Download - Heart Failure

CARDIAC FAILURE

04/10/23 1

Group members:

Karjome Lama Alok Chandra Thakur

Namita GyawaliNanayakkara Sattambi R.D.Thanuga

Dilhani

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NORMAL HEART HEART FAILURE

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INTRODUCTION One of the most common ailments treated by

the physicians. In simple words, “cardiac failure” means failure

of the heart to pump the blood to satisfy the bodily needs but it doesn’t mean that the heart has completely stopped like in cardiac arrest.

It is not considered as a disease. Rather, it is the result from any heart condition that reduces the ability of the heart to pump the blood due to decreased contractility of myocardium.

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Heart failure may occur suddenly, or it may develop gradually. When heart function deteriorates over years, one or more conditions may exist. The strength of muscle contractions may be reduced, and the ability of the heart chambers to fill with blood may be limited by mechanical problems, resulting in less blood to pump out to tissues in the body. Conversely, the pumping chambers may enlarge and fill with too much blood when the heart muscle is not strong enough to pump out all the blood it receives.

In addition, as the architecture of the heart changes as it enlarges, regurgitation of the mitral valve may develop, making the heart failure even worse.

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Cardiac Physiology(remember this?)

CO = SV x HR

HR: parasympathetic and sympathetic tone

SV: preload, afterload, contractility

Preload Contractility Afterload

Stroke Volume Heart Rate

Cardiac Output

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PreloadDef: Passive stretch of muscle prior

to contractionMeasurement: Swan-Ganz

LVEDP(Left Ventricular End-Diastolic Volume)

Really a function of LVEDVAffected by compliance

Low compliance = higher LVEDP @ lower LVEDV

False high estimate of preload04/10/23 7

AfterloadDef: Force opposing/stretching

muscle after contraction beginsMeasurement: SVR(Systemic

Vascular Resistance)Really a function of:

SVR Chamber radius (dilated

cardiomyopathies) Wall thickness (hypertrophy)

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ContractilityDef: Normal ability of the muscle to

contract at a given force for a given stretch, independent of preload or afterload forces

In other words: How healthy is your heart muscle?

Ischemia, Hypertrophy, Muscle loss 04/10/23 9

What Causes Heart Failure?

Health conditions that either damage the heart or make it work too hard Coronary artery disease Heart attack High blood pressure & Hypertension Abnormal heart valves Heart muscle diseases (cardiomyopathy) Heart inflammation (myocarditis &

pericarditis)

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ENDOCARDITIS PERICARDITIS

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NORMAL HEARTHYPERTROPHIED

HEART

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Congenital heart defectsSevere lung diseaseDiabetesSevere anemiaOveractive thyroid gland (hyperthyroidism)

Abnormal heart rhythms(Arrhythmias)

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Coronary artery diseaseCholesterol and fatty deposits

build up in the heart’s arteriesLess blood and oxygen reach

the heart muscleThis causes the heart to work

harder and occasionally damages the heart muscle

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Heart attackAn artery supplying blood to

the heart becomes blockedLoss of oxygen and nutrients

damages heart muscle tissue causing it to die

Remaining healthy heart muscle must pump harder to keep up

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High blood pressure & Hypertension

Uncontrolled high blood pressure and hypertension doubles a persons risk of developing heart failure

Heart must pump harder to keep blood circulating

Over time, chamber first thickens, then gets larger and weaker

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What Causes Heart Failure? Abnormal heart valves Heart muscle disease

Damage to heart muscle due to drugs, alcohol or infections

Congenital heart disease Severe lung disease

Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.04/10/23 17


DiabetesTend to have other conditions that make the heart work harder

ObesityHypertensionHigh cholesterol

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Severe anemiaNot enough red blood cells to carry

oxygenHeart beats faster and can become

overtaxed with the effort

HyperthyroidismBody metabolism is increased and

overworks the heart

Abnormal Heart Rhythm If the heart beats too fast, too slow or

irregular it may not be able to pump enough blood to the body

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TYPES OF HEART FAILURE Anatomically

Left versus Right

Physiologically Systolic versus Diastolic

Functionally How symptomatic is your

patient?04/10/23 20

Left versus Right Failure

Left Heart Failure Dyspnea Decrease exercise

tolerance Cough

OrthopneaPink, frothy

sputum

Right Heart Failure

Decrease exercise tolerance

Edema Hepatomegaly Ascites

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Bilateral pulmonary effusion in right heart failure

Pitting edema of the ankle.

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The renin–angiotensin–aldosterone system

1.Reduction of renal blood flow and glomerular filtration rate.

2.The renin–angiotensin–aldosterone system is activated.

3.Increase in peripheral vascular resistance.

4.Increase in sodium and water retention.

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THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM

ACE

ACE INHIBITORS

JGA

RENIN

ADRENAL

ALDOSTERONE

ANGIOTENSINOGEN ANGIOTENSIN 1

ANGIOTENSIN 2

VASOCONSTRICTS

Na RETENTION

INCREASED BP

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Systolic versus Diastolic

Systolic– “can’t pump” Aortic Stenosis HTN Aortic Insufficiency Mitral

Regurgitation Muscle Loss

IschemiaFibrosisInfiltration

Diastolic- “can’t fill” Mitral Stenosis Tamponade Hypertrophy Infiltration Fibrosis

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DIASTOLIC HEART FAILURE

SYSTOLIC HEART FAILURE

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ACUTE MITRAL REGURGITATION

CHRONIC MITRAL REGURGITATION

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Acute versus Chronic

Acute heart failure develops rapidly can be immediately life

threatening due to lack of time to undergo compensatory adaptations.

may result from cardiopulmonary by-pass surgery, acute infection (sepsis), acute myocardial infarction, valve dysfunction, severe arrhythmias, etc.

can often be managed successfully by pharmacological or surgical interventions.

Chronic heart failure a long-term condition

(months/years) that is associated with the heart undergoing adaptive responses (e.g., dilation, hypertrophy) to a precipitating cause.

These adaptive responses, however, can be deleterious in the long-term and lead to a worsening condition.

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Class

% of patient

s

Symptoms

I 35% No symptoms or limitations in ordinary physical activity

II 35% Mild symptoms and slight limitation during ordinary activity

III 25% Marked limitation in activity even during minimal activity. Comfortable only at rest

IV 5% Severe limitation. Experiences symptoms even at rest

Functional classification of Heart Failure by New York Heart Association

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Pathophysiology of the Heart Failure

1.Decreased stroke volume2.Raised end-diastolic volume and

pressure 3.Ventricular dilation will occur. 4.Chronic elevation of diastolic pressures.5.Increased capillary pressure.6.Increased peripheral vascular

resistance.7.Transudation of fluid with resulting

pulmonary or systemic edema.

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8. Activation of neural and humoral systems.

9. Frank –starling mechanism10.Increased LV afterload, so that

excessive sympathetic activity may further depress cardiac function.

11.Increased activity of the sympathetic nervous system(mainly adrenergic activity) but reduced vagal activity to heart.

12.Increased myocardial contractility, heart rate, and venous tone.

Pathophysiology of the Heart Failure

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Frank-starling Mechanism

The Frank-Starling law of the heart states that as the ventricular volume increases and stretches the myocardial muscle fibers, the stroke volume increases, up to its maximum capacity. After that point, increasing volume increases pulmonary capillary pressure (and pulmonary congestion), without increasing the stroke volume or cardiac output. The mechanism is the length-force relationships of muscle contraction.

Str

oke

volu

me

End-Diastolic volume

Maximum capacity to produce stroke volume

Normal range: stroke volume increases with end-diastolic volume

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An overall view of Heart Failure

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Shortness of Breath (Dyspnea)WHY?

• Blood “backs up” in the pulmonary veins because the heart can’t keep up with the supply an fluid leaks into the lungs

SYMPTOMS• Dyspnea on exertion or at rest• Difficulty breathing when lying flat

(Orthopnea)• Waking up short of breath

Signs and Symptoms of Heart Failure

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Persistent Cough or WheezingWHY?

•Fluid “backs up” in the lungs

SYMPTOMS•Coughing that produces white or pink blood-tinged sputum


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EdemaWHY?

•Decreased blood flow out of the weak heart

•Blood returning to the heart from the veins “backs up” causing fluid to build up in tissues

SYMPTOMS•Swelling in feet, ankles, legs or abdomen•Weight gain


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Tiredness, fatigueWHY?

•Heart can’t pump enough blood to meet needs of bodies tissues

•Body diverts blood away from less vital organs (muscles in limbs) and sends it to the heart and brain

SYMPTOMS•Constant tired feeling•Difficulty with everyday activities


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Lack of appetite/ NauseaWHY?

•The digestive system receives less blood causing problems with digestion

SYMPTOMS•Feeling of being full or sick to your stomach


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Confusion/ Impaired thinkingWHY?

•Changing levels of substances in the blood ( sodium) can cause confusion

SYMPTOMS•Memory loss or feeling of

disorientation•Relative or caregiver may notice this

first


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Increased heart rateWHY?

•The heart beats faster to “make up for” the loss in pumping function

SYMPTOMS•Heart palpitations•May feel like the heart is racing or

throbbing


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Clinical Data

CXR(Chest X-Ray) Kerley’s lines : A and B Pulmonary Edema Cephalization Pleural Effusions (bilateral)

EKG(Electrocardiogram) Left atrial enlargement Arrhythmias Hypertrophy (left or right)

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Cardiomyopathy Pulmonary Edema

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Clinical Data

HEART SOUNDS!!!Systolic Murmurs

Mitral Regurgitation Aortic Stenosis

Diastolic Murmurs Mitral Stenosis Aortic Insufficiency

S3: Rapid filling of a diseased ventricle

Mitral Stenosis

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Clinical DataLaboratory Data

Chemistry Renal Function: Be Wary

BNP(Brain Natriuretic Peptide) Test Used in ER departments the world over Good negative correlation Need baseline for positivity Pulmonary versus cardiac dyspnea

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Modified Framingham Criteria Diagnosis for Heart Failure

Major criteriaNeck vein distensionOrthopneaCardiomegaly on CXRCVP > 12 mm HgLeft Ventricular

dysfunction on EKGWeight lossAcute pulmonary

edema

Minor criteriaBilateral ankle

edemaNight coughDyspnea on exertionHepatomegalyPleural effusionTachycardia (> 120

beats/min)04/10/23 45

The more common forms of heart failure cannot be cured, but can be treatedLifestyle changesMedicationsSurgery

Treatment Options

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Stop smoking Avoid alcohol Avoid or limit caffeine Eat a low-fat, low-sodium diet

Exercise Reduce stress

Lifestyle Changes

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Lose weight Keep track of symptoms and weight and report any changes or concern to the doctor

Limit fluid intake See the doctor more frequently

Lifestyle Changes

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ACE InhibitorsCornerstone of heart failure therapy

Proven to slow the progression of heart failure

Vasodilator – cause blood vessels to expand lowering blood pressure and the hearts work load

Medications used to treat Heart Failure

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Diuretics (water pills) Prescribed for fluid build up, swelling or

edema Cause kidneys to remove more sodium

and water from the bloodstream Decreases workload of the heart and

edema Fine balance – removing too much fluid

can strain kidneys or cause low blood pressure


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PotassiumMost diuretics remove potassium from the body

Potassium pills compensate for the amount lost in the urine

Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles


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VasodilatorsCause blood vessel walls to relax

Occasionally used if patient cannot tolerate ACE

Decrease workload of the heart


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Digitalis preparationsIncreases the force of the hearts contractions

Relieves symptomsSlows heart rate and certain irregular heart beats


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Beta-blockersLower the heart rate and blood pressure

Decrease the workload of the heart Blood-thinners (coumadin)

Used in patients at risk for developing blood clots in the blood vessels, legs, lung and heart

Used in irregular heart rhythms due to risk of stroke


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Surgery and other Medical ProceduresNot often used in heart failure unless there is a correctable problemCoronary artery bypassAngioplastyValve replacementDefibrillator implantationHeart transplantationLeft ventricular assist device(LVAD)

Treatment Options

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Incidence of Heart Failure and its Prognosis

Heart failure is the leading cause of hospitalization of patients over 65 years in age.

> 15million new cases of Heart failure estimated each year worldwide.

Rapidly increasing number because of the aging population.

Despite many new advances in drug therapy and cardiac assist devices, the prognosis for chronic heart failure remains very poor.

One year mortality figures are 50-60% for patients diagnosed with severe failure, 15-30% in mild to moderate failure, and about 10% in mild or asymptomatic failure.04/10/23 57

Thank you for listening!!!

Questions?????

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Download - Heart Failure

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