Congestive Heart Failure

Hanna Al-Makhamreh, MD FACCInterventional cardiology

Heart Failure

Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).

The Vicious Cycle of Congestive Heart Failure

Decreased Blood Pressure andDecreased Renal perfusion

Stimulates the Release of renin, Which allows

conversion of Angiotensin

to Angiotensin II. Angiotensin II stimulates

Aldosterone secretion which causes retention of

Na+ and Water, increasing filling pressure

LV Dysfunction causesDecreased cardiac output

Types of Heart Failure

Systolic Heart Failure: decreased cardiac output Decreased Left ventricular ejection fraction

Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic

pressures May have normal LVEF

.

Causes of Low-Output Heart Failure

Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM)

50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) peripartum, HIV, connective tissue disease,

substance abuse, doxorubicin Hypertension Valvular Heart Disease(MR,AR)

Diastolic Dysfunction Hypertension Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy AS

Clinical Presentation of Heart Failure

Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea

(PND) Due to reduction in cardiac ouput:

Fatigue Weakness

Physical Examination in Heart Failure

S3 gallop Low sensitivity, but highly specific

Cool, pale, cyanotic extremities Have sinus tachycardia, diaphoresis and peripheral

vasoconstriction Crackles or decreased breath sounds at bases

(effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI

Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>

Lab Analysis in Heart Failure

CBC Since anemia can exacerbate heart failure

Serum electrolytes and creatinine before starting high dose diuretics

Fasting Blood glucose To evaluate for possible diabetes mellitus

Thyroid function tests Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF.

Iron studies To screen for hereditary hemochromatosis as cause of heart

failure. ANA

To evaluate for possible lupus Viral studies

If viral mycocarditis suspected

Laboratory Analysis (cont.)

BNP With chronic heart failure, atrial mycotes

secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures

Usually is > 400 pg/mL in patients with dyspnea due to heart failure.

Chest X-ray in Heart Failure

Cardiomegaly Cephalization of the pulmonary

vessels Kerley B-lines Pleural effusions

Cardiomegaly

Pulmonary vessel congestion

Pulmonary Edema due to Heart Failure

Cardiac Testing in Heart Failure

Electrocardiogram: May show specific cause of heart

failure: Ischemic heart disease Dilated cardiomyopathy: first degree AV

block, LBBB, Left anterior fascicular block Amyloidosis: pseudo-infarction pattern Idiopathic dilated cardiomyopathy: LVH

Echocardiogram: Left ventricular ejection fraction Structural/valvular abnormalities

Further Cardiac Testing in Heart Failure

Coronary arteriography Should be performed in patients presenting with

heart failure who have angina or significant ischemia

Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.

Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.

Classification of Heart Failure

New York Heart Association (NYHA) Class I – symptoms of HF only at levels

that would limit normal individuals. Class II – symptoms of HF with

ordinary exertion Class III – symptoms of HF on less than

ordinary exertion Class IV – symptoms of HF at rest

Classification of Heart Failure (cont.)

ACC/AHA Guidelines Stage A – High risk of HF, without

structural heart disease or symptoms Stage B – Heart disease with

asymptomatic left ventricular dysfunction

Stage C – Prior or current symptoms of HF

Stage D – Advanced heart disease and severely symptomatic or refractory HF

Chronic Treatment of Systolic Heart Failure

Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension

Lifestyle modification Lower salt intake Alcohol cessation Medication compliance

Maximize medications Discontinue drugs that may contribute to heart

failure (NSAIDS, antiarrhythmics, calcium channel blockers)

Order of Therapy

1. Loop diuretics2. ACE inhibitor (or ARB if not

tolerated)3. Beta blockers4. Digoxin5. Hydralazine, Nitrate6. Potassium sparing diuretcs

Diuretics

Loop diuretics Furosemide, buteminide For Fluid control, and to help relieve

symptoms

Potassium-sparing diuretics Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF

ACE Inhibitor

Improve survival in patients with all severities of heart failure.

Begin therapy low and titrate up as possible:

Enalapril – 2.5 mg po BID Captopril – 6.25 mg po TID Lisinopril – 5 mg po QDaily

If cannot tolerate, may try ARB

Beta Blocker therapy

Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV.

Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma Heart block

Management of Refractory Heart Failure

Inotropic drugs: Dobutamine, dopamine, milrinone,

nitroprusside, nitroglycerin Mechanical circulatory support:

Intraaortic balloon pump Left ventricular assist device (LVAD)

Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption

with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.