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HEART FAILURE
DEFINITION

 Heart failure is the state when the heart cannot maintain an adequate cardiac output or can
do so only at the expense of an elevated ventricular filling pressure.

CLASSIFICATION OF HEART FAILURE

According to onset PRECIPITATING / AGGRAVATING FACTORS
 Acute
 A – Arrhythmia ( eg: HF )
 Chronic
 Acute-on-chronic  B – Blood flow ( Ischemia )
 C – Compliance ( Poor compliance )
According to site  D – Demand ( eg: anemia, Hyperthy,
 Right heart failure pregnancy )
 Left heart failure  D – Drugs
 Biventricular failure ( CCF ) ( negative inotropes eg: -blockers
Fluid retaining eg: NSAID, steroids )
According to cardiac cycle  E – Pulmonary embolism
 Systolic failure  F – Fluid overload ( IV infusion )
 Diastolic failure  F – Fever / Infection

According to cardiac output

 Low-output failure
 High-output failure

According to EF
 HF with reduced EF ( <40% )
 HF with preserved EF ( ≥ 50% )

CAUSES OF HEART FAILURE

Reduced myocardial contractility COMMON CAUSES IN MYANMAR
 Myocardial infarct 1. Ischemic heart disease
 Cardiomyopathy 2. Rheumatic heart disease
 Myocarditis 3. Hypertensive heart disease
 Arrhythmia 4. Congenital heart disease
5. Cardiomyopathy
Ventricular inflow obstruction 6. Myocarditis
 MS, TS 7. Anemic HF
8. Beri Beri
Ventricular outflow obstruction
 LHF  AS, systemic hypertension
 RHF  PS, pulmonary hypertension

Reduced ventricular distensibility

 Restrictive CMP
 Cardiac tamponade
 Constrictive pericarditis

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Ventricular volume overload

 LV overload  MR, AR, VSD, PDA
 RV overload  TR, PR
 High-output  anemia, beri beri, hyperthyroid

CLINICAL FEATURES
 Age/sex – Any
 Onset – acute or chronic
 Risk factors – eg: h/o RHD, HT, IHD
 Precipitating factors – eg: poor compliance , Infections

Symptoms
1. Features of left-sided failure
 Due to reduced CO
 Muscle  fatigue, poor effort tolerance, listlessness
 Skin  cold extremities
 Kidneys  oliguria
 Due to pul: congestion
 Dyspnea, orhtopena, PND
 Cough , pink frothy serous sputum

2. Features of right-sided failure

 Due to  pul: perfusion – Dyspnea
 Due to backward congestion
 Liver  abd: discomfort
 LL  odema
 Ascites & pleural effusion ( in severe cases)

3. Features of underlying cause ( eg: chest pain )

Signs
General COMPLICATIONS OF HEART FAILURE
 Thin 1. Renal failure / Uremia
 Dyspnea / orthopnea 2. Impaired liver function
 Pitting odema 3. Electrolytes changes
( Hypo/Hyperkalaemia ,
Systemic Hyponatremia )
1. Pulse 4. Thromboembolism
 Rate – tachycardia ( both pulmonary & systemic )
 Volume – low vol: 5. Arrhythmias
 Character – pulsus alternan

2. JVP  increased
3. Precordial examination
 Features of underlying cause – murmurs

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 Features of HF – S3 / S4 / Triple rhythm / Gallop rhythm / Summation gallop /

bilateral basal crepitation

Abdomen
 Tender hepatomegaly
 Ascites

INVESTIGATIONS
For diagnosis
1. CXR
 Features of pulmonary odema
 Upper lobe veins dilatation
 Perihilar haziness
 Kerley’s B lines
 Bat wing appearance
 Small pleural effusion
 Cardiomegaly may be (+)
 Can detect underlying cause ( eg: mitrilization )

2. ECG
 Can detect underlying cause ( eg: arrhythmia, MI )

3. Echocardiogram
 For diagnosis  EF reduced
 Can detect underlying cause ( eg: valvular disease )

4. B-type Natriuretic peptide ( BNP )

 High BNP  diagnostic
 Can also use as marker of risk

For underlying cause & ppt factors

 For MI  cardiac enzymes
 For infections  Blood for CP
 For hyperthyroidism  Thyroid function tests
 For anemia  Hb%

For complications
 Liver function tests
 Urea & Cr, El

MANAGEMENT
General
 Health education – about the disease & treatment
 Diet – no added slat, weight control, adequate & balanced diet
 Exercise – regular moderate exercise ( 30min/day & 5days/week )
 Lifestyle – give up smoking, moderate alcohol is allowed ( except in alcohol-induced CMP )

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 Vaccination – consider influenza & pneumococcal vaccination

Specific
Medical Tx / Pharmacological Tx
1. Diuretics
 Action
 Reduce preload  improves pulmonary & systemic congestion 
symptomatic relief ( 1st line for symptoms )
 May reduce afterload
 Eg: Frusemide IV or Oral

2. ACEI / ARB
 Action
 Interrupt vicious cycle
 Reduces afterload & preload
 Improve effort tolerance ( ARB – better tolerated )
 Eg: ACEI ( Enalapril / Lisinopril / Ramipril ) , ARB ( Losartan / Valsartan )

3. Beta-blockers
 Action ( Use with action – Start low & Go slow )
 Improves s/s & EF
 Prevent arrhythmia & sudden death ( hospitalization & mortality )
 Bisoprolol, Carvedilol, Metoprolol succinate, Nebivolol

4. Mineralocorticoid R/c anatagonist

 Action
 Inhibit vicious cycle  aldosterone antagonist
 Can also reduce preload
 mortality when added to conventional Rx
 Eg: Spironolactone ( low dose ) or Eplerenone

5. Digoxin
 Action
 Rate control in patients with HF & AF
 Improve symptoms even in those with sinus rhythm

6. Vasodilators
 Action ( valuable in chronic HF )
 Arterial dilators eg: Hydralazine  reduces afterload
 Venodilators eg: Nitrates ( Isosorbide dinitrate )  reduce preload

7. Ivabradine
 Action
 Inhibit 𝐼𝑓 channel in SA node  reduce HR
 Reduce mortality & hospitalization

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8. Neprilysin inhibitors
 Action
 Inhibits neprilysin which is responsible for the breakdown of ANP & BNP
 Additional symptomatic & mortality benefit over ACE inhibition
 Sacubitril is the only drug of this class

Surgical Tx / Role of Surgery

1. Device therapy ( if severe symptomatic HF with medical Rx )
 Implantable cardiac defibrillator ( ICD )
 Cardiac resynchronization therapy ( CRT ) – if asso: BBB(+)
2. Coronary revascularization therapy ( in IHD )
 CABG ( Coronary Artery Bypass Graft )
 PCI ( Percutaneous Coronary Intervention )
3. Valvular Surgery ( in valvular disease )
4. Heart transplantation ( in intractable HF )

NYHA CLASSIFICATION FOR HEART FILURE

Class I No limitation during ordinary activity

Class II Slight limitation during ordinary activity
Class III Marked limitation of normal activities without symptoms at rest
Class IV Unable to undertake physical activity without symptoms, Symptoms may be
present at rest

DRUGS USED IN HEART FAILURE

1. Loop diuretics ( eg: Frusemide )

Action
 Increase Na & water excretion  preload, some degree of arterial & venous
dilatation
Role
 1st line symptomatic Rx
Side effects
 Hypotension, hypokalaemia, hypocalcemia, hyperuricemia, hyperglycemia,
dyslipidemia
Contraindications
 Sulphomaide allergy, severe Hypotension

2. ACEI ( eg: Captropril, Enalapril, Lisinopril )

Action
 Inhibit Angiotensin II synthesis  vasodilatation  afterload
 Inhibit aldosterone formation  inhibit Na & water retention  preload
 Interrupt the vicious cycle  bradykinin breakdown  vasodilation
Role
 Improvement in effort tolerance & mortality , delay the develop: of Ht failure

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Side effects
 Hyperkalaemia, 1st dose hypotension, renal dysfunction, dry cough
Contraindication
 Pregnancy, bilateral renal artery stenosis
3. ARB ( eg: Losartan, Valsartan )
Action & Side-effects & CI
 Similar to ACEI but no effect on bradykinin metabolism ( No dry cough )
Role
 ACEI + ARB – more adverse effect
Beta-blocker
4. Beta-blocker ( eg: Carvedilol, Bisoprolol )  Initiation with std dose can
Action ppt Ht failure
 Inhibit sympathetic stimulation  Given in very small dose
 Inhibit beta-1 R/c on Heart - HR & contraction under careful supervision
 Inhibit vicious cycle  Increase gradually to std Rx
Role ( start low & go slow )
 Prevent arrhythmias & sudden death
 Improve s/s & increase EF
 Reduce frequency of hospitalization & reduce mortality ( additional to ACEI )
Side-effects
 Bronchospasm, bradycardia, rebound phenomenon in abrupt withdrawal
Contraindications
 Asthma, Ht block

5. Spironolactone or Eplerenone
Action
 Inhibit vicious cycle
 Reduce preload
Role
 Reduce mortality when adding to conventional Rx
Side-effects
 Hyperkalaemia, painful gynaecomastia, menstrual inregularity

6. Digoxin
Action
 Inhibit SA node – reduce HR
 Inhibit Na-K pump – increase myocardial contraction
Role
 1st line Rx in patient with AF
 Improve s/s even in those with sinus rhythm
 No effect on overall survival but reduce hospitalization
Side-effects
 Digoxin toxicity ( Nausea, vomiting, diarrhea, VE, VF, VT, bradycardia, altered color
vision) – aggravated by hypokalaemia
Contraindication
 Hypokalaemia , Ht block, ventricular arrhythmia

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7. Vasodilators
 Venodilator ( eg: nitrates )
 Arterial dilator ( eg: hydralazine )

8. Ivabradine
Action
 Inhibit If channel in SA node  reduce HR
Role
 Reduce mortality & hospitalization