Download - Heart failure
Approach toHEART
FAILUREDr. Subroto Mandal, MD, DMAssistant Professor, Cardiology
NRI Heart Centre & Research Institute
Definition of Heart Failure
HF is a complex clinical syndrome that canresult from any structural or functionalcardiac disorder that impairs the ability ofthe ventricle to fill with or eject blood.
ACC/AHA Task force
“Heart Failure” vs. “Congestive Heart Failure”
Because not all patients have volume overload atthe time of initial or subsequent evaluation, theterm “heart failure” is preferred over the older term “congestive heart failure.”
• Relatively common disorder• The incidence of HF approaches 10 per 1000
population after age 65• 1-2 % at the age of 45-50yrs• >10% at the age >75yrs• At 40yrs age life time risk for HF 21%for men
20.3% for women• 80% admission for HF > 65yrs old• Cost of hospitalization for heart failure is twice
that for all form of cancer and myocardial infarction combined
PREVALENCE & INCIDENCE
CLASSIFICATION
• Forward Vs Backward• Rt. Vs Lt. sided HF • Acute Vs Chronic HF• Low Vs High output HF • Systolic Vs Diastolic HF
NYHA Classification
Stages of Heart Failure
At Risk for Heart Failure:
STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
Heart Failure:
STAGE C Past or current symptoms of HF
STAGE D End-stage HF
Stages of Heart Failure
• Designed to emphasize preventability of HF
• Designed to recognize the progressive nature of LV dysfunction
Stages of Heart Failure
COMPLEMENT, DO NOT REPLACE NYHA CLASSES
• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)
• Stages - progress in one direction due to cardiac remodeling
Rapid classification of hemodynamic states
PRECIPITATING FACTORS
• INAPPROPRIATE THERAPY• HIGH SALT INTAKE • ARRYTHMIAS• INFARCTION OR ISCHAEMIA• PULMONARY EMBOLISM• SYSTEMIC INFECTION• PHYSICAL & EMOTIONAL STRESS• INFECTIVE ENDOCARDITIS• COMORBIDITY ( renal failure, sepsis)• MYOCARDIAL DEPRESSANT DRUGS• CARDIAC TOXINS• HIGH OUTPUT STATES
Evaluation of HF patient
RIGHT SIDED• SYMPTOMS
– Abdominal Pain– Nausea– Constipation– Anorexia– Bloating– Ascites
• SIGNS– Peripheral edema– Hepatomegaly– JVD or JVP– HJR
LEFT SIDED DOE PND Orthopnea Tachypnea Cough Hemoptysis Bibasilar rales Pulmonary edema S3 gallop Pleural effusion Cheyne-Stokes
respiration
COUGH
• Caused by pulmonary congestion
• Nonproductive cough in LVF (Dyspnea equivalent)
• Cough at recumbency (Orthopnea equivalent)
Normal upper limit of JVP are 4 cm from sternal angleTR V wave and Y descend are prominent
Kussumal sign in constrictive pericarditis
JVP
Right heart failure
INVESTIGATIONS
• BNP• ECG• CXR• ECHOCARDIOGRAPHY ( TTE, TEE)• CARDIAC CATHETERIZATION• MUGA SCAN, CT, MRI ANGIO• ENDOMYOCARDIAL BIOPSY• VIABILITY ASSESMENT (DSE, MRI,
SPECT, PET scan)• ARRYTHMIA WORK UP
Atrial fibrillation
Myocarditis
Cardiomegaly
Dextrocardia – Acute pulmonary edema
CCF
Mitral stenosis
Pericardial effusion
Mitral Stenosis
Mitral Stenosis
Pre PBMV Post PBMV
MVP - MR
Aortic Stenosis
LA Myxoma
Post MI-VSD
DCM
DCM
DCM
MR Coronary Angiogram
CT Coronary Angiogram
HCM
Framingham Criteria for Congestive Heart FailureMajor criteria:
Paroxysmal nocturnal dyspnea Neck vein distention Rales Radiographic cardiomegaly Acute pulmonary edema S3 gallop Increased central venous pressure (>16 cm H2O at right atrium) Hepatojugular reflux Weight loss >4.5 kg in 5 days in response to treatment
Minor criteria: Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Decrease in vital capacity by one third from maximum recorded Tachycardia (heart rate>120 beats/min.)