HEART

FAILURE
PRESENTED BY: DR.RAJVI KAMDAR
GUIDED BY: DR.NIDHI VED
WHAT IS HEART FAILURE
❑Heart failure is a syndrome characterized by
impaired cardiac pump function, resulting in
inadequate systemic perfusion and an
inability to meet the body's
metabolic demands.

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Causes of Heart Failure
❑The most common cause of heart failure is
cardiac muscle dysfunction.
❑ Cardiac muscle dysfunction is a general
term describing altered systolic and/or
diastolic activity of the myocardium that
usually develops as a result of an underlying
abnormality within the cardiac
structure or function.
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Causes of Heart Failure
❑Hypertension
❑Coronary artery disease
❑Cardiac dysrhythmias
❑Valve abnormalities
❑Pericardial pathology
❑Cardiomyopathies

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 Types of Heart Failure
❑Heart failure may be categorized based on a structural
perspective and a functional perspective.
A. From a Structural perspective, heart failure is
described as being left-sided heart failure or right-
sided heart failure.
▪ Left- sided heart failure occurs with LV insult.
▪Pathology of the LV reduces the CO leading to a
backup of fluid into the LA and lungs.
▪The increased fluid in the lungs produces the two
hallmark pulmonary signs of left-sided heart
failure: shortness of breath (SOB) and cough.
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Continue. . .
❑Primary right-sided heart failure occurs from direct
insult to the RV caused by conditions that increase
PA pressure.
❑ Increased pressure within the PA subsequently
increases the afterload, thereby placing greater
demands on the RV and causing it to go into failure.
❑ With RV failure, blood is not effectively ejected
from the RV and backs up into the RA and venous
vasculature, producing two hallmark peripheral
signs: jugular venous distention and
peripheral edema.
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Continue. . .

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Continue. . .
❑Often, left-sided heart failure may be severe as
seen in patients experiencing a heart failure
exacerbation.
❑With severe LV pathology, fluid from the LV backs
up into the lungs, increasing PA pressure and
causing fluid to back up into the right side of the
heart and the systemic venous vasculature.
❑This is termed biventricular failure.
❑Therefore, patients with biventricular failure will
present with both pulmonary and systemic signs
of heart failure.

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Continue. . .

B. From a Functional perspective, heart failure is

described as systolic or diastolic dysfunction.
▪ Systolic dysfunction is characterized by
compromised contractile function of the
ventricles causing reductions in the SV,CO, and
EF.
▪ Patients with systolic dysfunction will usually
present with compromised ejection fractions
(EFs) less than 40%.

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 Continue. . .
❑Diastolic dysfunction is characterized by the
compromised diastolic function of the ventricles.
❑ With this condition, the ventricles cannot relax and fill
appropriately during the relaxation (diastolic) phase of
the cardiac cycle.
❑ The impaired ability to fill the ventricles with blood
reduces the volume of blood ejected with each con-
traction (the SV) and the overall volume of blood ejected
per minute (the CO).
❑EF is unaltered and remains normal between 55% and
75%.
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 Continue. . .
❑No reduction in the ratio is noted because there is no
change in the contractile ability of the ventricles.
❑However, there is a low volume of blood. being ejected
with each contraction as less blood entered into the
ventricle before the contraction phase.

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Pathophysiology of Heart Failure
❑When the myocardium is dysfunctional, compensatory
mechanisms are activated with the goal of maintaining
adequate cardiac output.
❑Neurohormonal mechanisms including activation of the
sympathetic nervous system are triggered to increase
HR and maintain CO at rest.
❑Thus patients experiencing an acute bout of heart
failure are very likely to be tachycardic at rest.

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 Continue. . .
❑When patients are in heart failure and the ventricle is
ejecting low blood volumes, blood begins to accumulate
within the ventricles, causing congestion.
❑This congestion increases the LVEDV (left ventricular
end diastolic volume) and contributes to an elevation in
LV pressure.
❑The increased pressure is transmitted retro- grade
toward the LA and the pulmonary veins.
❑ This increase in hydrostatic pressure in the pulmonary
veins causes fluid to move from the veins into the
interstitial space of the lung, resulting in
pulmonary edema.
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 Continue. . .
❑It is also important to consider kidney function for
patients with heart failure.
❑Low blood volume pumped out of the heart causes less
blood to perfuse the kidney and is likely to put the
kidney in failure.

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Clinical Manifestations of
Heart Failure
❑Common signs and symptoms of CHF include
fatigue, dyspnea, edema (pulmonary and
peripheral), fluid weight gain, presence of an S3
heart sound, and renal dysfunction.
❑Two other symptoms reported by patients in CHF
are paroxysmal nocturnal dyspnea and orthopnea.
❑ Paroxysmal nocturnal dyspnea (PND) is
characterized by sudden episodes of SOB occurring
in the night.

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Continue. . .
❑Orthopnea is increased SOB in the recumbent
position.
❑ The severity of orthopnea is often crudely
documented by observing the number of pillows a
patient needs to keep the upper body in an upright
or semi-recumbent position.
❑Therefore, a patient with three- or four-pillow
orthopnea suggests a greater severity of heart
failure when compared to a patient with one-
pillow orthopnea.

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Medical Examination and
Evaluation of Heart Failure
❑Medical interventions include a variety of tests to
identify the etiology and evaluate the severity of
heart failure.
❑ Following an examination of signs and symptoms
of heart failure in a given patient, several key tests
are typically performed.
❑These include a chest x-ray, laboratory tests,
echocardiography, and nuclear imaging studies.

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Radiological Findings in CHF
❑Three hallmark characteristics of the chest x-ray help confirm the diagnosis
of CHF
1. An enlarged cardiac silhouette: The enlargement of the heart in patients
with CHF occurs secondary to congestion of fluid in the lungs and possible
pathological hypertrophy of the ventricles.
2. Opacities (white areas) in the lung field with interstitial and parenchymal
edema.
▪ This occurs when excessive fluid collects in the lung when LV end-
diastolic pressures exceed 25 mm Hg.
3. Blunting of the costophrenic angle.
▪ The lower ribs meeting the diaphragm creates this sharp image
observed on the chest x-ray.
▪ In patients with CHF fluid settles to the lower, dependent aspect of the
lung, producing an opaque appearance, and blunts the
costophrenic angle.

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Continue. . .

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Exercise Prescription Parameters:
Special Considerations
❑Frequent periods of paced activity interspersed between sitting and rest
periods guided by symptoms (i.e., within breathing tolerance to avoid
exacerbating cardiopulmonary congestion)
❑Stretching: Low-level warm-up/cool-down commensurate with goal activity
or exercise.
❑Aerobic :
F- Several times daily.
I- 40% to 80% HRR or less (Karvonen formula), guided by responses and
avoidance of cardiopulmonary congestion.
Karvonen formula: Target HR= HRrest + intensity%(HRmax - HRrest).
T- Gently paced physical activity and aerobic walking.
T- From a couple to several minutes of exercise interspersed with rests
guided by recovery(increasing length of exercise duration with reduced
duration of rests between).
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Continue. . .
❑Strengthening (Note: The responsivity of muscle exposed to chronic
hypoxia secondary to chronic heart failure and associated myopathy has
not been well documented; assess and monitor the individual's
response):
F- Daily (if moderately severe); 2-3 times/week (if less severe or well
tolerated).
I- Low-level resistance (arms and legs) coordinated with breathing control;
commensurate with tolerance and avoidance of strain and
cardiopulmonary congestion .
T- Weights, dumbbells.
T- 3 sets of 5-10 estimated repetition maximum contractions performed
deliberately with rest and recovery time between sets.

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references
1. Susan B. O'Sullivan, physical rehabilitation,6th edi.(2014)541-545.
2. Donna L frownfelter, chest physical therapy & pulmonary rehabilitation, 2nd edi.,
738-739.

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