Heart Failure

Heart failure
Definition of heart failure

• Inability of the heart to pump the amount of blood that meet the
metabolic demand of the tissue.
Metabolic Blood
demand ejected
1st point: Terminology
• End-diastolic volume (EDV): the volume of
blood in the ventricle at end of filling in
diastole.
• End-systolic volume (ESV): the volume of blood
in a ventricle at the end of contraction.
• Stroke volume (SV): the volume of blood
pumped from the left ventricle per beat.
• Ejection fraction (EF%): percentage, of how
much blood the left ventricle pumps out with
each contraction (SV/EDV) (Normal 50%-70%)
• Cardiac output (CO):The amount of blood the
heart pumps through the circulatory system in
a minute.
(cardiac index? > divided by surface area)
2 point: BP regulation
nd
1. Neuronal regulation of BP
2 point: BP regulation
nd
2. Renin-angiotensin aldosterone system

3rd Point: Cardiac
remodeling
• Definition: a group of molecular, cellular and
interstitial changes that manifest clinically as
changes in size, mass, geometry and function
of the heart after injury.
• Causes of remodeling:
1. Angiotensin-2 and aldosterone
2. Catecholamines (sympathetic activation)
3. Mechanical stress on the myocardium
(increase preload and afterload) > cellular
damage and fibrosis.
Types of Heart failure
1. High-output heart failure vs Low output
• High-output heart failure: normally functioning heart cannot keep up
with an unusually high demand.( CO > 8 L/min or 4 L/min/m2)
Examples: Thyrotoxicosis, Chronic severe anemia.
• Low-output heart failure: decrease in systemic perfusion secondary
to myocardial dysfunction. ( CI <2.4 L/min/m2)
Examples: Cardiomyopathies, myocardial ischemia, arrythmia,
valvular diseases.
2. Systolic heart failure vs diastolic heart
failure
• Systolic heart failure (HFrEF): the ventricles contract poorly and
empty inadequately, leading to depressed systolic function and
reduced ejection. ( Low SV, Low CO/CI, High EDV, Low EF)
• Diastolic heart failure (HFpEF): decrease in systemic perfusion
secondary to myocardial dysfunction. ( CI <2.4 L/min/m2)
Examples: Cardiomyopathies, myocardial ischemia, arrythmia,
valvular diseases. ( Low SV, Low CO/CI, Low EDV, High EF)
3. Right sided vs left sided heart failure
Symptoms and signs of heart failure
1. Low cardiac output symptoms: Low blood pressure + inadequate
perfusion:
1. Dizziness, syncope and weakness
2. Acute kidney injury
3. Myocardial ischemia
More prominent at acute decompensated heart failure.
2. Congestive symptoms: edema symptoms!

May present in both compensated and decompensated!
2. Congestive symptoms
Back-pressure!!!
• Left sided heart failure:

congestion in pulmonary
capillaries > pulmonary
edema.
• Right sided heart failure:
congestion in systemic
capillaries (including
peritoneum, pericardium
and pleura).
Left-sided heart failure
Pulmonary edema
• Symptoms:
1. Dyspnea
2. Orthopnea: dyspnea at supine position (
patient may use pillow )
3. Paroxysmal nocturnal dyspnea:
dyspnea during sleep that comes on
suddenly, causing the person to wake up
gasping.
4. Cough
• Physical exam:
1. Palpation: displaced apex beat
downward and laterally due to
cardiomegaly ( normally at 5th intercostal
space midclavicular line).
2. Auscultation
Lung: bilateral basilar crackles (rales)
Heart: S3 gallop (in systolic) and S4 gallop
Left-sided heart failure
Pulmonary edema
• Chest X-ray findings:
1. Lung field:
A. Bilateral homogenous alveolar and
interstitial opacities (prominent
interstitial lung markings) +/- pleural
effusion.
B. Septal lines (Kerley B lines):
horizontal line near periphery of lung
indicate dilatation of lymphatics
2. Heart: cardiomegaly ( increase

cardiothoracic ratio)
Right-sided heart failure
1. High JVP
• Normally, the pressure in the
jugular vein is 5-8 cm water
• In right sided heart failure >8
cm
• There is distended neck veins
too.
2. Pleural effusion
• Presence of fluid inside pleural cavity not
inside the alveoli.
• Physical examination:
1. Palpation: decrease tactile fremitus
2. Percussion: dull
3. Auscultation: absence breath sound
• Chest x-ray findings:
1. Obliteration of costophrenic angle
2. Meniscus sign “concave line obscuring
the costophrenic angle”.
3. Pericardial effusion
• Presence of fluid inside pericardial cavity.
• Symptoms: Chest discomfort and SOB.
• Physical examination:
Auscultation: Distant heart sound or
absence heart sound. (muffled heart
sounds)
Chest x-ray findings:
1. Globular enlargement of the cardiac
shadow “water bottle configuration”
2. flattening of the upper heart borders
3. Pulmonary oligemia ( decrease
pulmonary vascular markings).
4. Ascites
• Collection of fluid inside the
peritoneal cavity.
• Physical examination findings:
1. Distended abdomen
2. Shifting dullness
3. Transmitted thrill
5. Hepatomegaly & GI
tract
• GI tract symptoms: Nausea, discomfort
• Liver enlargement:
1. Liver edge can be palpated under the rib
cage
2. Liver span >12 cm (normally 6-12 cm)
• Hepatojugular reflux?
6. Lower limbs edema
• Pitting edema.
• Grades of edema:
Grade 1: Immediate rebound
with 2-millimeter (mm) pit.
Grade 2: Less than 15-second
rebound with 3 to 4 mm pit.
Grade 3: Rebound greater
than 15 seconds but less than
60 seconds with 5 to 6 mm pit.
Grade 4: Rebound between 2
to 3 minutes with an 8 mm pit.
Investigations
A. Echocardiography: measurement of ejection fraction (EF%), SV, and
CI.
VERY IMPORTANT!!!:
1. Confirmation of Dx.
2. Knowing the type of heart failure (systolic vs diastolic).
B. CXR: pulmonary edema + signs of heart failure
C. To know the cause of heart failure:
1. ECG and cardiac enzymes: ischemic heart diseases, arrythmia
2. Echo: Valvular diseases, pericardial diseases.
3. Other relevant investigations.
Treatment
• Decrease preload: Diuretics ( Furosemide ), Nitrate
• Increase contractility: inotropes ( Dobutamine, Digoxin )
• Blockage of hormonal pathway to prevent remodeling:
1. RAAS: ACE-Is, ARBs and aldosterone antagonists
2. Catecholamines: beta blockers
• Decrease afterload: Hydralazine + Nitrate, ACE-Is ARBs.
Management plan
1. Acute decompensated heart failure ( Beta blockers and CCBs are
contraindicated): Treat the cause if possible then:
1. Low blood pressure + edema: Dobutamine + O2 > after stable blood
pressure > IV furosemide (nitrate + morphine if pulmonary edema).
2. Normal blood pressure + edema: IV furosemide (nitrate + morphine if
pulmonary edema)
2. Compensated heart failure:
1. Remodeling prevention: ACE-Is, ARBs or/and aldosterone antagonist +
beta blockers
2. Diuretics ( to prevent decompensation
3. Digoxin ( not a usual treatment)
Drugs that improve mortality
1. ACE-Is
2. ARBs
3. Aldosterone antagonists ( spironolactone )
4. Beta blockers (carvedilol, bisoprolol, and sustained-release
metoprolol succinate)
5. Hydralazine + nitrate
Other diuretics and digoxin don’t improve mortality (only symptoms

and hospitalization rate).

Heart Failure

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Heart failure

Definition of heart failure

2. Renin-angiotensin aldosterone system

More prominent at acute decompensated heart failure.

2. Congestive symptoms: edema symptoms!

• Left sided heart failure:

2. Heart: cardiomegaly ( increase

Other diuretics and digoxin don’t improve mortality (only symptoms

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