Congestive Heart Failure

Congestive Heart FailureTexas Womens UniversitySpring 2015

Learning ObjectivesOverview of Cardiology SystemPathophysiologyEtiologyWho is at riskSigns and SymptomsDiagnosisDiagnostic Images TreatmentsPreventionPsychosocial Case Study

The Heart as a PumpDivided in half by the septum creating 2 pumps:Left heart: receives deoxygenated blood from the organs and pumps it to the lungsRight heart: receives oxygenated blood from the lungs and pumps it to the organsEach pump is composed of an atria (primers pumps of the ventricles) and ventricles (propels blood into the circulation)Has a conduction system that maintains its own rhythm (Guyton & Hall, 2001)Cardiac Location & AnatomyLies to the left of the body midlineIs in a close-fitting fiber-like sac in the mediastinum between the lungsBetween the heart and the pericardial sac (pericardium) is a lubricating fluid which allow the heart to beat freely without rubbing or sticking

image: http://www.bem.fi/book/06/06.htm

Cardiac AnatomyComposed of muscle linings:endocardium: inner lining is a thin strong membrane also forming the heart valves and lining the blood vessels

myocardium: located between the endocardium and pericardium able to contract with and without stimulation and at a continuous rate

image: http://en.wikipedia.org/wiki/Heart(Guyton and Hall, 2001)

Cardiac Anatomy2 heart valves:Tricuspid valve: separating the right atrium from the right ventricleCalled tricuspid because of its 3 cusps or flapsMitral or Bicuspid valve: separating the left atrium from the left ventriclesCalled Bicuspid because of its 2 flaps and its resemblance to a bishops miterThe valves prevent backward blood flowThe left ventricle is thicker than the right because it needs to generate a greater force to pump the blood upward into the aorta, in comparison to the right ventricle pumping blood into the pulmonary artery

(Guyton & Hall, 2001)

Cardiac AnatomySpecialized conduction system consist of:Sinus node: normal pacemaker because able to discharge faster than the other tissues of the cardiac conduction systemIntrinsic discharge rate of 70 to 80 times per minute and sends impulses to the AV nodeAV node: receives impulses and sends impulses to the purkinje fibers. Intrinsic discharge rate of 40 to 60 times per minutePurkinje fibers: sends impulses to the heart muscleIntrinsic discharge rate of 15 to 40 times per minute

(Guyton & Hall, 2001)Cardiac CirculationBlood from the organs enters:

Right atrium

Tricuspid valve

Right ventricle

Pulmonic valve

Pulmonary artery

To the lungs for reoxygenation From the Lungs enters:

Left atrium

Bicuspic (Mitral) valve

left ventricle

Aortic valveCoronary Sinus

To the organs and heart for organs perfusion

Image: http://antranik.org/blood-flow-of-the-heart/

Heart FailureHeart Failure (HF) is called the new epidemic of cardiovascular disease of the 21st century. This is mainly attributed to improvements in management of both patients with ACS and chronic coronary disease. These medical improvements have decreased mortality rates and increase the number of patients living with ventricular dysfunction. But despite advances in diagnosis and treatment, the prognosis of HF remains unfavorable.Common comorbidities with HF are atrial flutter and atrial fibrillation

(Ky, et al., 2012)Pathophysiology of Heart FailureStroke Volume and HR are positively correlated with CardiacOutputAnything that increases StrokeV or HR, will also increase COutputAnything that decreases SV and HR will decrease CO

image: http://corposcindosis.blogspot.com/2013/05/individual-effectors-part-i.html

Pathophysiology of Heart FailureWhen body senses reduced COutput, the sympathetic nervous system tries to compensate by releasing norepinephrine which stimulates the hearts beta-adrenergic receptors resulting in an increase of COutputProduces tachycardia (raises HR)Increases contractility (raises SV)Increases diastolic relaxation (allows ventricular dilation to accommodate extra blood)Increases stretching of myocardial walls or preload (boosts the SV)

Pathology of Left Ventricular Heart FailureMyocardial injury and chronic increased loading conditions are associated with structural and functional remodeling which are causing heart failure (HF)Despite the different cause of HF, the adaptive physiologic mechanisms are the sameThe goal is to maintain normal resting stroke (SV) which is left ventricle (LV) performanceFunction and ventricle size have important prognostic implications on clinical outcomesThey have been used to determine the extent and therefore the severity of HF

(Ky, et al., 2012)LV Function and ArchitectureAs the LV increases in size its shape changes from oval to roundAs determine by ejection fraction (EF): inverse relationship exist between LV size and cardiac functionEF declines as LV volume increases

(Ky, et al., 2012)LV Remodeling Post Myocardial Infarct

image: http://www.hindawi.com/journals/jnm/2013/108485/fig1/

Cardiac Performance and LV ArchitectureResting LV is used as an indicator of LV systolic performance, remains consistently and relatively unchanged for EF 55% to 20%With EF below 20%, SV decreases significantlyLV dilation and increase LV load leads to ventricular enlargement

image: http://www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz3RZon9rAa(Ky, et al., 2012)

Important Determinants of Heart FailureImportant determinants along with prognosis value for the clinical course of HF are:ageleft ventricular ejection fraction (LVEF)renal functiondiastolic and systolic blood pressureIndependent prognosis function is the etiology of HFIschemic HF, which imposes a greater strain on the left ventricle (LV), has a worse prognosis than dilated cardiomyopathy(Ky, et al., 2012)

Left Atrial Function Predicts Heart FailureLeft atrial (LA) contractile reserve impairment might be an early sign of the progression of HF. Atrial dysfunction could lead to impaired atrial emptying and in term decreased cardiac output (CO). It could also be an early indicator of cardiac congestion of failure if LVEF is preserved.Etiology: Left Ventricular Failure

image: http://www.barnesjewish.org/innovate/fall13/new-cardiac-dyspnea-center

Etiology: Left Ventricular FailureSystolic Dysfunction (Ejection Fraction EF < 40%) AKA depressed EFProblem with the ventricle contractingDecrease in stroke volumeDecrease in cardiac output

Etiology: Left Ventricular FailureDiastolic Dysfunction (EF>40%) AKA preserved EFProblem with the ventricle relaxing Caused by any process that decreases relaxation, decreases elastic recoil, or increases stiffness of ventricleDecrease in stroke volume

Etiology: Left Ventricular FailureVolume OverloadArrhythmiasMitral or Aortic Valve Regurgitation

Etiology: Left Ventricular FailureHigh Output Failure: Systemic arteriovenous fistulaHyperthyroidismAnemiaBeriberi heart disease:thiamine deficiencyPagets Disease of BoneDisruption in normal bone recycling processPregnancyGlomerulonephritis

Etiology: Left Ventricular Failure

Pressure OverloadHypertensionOutflow ObstructionAortic Stenosis

Loss of ContractilityAlcoholDrugs (therapeutic or recreational)Viral or Bacterial Infections

Loss of MuscleCoronary Artery DiseaseMyocardial Infarction

Restricted Filling Mitral Valve StenosisHypertrophic cardiomyopathyRestrictive cardiomyopathy Constrictive pericarditis

Etiology: Left Ventricular Failure

Other causes *may fit multiple categoriesInfection or inflammationCongenital heart diseaseDrugs (recreational or therapeutic)Idiopathic cardiomyopathyRare conditions (endocrine, rheumatologic, Neuromuscular)

Etiology: Right Ventricular FailureLeft Ventricular FailureMost common cause

Primary Right Ventricular Failure CADRight Ventricular Infarction

Precapillary ObstructionIdiopathic pulmonary hypertensionCongenital shunts/obstructionsPulmonary valve stenosis

Cor PulmonaleChronic pulmonary diseasePulmonary embolism

Etiology Heart failure is usually caused by a combination of risk factorsMany possible causes; finding the proximate cause is essential to therapyMain goal of therapy is to prevent decompensationMost common risk factors of Heart FailureCoronary Artery DiseaseDiabetesHypertension

Acute Decompensated Heart Failure Sudden or gradual onset of the signs or symptoms of heart failureSeen when the intrinsic pathological process has advanced to critical pointFailure or exhaustion of compensatory mechanismsUsually seen in worsening chronic HF 15%-20 % of cases are new HF diagnosesVaries in severity

Acute Decompensated Heart Failure

Most common causes:Reduction in treatmentUncontrolled hypertensionCardiac arrhythmias

Signs and SymptomsBreathlessnessAcute and/or chronicBreathlessness at rest is either acute decompensation, end-stage condition or other causesConfounding comorbidities like respiratory disease or anemia

Orthopnea (shortness of breath when lying flat)Soon after lying flatRelieved by sitting upSymptom of acute or advanced diseasePatients with severe chronic obstructive pulmonary disease (COPD) and arthritis may sleep upright

Signs and SymptomsParoxysmal nocturnal dyspnoea (PND) (sudden difficulty breathing at night)Soon after going to sleepSymptom of acute or advanced diseaseSometimes with copious, frothy,even blood-speckled, sputumPatients may also wake acutely breathless

Nocturnal coughWith or without PNDSleep disordersSleep apnoea and left ventricular dysfunction associatedCortisol release changes sleep patterns in heart failure

Signs and SymptomsFatigueCommon symptom but non-specificFatigue patterns and changes over timeRule out other causes like anaemia, nutrition and exercise levels

Reduced exercise capacityCommon symptomRule out other causes

Signs and SymptomsPeripheral edemaEdema settles by gravity so usual pattern of progression through feet, ankles, legs, genitalia/sacrum and abdomenEdema due to heart failure is soft, pitting and bilateralPersistent edema can compromise tissue and result in secondary cellulitisConsider alternative systemic and local causes

Lung crepitationSign of possible fluid in lungs secondary to acute left ventricular failureAlso occurs in smokers and patients with respiratory diseaseWeight changesRapid weight gain >2-3kg a week may be fluid retention

Signs and SymptomsBloated feelingAssociated acutely with fluid retention in the abdomen and chronically with hepatomegaly

ConfusionAssociation between heart failure and progressive cognitive impairment.Acute confusion with acute metabolic derangement secondary to heart failure and/or its treatment

Signs and SymptomsPalpitationsMay be a symptom of sinus tachycardia, atrial or ventricular arrhythmia, or ectopic (early or missed heart beats)All of which are common in heart failure patients

Angina (chest pain of cardiac origin)May indicate the underlying cause of heart failure or may be secondary consequence of poor myocardial perfusion when cardiac output low

Signs and SymptomsSyncope (transient loss of consciousness)May occur with arrhythmias, hypotension and valve disorders

Depression and AnxietyCommon symptoms that affect morbidity and quality of life

Loss of appetite Associated acutely with abdominal fluid retention and chronically with the metabolic changes in end-stage disease

Signs and SymptomsTachycardiaHigh resting heart rate always significant and could be hemodynamic compensatory responseAcute tachyarrhythmia can provoke heart failure in a patient with a normal heart and likely to make patients with an abnormal heart unwell

Basal pleural effusionsReduced basal air entry can suggest pleural effusions with/after acute pulmonary edema

HepatomegalyEnlarged liver can occur with right heart failure

Signs and SymptomsAbnormal pulseAn irregular pulse could be atrial fibrillationA pattern of regular strong and weak pulse may be pulse alternanceA sign of advanced heart failure

Displaced apex beatThe apex beat is the point of maximal impulse on precordiumIt can be displaced down and left laterally when the heart is dilated

Signs and SymptomsThird heart sound: Gallop RhythmRaised jugular venous pressure, usually due to volume overloadHeart murmurs commonly noted in patients with heart failure are mitral regurgitation, tricuspid regurgitation and aortic stenosis

WheezingNew acute wheezing can be sign of acute lung congestionRule out alternative respiratory causes like acute asthma and COPD exacerbation

Risk FactorsHigh blood pressureCoronary artery diseaseHeart attackDiabetesSleep apneaCongenital heart defectsValvular heart disease

VirusesTobacco useAlcohol useObesityIrregular heart beats

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=OCAcQjRw&url=http://facweb.northseattle.edu/troot/HEA150/week3/wk3read_CV_disease_htm&ei=W9XYV0zh08yfqwTPm4s4Bw&brm=bv.85464276,d.exy&psiq=AFQjCNH25016uz0naoE7s7vAZQ1tccNjEw&ust=1423517490394338

CT of a patient with congestive heart failurehttp://www.radiologyassistant.nl/data/bin/a509797a67853a_Kerley.jpg

Interior view of a normal and congestive heart.http://www.medindia.net/images/patientinfo/300x250/congestive-heart-failure.jpg

Illustration of features that can be seen on a CXR in a patient with CHF.http://www.radiologyassistant.nl/data/bin/a509797a669168_BASIC_CHEST-A.jpg

Video Overview of CHFhttp://youtu.be/3d-7uJ5Mz-o

http://youtu.be/3d-7uJ5Mz-o

TreatmentsMedicationsSurgeryMedical Devices

Medications to Treat CHFAngiotensin-converting enzyme (ACE) inhibitorsAngiotensin II receptor blockersBeta blockersDiureticsAldosterone antagonistsInotropesDigoxin

Surgery to Treat CHFHeart valve repair or replacementValvuloplasty: modifying the original valve to decrease backward flowReconnect/remove valve leafletsAnnuloplasty: tightening or replacing the ring around the valveProsthetic valve is placed when repair can not be achieved successfullySome repair and replacements can be performed without open heart surgery Minimally invasive surgery Advanced cardiac catheterization techniques

Surgery to Treat CHFCoronary bypass surgeryBlocked coronary articles are bypassed with blood vessels from your leg, arm or chest

Medical Devices to Treat CHFImplantable cardioverter-defibrillators (ICDs)The ICD monitors the heart rhythm and if a dangerous rhythm or asystole is recognized ICD paces or shocks the heart back to a sustainable rhythm and has ability to pace during bradycardia Cardiac resynchronization therapy (CRT), or biventricular pacingA CRT electrical impulses to left and right ventricles to sync their contractions

Medical Devices to Treat CHFHeart pumpsventricular assist devices (VADs) are placed in abdomen or chest in simply help the ventricle contract. The most common is an LVAD (left ventricle), but can be use for both ventriclesHeart transplant

Heart Failure PreventionRisk factors you can change to prevent heart failure starts with preventing other cardiovascular risk factors:

Eat healthy well balanced dietStop SmokingExerciseLose weight

(Jugdutt, 2012)

Heart Failure PreventionDecrease stressLimit exposure to environmental toxinsBeing able to manage other disease processes if present:HypertensionDiabetes type 2Dyslipidemia

(Jugdutt, 2012)

Preventing Worsening Heart Failure Symptoms and Disease ProgressionTake your prescribed medications3-Drug Regimen:Diuretic eliminates excess fluid and sodiumACE/ARB relax blood vesselsBeta blocker lowers the hearts workloadMonitor fluid intake no more than 2 L/dayWeigh yourself daily/weekly call the doctor if you have an excess of 2-3 lb weight gain in one day or 5-7 lb weight gain in 1 week

(5 Action Steps for Early Heart Failure, 2014)

Preventing Worsening Heart Failure Symptoms and Disease Progression Listen to your bodyWorsening shortness of breathPalpitationsSyncope episodesKeep blood pressure under control measure dailyExercise and lose weight

(5 Action Steps for Early Heart Failure, 2014)