Heart Failure: Presentation by Dr. Tooba Shahbaz

HEART FAILURE
PRESENTATION BY DR. TOOBA SHAHBAZ

LEARNING OBJECTIVES
 What is cardiac failure?

 Etiology of heart failure.
 Classification of heart failure.
 Compensatory changes those take place incase of chronic heart failure.
 Clinical features of heart failure. Investigations and management of
heart failure?
 Management of acute pulmonary edema
DEFINITION
 Congestive heart failure, or heart failure, is a long-term

condition in which your heart can’t pump blood well
enough to meet your body’s needs. Your heart is still
working. But because it can’t handle the amount of blood
it should, blood builds up in other parts of your body.
Most of the time, it collects in your lungs, legs and feet.
ETIOLOGY
 MYOCYTE LOSS:
• Leads to reduced ventricular contractility
• Post MI, chronic ischemia.
 INAPPROPRIATE WORKLOAD:
• Ventricular outflow obstruction as in hypertension,
aortic stenosis, pulmonary hypertension, pulmonary
valve stenosis.
• Ventricular inflow obstruction as in mitral stenosis,
tricuspid stenosis.
• Ventricular volume overload as in aortic regurgitation,
ventricular septal defect, atrial septal defect.
• Arrhythmia as in atrial fibrillation, tachycardia,
cardiomyopathy, complete heart block.
 RESTRICTED FILLING:
• Diastolic dysfunction as in constrictive pericarditis,
restrictive cardiomyopathy, left ventricular hypertrophy
and fibrosis, cardiac tamponade.
CLASSIFICATION OF CARDIAC
FAILURE
 LEFT SIDED HEART  RIGHT SIDED HEART

FAILURE: FAILIURE:
Failure of left ventricle to pump Failure of Right side of heart to
the blood into aorta resulting in pump the blood into lung
increased left atrial and circulation causing increased
pulmonary venous pressure right atrial and systemic venous
causing pulmonary edema. pressure.
 BIVENTRICULAR HEART FAILURE:
Failure of both right and left heart to pump blood effectively.
 HIGH OUTPUT CARDIAC FAILURE:

High-output heart failure is a rare type of heart failure that doesn’t have the
low blood output of the other types. But like the others, it’s a condition in
which your heart can’t pump enough blood to meet your body’s demand for
it. For example, severe anemia, thyrotoxicosis, pregnancy.
 SYSTOLIC HEART  DIASTOLIC HEART
FAILURE: FAILURE:
It occurs due to impaired It occurs due to impaired
contractility of heart. ventricular filling during
diastole.
 ACUTE AND CHRONIC HEART FAILURE:
Heart failure can develop suddenly as well as gradually.
When it develops gradually, several compensatory changes
takes place.
COMPENSATORY CHANGES IN CHRONIC HEART
FAILURE
 The compensatory changes in heart function that occur in chronic

heart failure include:
 Increased heart rate: The heart may beat faster to increase cardiac
output and maintain blood flow to the body.
 Increased contractility: The heart may contract more forcefully to
increase the amount of blood ejected with each beat.
 Cardiac hypertrophy: The heart may enlarge in size, a process known as hypertrophy,
to increase its pumping ability.
 Activation of the renin-angiotensin-aldosterone system (RAAS): The RAAS is a
hormone system that helps regulate blood pressure and fluid balance. In chronic heart
failure, the RAAS may be overactive, leading to increased fluid retention and
vasoconstriction, which can further strain the heart.
 Activation of the sympathetic nervous system: The sympathetic nervous system helps
regulate heart rate and contractility. In chronic heart failure, the sympathetic nervous
system may become overactive, leading to further increases in heart rate and
contractility.
CLINICAL FEATURES
 LEFT SIDED HEART FAILURE:
• Dyspnea (difficulty breathing)
• Orthopnea (dyspnea on lying flat)
• Paroxysmal nocturnal dyspnea (sudden attack of dyspnea at night)
• S3 heart sound
• Bibasilar inspiratory crackles heart in chest due to pulmonary edema.
• Functional mitral valve regurgitation can occur. (pansystolic murmur).
RIGHT SIDED HEART FAILURE:

• Elevated JVD.
• Functional tricuspid valve regurgitation.
• Painful hepatomegaly.
• Ascites
• Edema: pitting pedal and pretibial edema.
• Generalized edema (anasarca)
INVESTIGATIONS
 Echocardiography is the Gold standard and best initial is

TTE (transthoracic echocardiography)
 Other tests:
ECG: MI (old or recent) ,Heart block, Arrhythmia, LBBB
Chest X-ray: Initial and best for pulmonary edema
 Blood tests: CBC for anemia, LFT for impaired liver
function, Brain natriuretic peptide (BNP), cardiac
enzymes, TFT.
MANAGEMENT
 Systolic Dysfunction:
 loop diuretics(furosemide, torsemide, bumetanide): Initial therapy
used to relieve the symptoms by ↓ preload. Does not reduce the
mortality. Note : not giving to asymptomatic patient
 ACE inhibitors : initial therapy used to ↓ afterload by
vasodilatation and ↓ preload by absorption of the fluid and it
reduces the mortality.
 Adverse effects → angioedema + cough Note: If patient
developed cough switch from ACEi to ARB. Note: If
patient developed hyperkalemia or renal impairment or
pregnant→ switch from ACEi to Hydralazine(arterial
dilator) with isosorbide dinitrate (Venodilator). Both
Hydralazine with isosorbide dinitrate and ARB reduce
the mortality
 B-Blockers (metoprolol, bisoprolol, carvedilol) :anti-
ischemic , antiarrhythmic , decreased the heart rate
(decrease oxygen consumption increasing filling time)
& reduced remodeling of the heart → It decreases
mortality Note : The combination of B blockers and an
ACE inhibitors required for patient with LVEF less
than 40% either symptomatic or asymptomatic

 spironolactone (potassium sparing diuretic that is used in
chronic CHF) : aldosterone antagonist, it reduces the
mortality. Note : if the patient developed gynecomastia,
impotence (cause its structurally similar to progesterone)
switch to eplerenone.
 Digoxin : + inotropic effect used only relieve symptoms
with EF< 40% and it does not improve mortality.
 The standard treatment for systolic cardiac failure is
diuretics + ACEin + B-blockers
 The initial treatment for symptomatic patient is diuretics
+ vasodilation (ACEin, ARBs or hydralazine with
isosorbide)
 When there is no benefit with medication devices are used and have been
shown to reduce mortality.
ICD (implantable cardiovascular defibrillator) indicated for patients
atleast 40 days post MI and EF <35%.
Cardiac resynchronization therapy: biventricular pacemaker has similar
indications as ICD except that these are used in prolonged QRS duration
>120msec.
Cardiac transplantation : last choice if the medication and devices can’t
control symptom
 Diastolic Dysfunction:
 The standard treatment for diastolic dysfunction is β blockers and
Diuretics
 Digoxin and spironolactone should NOT be used.
 ACE inhibitors and ARBs—benefit is not clear for diastolic dysfunction.
 No medication have proven the mortality in diastolic dysfunction
 Management of Acute decompensated Heart Failure (Acute Pulmonary edema)
 A. Oxygen
 B. loop diuretics (furosemide): most important drug that decreases the preload *Best initial
 therapy
 C. Nitrate (IV) : that decrease the afterload
 D. Morphine can be used
 Note : If pulmonary edema continuous despite these 4 so should add dobutamine (increased
contractility & decrease afterload)
 Remember: - We don’t give β blockers in Acute cases (only in stable patient ).
 - Digoxin (not used in acute settings, usually used if there was AFib ).
 Contraindicated Medication on CHF
 ★ Metformin : may cause potentially fatal lactic acidosis.
 ★ Thiazolidinediones (glitazone): causes fluid retention.
 ★ NSAIDs : may increase risk of CHF exacerbation.
 ★ some of Calcium Channel blockers : may raise mortality.
THANK YOU!

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HEART FAILURE

PRESENTATION BY DR. TOOBA SHAHBAZ

 What is cardiac failure?

 Congestive heart failure, or heart failure, is a long-term

 LEFT SIDED HEART  RIGHT SIDED HEART

 HIGH OUTPUT CARDIAC FAILURE:

 The compensatory changes in heart function that occur in chronic

RIGHT SIDED HEART FAILURE:

 Echocardiography is the Gold standard and best initial is

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