Heart failure

Presenter – Kalema James (MBChB V)

Facilitator - Dr Eleku Simon (Physician)
 Outline
• Definition
• Epidemiology
• Classification
• Pathophysiology
• Diagnosis
• Management
• Prognosis
 Heart failure
• Clinical syndrome that develops when the
heart cannot maintain adequate output to
meet the metabolic needs of peripheral
tissue , or can only do so at the expense of
elevated ventricular filling pressure
 Epidemiology
• HF predominantly affects elderly
• Affects approx 64m worldwide
• Prevalence 1-2% of adults, upto >10% in 70yrs
and above
• In LMIC – untreated HTN, RHD
• Global incidence – 1-10 cases per 1000persons
annually
• HF is the leading cause of hospitalisation in
people >65years
 Classification of HF
Based on
• Duration
• Clinical presentation
• Cardiac output
• Ejection fraction
• NYHA
• ACC/AHA
 Classification of HF
• Duration
• Acute – sudden onset of symptoms (MI,
valvular rupture, arrhythmias, acute infections
or fluid overload)
• Chronic – long standing, progressive with
episodic exacerbations (underlying structural
dz - DCM)
 Classification of HF
• Clinical presentation
• LVF – HTN, MI, aortic stenosis
• RVF – Chronic lung dz, LVF, pulmonary valvular
stenosis
• BVF – IHD, dilated cardiomyopathy (DCM)
 Classification of HF
• Cardiac output
• High output HF – S. anemia, thyrotoxicosis, AV
fistula, preg, beriberi, sepsis – severe
vasodilation
• Low output – MI, valvular HD, cardiomyopathy
Functional classification
 Classification of HF
• ACC/AHA – stages of disease progression
A. High risk for HF but no structural HD or Sx –
HTN, DM, obesity, metabolic syndrome
B. Structural HD without Sx – LVH, valvular dz,
low EF
C. Structural HD with current or prior Sx
D. Refractory HF requiring specialized
interventions - inotropes, VAD
Pathophysiology

Starling’s law
CO is determined
by
• preload
• afterload
• myocardial
contractility
 Pathophysiology cont’d…
• Ventricular dysfunction – commonest
• Due to impaired systolic contraction because of myocardial disease
• Or diastolic dysfunction – non-compliant ventricle.
• This is most commonly found in patients with LVH.
• Systolic and diastolic dysfunction often coexist, particularly in patients
with CAD
• Overall – reduction in CO
• Activation of SNS and RAAS
• Normally, these supports cardiac function
• But, in the setting of impaired ventricular function, the consequences
are negative and lead to an increase in both afterload and preload
• A vicious circle ensues worsening CO each time
 Pathophysiology cont’d…
Compensatory mechanisms
• Cardiac
• Homeostatic
• Neuro-hormonal
• Cardiac remodelling
 Risk factors
Primary Contributing
• Advancing age • HTN
• CAD • DM
• Tobacco
• Thyroid dysfunction
• Obesity
• Hypercholesteremia
• Valvular HD
 Etiology
• Volume over load: Regurgitant valve, High output status,
ASD, PDA
• Pressure overload: Systemic HTN, pulmonary HTN
Outflow obstruction
• Loss of muscles: Post MI, Chronic ischemia
Connective tissue diseases
Infection, Poisons (alcohol,cobalt,Doxorubicin)
• Restricted Filling: Pericardial diseases, Restrictive
cardiomyopathy, tachyarrhythmia
• inflow obstruction : mitral stenosis, tricuspid stenosis,
EMF
Impaired ventricular function – MI, myocaditis,
endocarditis, cardiomyopathy
 Aggravating factors
• F – forgot meds
• A – arrhythmias/anemia
• I – ischemia/infarction/infection
• L – lifestyle (too much salt intake)
• U – upregulated states
• R – renal failure
• E – pulmonary embolism
 Clinical presentation - Hx
• CVS – Dyspnea (exertional, orthopnea, PND),
nocturnal cough, fatigue, poor effort
intolerance, bilateral LL swelling
• GI - anorexia, nausea, early satiety, RUQ abd
pain & fullness
• CNS – headache, dizziness, confusion
• GU – reduced urinary frequency
Examination
 Clinical presentation - Exam
• General – distress, weakness, cyanosis, cool clammy
skin, peripheral edema
• CVS – cool extremities, tarchycardia,
hypo/hypertension, raised JVP, Hepatojugular reflux,
displaced apex beat, prominent P2, S3, basal
crackles
• Resp – tarchypnea, Hypoxia, use of accesory
muscles, expiratory wheeze, pleural effusion
• P/A – abd distension, ascites, tender hepatomegaly
• CNS - Lethargy
Warm vs cold, Wet vs Dry
 Heterogeneity of Acute HF
1. Acute decompensation (typical) – volume
overload
2. Acute decompensation (low output) –
volume overload + hypoperfusion with EOD
3. Acute pulmonary edema – severe pulmonary
congestion + hypoxia
4. Cardiogenic shock – hypotension with low CO
+ EOD
 Framingham Criteria for Dx of Heart
Failure
• Major Criteria:
Minor criteria
– PND
– JVD • Bilateral ankle
– Rales edema,
– Cardiomegaly • Night cough
– Acute Pulmonary Edema
• Dyspnea on exertion
– S3 Gallop
– Positive hepatic Jugular reflux • Hepatomegaly
– ↑ venous pressure > 16 cm • Pleural effusion
H2O
– Weight loss > 4.5 kg over 5 • Tachycardia >120
days management bpm
 Evaluation
Comorbidities Diagnostic
• CBC
• BNP
• Urinalysis
• Extended serum electrolytes • ECG
• BUN & creatinine • Echocardiography
• RBS, HBA1c
• Chest X-ray
• Fasting lipid profile
• LFT • Coronary angiography
• TSH • Cardiac MRI
• Serum iron, TIBC
• ABG
• Cardiac troponins
 Biomarkers
1. BNP
• Acute HF - >100pg/dl, CHF - >35pg/dl
• Sensitive marker for HF
• Supports dx, prognosis
• False positive – acute cardiac illness, sepsis, PE,
AKI
1. Pro BNP
• Acute HF - >400pg/dl, CHF - >125pg/dl
1. Troponin T – ischemia
CXR – PA (ABCDE)
ABCDE
44/M with CHF, Annotate the radiograph below
ECG changes
 Complications
• Pleural effusion
• Fatal dysrhythmias – Afib, ventricular
tarchycardia
• Cardiogenic shock
• Cardiac cirrhosis
• Cardiorenal syndrome
• Electrolyte imbalance – hypo/hyperkalemaia,
hyponatremia
• Thromboembolism
 Differentials
• Pericardial dz
• ACS
• COPD exacerbation
• PE
• Lobar pneumonia
• Nephrotic syndrome
• Liver dz
 Management
• Lifestyle changes
• Physical and emotional rest
• Dietary changes
• Medical
• Surgical
Drugs of mortality benefit
Other Rx options
 Acute HF
• Oxygen therapy
• Opiates – IV morphine
• LMWH
• Vasodilator – glycerol trinitrate
• Loop diuretic
• Inotrope
• Digoxin
Approach to Rx of symptomatic HF
Based on stage
 General measures
• Vaccination – influenza, pneumocccal
• Rx of risk factors – dyslipidemia, HTN, DM,
obesity
• Explanation of disease nature, self help
strategies
• Patient education on – low salt & fat diet,
weight reduction, regular exercise within limit,
cessation of smoking and alcohol
consumption, No PDEIs on nitrate therapy
 Prognosis
• Overall 5-year survival is 50%, though varies with
severity and Rx
• 1 year mortality ranges from 20-30% in advanced HF
• Poor prognostic factors include – NYHA III-IV, HFrEF,
comorbidities, RHF, ventricular dysynchrony,
troponin release, hyponatremia, High BNP
• ACEI/ARBs/ARNIs, BB, MRAs, SGLT2I improve
survival
• Diuretics and Digoxin relieve symptoms but do not
improve survival
 References
• Davidson 24th edition
• Kumar and Clarks clinical medicine 10th edition
• Harrison 21st edition
• Medscape