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.)