastolic volume of blood 19

Preload: 

Preload 20

Afterload - definition: 

Afterload - definition Afterload is the pressure that the chambers of the heart have to generate in order to eject blood out of the heart and thus is a consequence of aortic and pulmonic pressures 21

After load: 

After load 22

Classifications : 

Classifications 23

Slide 24: 

Forward Failure Backward Failure Reduction in cardiac output Pulmonary/systemic venous congestion Aorta Tissues LV LA 24

Slide 25: 

25

Most important: 

26 Most important

Normal Heart Function: 

Fill normally during diastole Ejection Fraction: 65-70% 27 Normal Heart Function

Systolic Heart Failure: 

Ventricles are dilated Ejection Fraction: 40-50% Systolic Heart Failure 28

Systolic failure -causes: 

Systolic failure -causes Coronary artery disease Myocarditis Heart valve disorders Pulmonary hypertension 29

Diastolic Heart failure: 

Ventricles stiff EF: 50-60% Diastolic Heart failure 30

Diastolic Failure- Causes: 

Diastolic F ailure- Causes High blood pressure Aortic valve stenosis Constrictive pericarditis Amyloidosis 31

Right Heart Failure: 

Right Heart Failure Raised JVP Hepatomegaly Edema Venous congestion Causes Pulmonary artery hypertension Pulmonary artery stenosis Pulmonary embolism 32

Left Heart Failure: 

Left Heart Failure Breathlessness Tachycardia Gallop rhythm B/L basal crepitations Causes Mitral/aortic valve disease Chronic Ischemic heart disease Systemic hypertension 33

Essential classification: 

34 Essential classification

Acute Pulmonary Edema: 

Acute Pulmonary Edema 35

Left Heart Failure -Features: 

Left Heart Failure -Features Shortness of breath, Orthopnoea and PND Cough and wheezing-cardiac asthma Normal or low volume pulse, Pulsus alternans Normal or low systolic BP, Cardiomegaly Tachycardia and gallop rhythm Bilateral basal crepitations 36

Orthopnoea: 

Orthopnoea 37

Paroxysmal Nocturnal dyspnoea: 

Paroxysmal Nocturnal dyspnoea 38

Cheyne-Stokes Breathing: 

Cheyne - Stokes Breathing 39

Differential Diagnosis of LVF: 

Differential Diagnosis of LVF Acute Pulmonary Edema Acute severe asthma Acute Exacerbation of COPD Pneumothorax Pneumonia Pulmonary embolism Acute respiratory Distress Syndrome Inhalation of foreign body Laryngeal edema 40

Symptoms of Rt Heart Failure: 

Symptoms of Rt Heart Failure 41

Observation of JVP: 

Observation of JVP 42

Measurement of JVP: 

Measurement of JVP 43

Ascites: 

Ascites 44

Bilateral Pedal Edema: 

Bilateral Pedal Edema 45

Chest X-Ray in LVF: 

Chest X-Ray in LVF Cardiomegaly Prominent UL veins Full fuzzy hilum Bilateral hydrothorax Kerly B lines Butterfly distribution Bat wing appearance 46

ECG in LVF: 

ECG in LVF 47

X-Ray in CHF: 

X-Ray in CHF 48

Differential Diagnosis of CHF: 

Differential Diagnosis of CHF Chronic Congestive heart failure Chronic Obstructive Pulmonary Disease Chronic Asthma Chronic Pulmonary thromboembolism Interstitial lung disease Fibrosing alveolitis Extrinsic allergic alveolitis Lymphangitis carcinomatosis Large pleural effusions 49

Management Principles: 

Management Principles Heart Failure 50

Management of LVF: 

51 Management of LVF

Propped up Position Gives comfort to the patient: 

Propped up Position Gives comfort to the patient 52

Oxygen Inhalation 100% oxygen 4-6 liters per minute through face mask: 

Oxygen Inhalation 100% oxygen 4-6 liters per minute through face mask 53

Injection Morphine 15 mg in 1ml ampoule diluted with 9ml of NS; 1.5-3.0mg given slow IV stat and repeated SOS till relieved : 

Injection Morphine 15 mg in 1ml ampoule diluted with 9ml of NS; 1.5-3.0mg given slow IV stat and repeated SOS till relieved 54

Injection Frusemide 20-80mg IV Stat, BID or q8h as indicated: 

Injection Frusemide 20-80mg IV Stat, BID or q8h as indicated 55

Physiological Venesection Tying and rotating tourniquets in 3 limbs at atime : 

Physiological Venesection Tying and rotating tourniquets in 3 limbs at atime 56

Positive Pressure Ventilation inpatients not relieved with previous methods: 

Positive Pressure Ventilation inpatients not relieved with previous methods 57

Nitrate Injection Low dose infusions in resistant case: 

Nitrate Injection Low dose infusions in resistant case 58

Surgical Venesection Cautious removal of 150-200ml of venous blood : 

Surgical Venesection Cautious removal of 150-200ml of venous blood 59

Intra-aortic balloon counterpulsation: 

Intra-aortic balloon counterpulsation 60

Intra-aortic balloon pump: 

Intra-aortic balloon pump 61

Management of CHF: 

Management of CHF 62

Medical Treatment: 

Medical Treatment 63

The Donkey Analogy: 

The Donkey Analogy Ventricular dysfunction limits patient's ability to perform routine activities of daily living 64

Diuretics: 

Diuretics 65

Diuretic Therapy: 

Diuretic Therapy 66

Benefits of Diuretics: 

Benefits of Diuretics 67

Diuretics-limitations: 

Diuretics-limitations 68

ACE Inhibitors: 

ACE Inhibitors 69

Comparison: 

Comparison 70

ACE Inhibitors: 

ACE Inhibitors 71

Diuretics and ACE inhibitors: 

Diuretics and ACE inhibitors Reduce number of sacks on the wagon 72

The treatment paradigm: 

The treatment paradigm 73

The role of chronic adrenergic activation: 

The role of chronic adrenergic activation 74

Carvidilol in CHF: 

Carvidilol in CHF 75

B Blockers: 

B Blockers Limit the donkey’s speed, thus saving energy 76

Digitalis purpurae (Foxglove) : 

Digitalis purpurae (Foxglove) 77

Mechanism of action : 

Mechanism of action 78

Digoxin - dose: 

Digoxin - dose 79

Digoxin toxicity: 

Digoxin toxicity 80

Why sudden cardiac death?: 

Why sudden cardiac death? 81

Ventricular Fibrillation: 

Ventricular Fibrillation 82

What happens to the patient?: 

What happens to the patient? 83

Prevention of Sudden Cardiac death: 

Prevention of Sudden Cardiac death 84

What can it do?: 

What can it do? 1. Anti Tachycardia Pacing 2. Defibrillation 85

What is Cardiac Desynchrony?: 

What is Cardiac Desynchrony ? Intra-ventricular conduction is depressed L eads to dysynchrony of cardiac contraction Manifest as prolongation of QRS complex Impairs cardiac function and thus aggravates HF 86

Cardiac Resynchronization Therapy: 

Cardiac Resynchronization Therapy 87

Cardiac Resynchronization : 

Cardiac Resynchronization 88 Increases the donkey’s (heart’s) efficiency

Slide 89: 

Limit the donkey’s speed, thus saving energy Reduce the number of sacks on the wagon Like the carrot placed in front of the donkey Increases the donkey’s (heart’s) efficiency 89

Heart Transplantation: 

Heart Transplantation 90

Hearts in short supply: 

Hearts in short supply Available hearts 91

Left Ventricular Assist Device: 

Left Ventricular Assist Device 92

Indications of LVAD: 

Indications of LVAD 93

Mechanical Ventricular Constraint: 

Mechanical Ventricular Constraint Don’t have money? 94

The Acorn CorCap® Cardiac Support Device: 

The Acorn CorCap ® Cardiac Support Device 95

Cost Effectiveness: 

Cost Effectiveness Very cheap? $0 $ 100,000 $ 200,000 $300,000 0 1 2 3 4 5 6 7 8 9 10 11 12 Weeks Dollars Electric System Air-driven System ICU Rs 15,00,000 Rs 10,00,000 Rs 6,00,000 3 months 96

Money or Heart: 

Money or Heart 97

Total Artificial Heart: 

Total Artificial Heart Bridge the gap to OHT 98

Risk: 

Risk Breakdown Rejection 99

A genetically cloned heart: 

A genetically cloned heart Complete new organ No rejection 100

Slide 101: 

101 Reduce risk factors, Educate patient and family Treat Hypertension, Diabetes, Dyslipidemia ACI-Is or ARBs in all, B Blockers in selected ACI-Inhibitors and B Blockers in all patients Dietary sodium restriction, Diuretics, Digoxin Cardiac Resynchronization if LBBB present Revascularization, Mitral Valve Surgery Aldosterone Antagonists, Eg . Nesiritide Inotropes - Dobutamine Dopamine LVAD, Restraint, Transplantation Hospice Stage A High risk with no symptoms Stage B Structural Heart Disease No symptoms Stage C Structural Disease Current symptoms Stage D Refractory Symptoms Special Intervention Summary and Conclusions

Slide 102: 

Thank You 102 Save Y our Heart