Heart Failure Flashcards
Heart failure
DEFINITION
• Heart failure (HF) is a clinical syndrome determined by any structural and functional impairment of the heart
• “The heart cannot pump enough blood to fulfill the metabolic needs of the body or perform that with increased diastolic filling pressures”
• “Impaired ability of the ventricle to fill with or eject blood”
• Final pathway of evolution common for any cardiovascular disease
• Natural history
→ progresive disorder
→ decreased life expectancy
EPIDEMIOLOGY
- ↑ Incidence →population is aging (85% of HF cases → > 65 y)
- prevalence depends on the definition ~ 1–2% of the adult population in developed countries, rising to ≥10% among people >70 years of age (2016 ESC guideline)
- The lifetime risk of HF at age 55 years is 33% for men and 28% for women
PROGNOSIS = POOR
• ↑ Risk of death
5 -10% annually in patients with mild symptoms
30- 40% annually in patients with advanced disease
1 in 5 pt with CHF will die within 1 year of diagnosis
~ half of those diagnosed with HFrEF will be dead within 5 years
• the leading cause of hospitalization in patients older than 65 y
2016 ESC (European Society of Cardiology) definition
“HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural
and/or functional cardiac abnormality, resulting in a reduced cardiac output and/ or elevated intracardiac pressures at rest or during stress.”
2013 American College of Cardiology (ACC)/American Heart Association (AHA) definition
“Heart failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood”.
Etiology
- Coronary artery disease 4. Valvular heart disease
- Hypertension 5. Cor pulmonale
- Cardiomyopathy 6. Other
Pathophysiological causes of HF
- Increased work load (HTN)
- Myocardial Dysfunction (MI, DCM)
- Decreased Ventricular Filling (Valvular, cardiomyopathy)
HF classification
Depending on EF
- Asymptomatic Systolic dysfunction (without HF symptoms)
- HF with Preserved LVEF (with HF symptoms)
- HF with Reduced LVEF (Systolic dysfunction) (EF<40%)
- HF with mid range EF (>40–50%)
PLVEF preserved left ventricular ejection fraction
LVEF left ventricular ejection fraction
Classification according to
Symptoms and the Stage of the disease
NYHA (functional classes)
Class Function 1 yr mortality
I Asymptomatic with ordinary activity 5%
II Slight limitation of normal function 15%
III Marked limitation of current physical activities 30%
IV Dyspnea at rest 60%
Compare the patient with himself !
Stage ACC/AHA Stages of heart failure
A High risk for heart failure without structural disease,
currently asymptomatic
B Heart disease with asymptomatic LV dysfunction
C Prior or current symptoms of Heart failure
D Advanced structural heart disease, severely
symptomatic or refractory heart failure therapy
Descriptive terms in HF
- Acute (New onset, transient, ADHF) vs Chronic HF
- Diastolic vs Systolic Heart Failure
Systolic HF - reduced cardiac contractility
Diastolic HF – impaired cardiac filling
the term “congestive” no longer used because
not all the patients have volume overload
- Other
• Left vs Right HF
Right ventricular systolic dysfunction
Consequence of LV dysfunction
Direct causes: RV Infarction, PAH, chronic. severe TR,
Arrhythmias, RV dysplasia • High output vs Low output High output HF Thyrotoxicosis Arteriovenous fistulae Pregnancy Severe anemia
• Etiology based : ischemic or nonischemic HF
ADHF- acute decompensated heart failure LV- left ventricle RV- right ventricle TR- tricuspid regurgitation PAH- pulmonary arterial hypertension
Mechanisms of heart failure
- Hemodynamics abnormalities
- Activation of neurohormonal systems
- Cardiorenal interactions
- Abnormal calcium cycling
- Alterations in myocite regeneration, cel death
Replacement with fibrosis of extracellular matrix
Beta-adrenergic desensitization - Myocardial genetics (inherited, mutations)
Compensatory mechanisms
Increased Heart Rate
Sympathetic mediated (Norepinephrine)
Dilatation
Frank Starling (Contractility) The Frank-Starling mechanism: by increasing preload try to sustain cardiac performance Activation of neurohormonal systems
Activation of SNS
Activation of RAAS
Release of ADH
Release of atrial natriuretic peptide
→ Redistribution of Blood
Myocardial hypertrophy with or without cardiac chamber dilatation, in which the mass of contractile tissue is augmented
→ impaired diastolic and systolic function
HF: Progressive Disorder
Due to:
- Ventricular dysfunction
• begins with injury or stress to the myocardium
• Is progressive - Remodeling → heart chamber dilates, hypertrophies, and becomes spherical with increased walls stress
Remodeling (LV)
• factors that alter the ventricular size and function
- Mechanical
- Genetic
- Neurohormonal
↑ levels of
Norepinephrine
Angiotensin II, Aldosterone
Endothelin, Vasopressin
Cytokines
- Hypertrophy, myocyte death, ↑ interstitial fibrosis
- Consequences of Remodeling
- Mitral Regurgitation
- Arrhythmias
- Bundle Branch Block
Consequences of Remodeling (LV)
MR- mitral regurgitation SVT- supraventricular tachycardia Afib- atrial fibrilation VT- ventricular tachycardia SCD- Sudden Cardiac Death LBBB- left bundle branch block
• Mitral Regurgitation
- LV dilates → spherical heart with thinned walls
- distortion of the papillary apparatus → MR→further Progression
• Arrhythmias & Bundle Branch Block→ x 6-9 SCD
Arrhythmias (e.g.: SVT→ AFib; VT)
- consequence of Ischemia, Inflammation, Fibrosis,
Aging -
elevation in LVED volume → atrial stretch → electrical
instability
Abnormal myocardial conduction
LBBB → predictor of Sudden Cardiac Death (SCD)
- ventricular dyssynchrony -> abnormal ventricular
activation & contraction
- delayed opening and closure of the Ao and Mi valves
- abnormal diastolic function
- Lead to paradoxical septal motion, ↓EF, ↓cardiac
output, ↓arterial pressure
The progression of HF is favored by:
• Angiotensin system
• SNS activation in heart failure determine
Dysfunction/death of cardiac myocytes
Provokes myocardial ischemia
Provokes arrhythmias
Impairs cardiac performance
These effects are mediated via stimulation of beta and α1 receptors
Consequences of compensatory mechanisms
Catecholamines
• aggravate ischemia, determine arrhythmia
• induce cardiac remodeling, toxic to myocytes
Stimulated RAA system & sympathetic stimulation
• arteriolar constriction
• Na+ H20 retention
• ↑ aldosterone, fibrosis
• endothelial dysfunction
Baroreceptor and osmotic stimuli
• hypothalamic vasopressin →H20 reabsorption in collecting duct
• ↑ endothelin
• ↑ cytokines → cashecxia & apoptosis
Natriuretic peptides from cardiomyocytes • vasodilatation • enhanced Na +H20 excretion • suppress neurohormones Neurohormonal modulation is the basis of current treatment of HF
Heart failure – clinical diagnosis
- Dyspnea
- Orthopnea
- bendopnea
- paroxysmal nocturnal dyspnea PND
- Fatigue and weakness
- Decreased effort capacity
- Palpitations and Chest Pain/Pressure
- Nocturia and oliguria
- Cardiac Cachexia
- Right upper quadrant abdominal pain
- Cognitive Dysfunction and Mood Disorders
- Sleep Disorders
- Cheyne-Stokes respiration & Central sleep apnea
Dyspnea (Shortness of Breath defined by NYHA classification) with activity (at slight, moderate or current effort) DOE
most common but nonspecific (exist in pts with lung disease or anemia)
cause: pulmonary congestion that increases the accumulation of interstitial or intra-alveolar fluid,
reduces lung compliance, and increases the work of breathing
orthopnea=
dyspnea occurs at rest in the recumbent position→ NYHA IV
specific symptom of heart failure
characterized by the number of pillows a patient requires to sleep without
dyspnea
intolerance of lying flat due to a rapid increase in filling pressure (results from the
increase in venous return from the extremities and splanchnic circulation to the
central circulation with changes in posture)
Sleeping possible only sitting upright
correlates well with the severity of pulmonary congestion → When ventricular
preload increases pulmonary venous and pulmonary capillary hydrostatic
pressures raises
bendopnea =
= dyspnea that occurs while bending over (Mechanism unknown,just presumed)
paroxysmal nocturnal dyspnea PND is
an acute dyspnea
awakens the patient from sleep
usually occurs ≥1 hour after the patient lies in dorsal decubitul and resolves with sitting or standing.
Mechanism: increased venous return + mobilization of interstitial fluid from the splanchnic circulation and lower extremities, with accumulation of alveolar edema
Fatigue and weakness
nonspecific
Occur in > 90% of patients
Cardiac Cachexia
Secondary to: constitutional symptoms: nausea, vomiting, anorexia, abdominal pain, and /or muscle wasting
Characteristic to right-sided heart failure, ± tricuspid regurgitation
Cognitive Dysfunction and Mood Disorders particularly in elderly
due to relative hypotension with cerebral hypoperfusion
memory impairment, limited attention .altered mentation.
Depression~25% of patients
Physical Examination
General appearance and Vital signs
• Sitting upright or Feel uncomfortable when lying flat few minutes (NYHA IV)
• Labored breathing
• SBP- depending on stage (low when low cardiac output inadvanced HF)
• The pulse: variable – if diminished reflect a ↓stroke volume
• Increased heart rate (tachycardia=nonspecific
↑ adrenergic activity
• Peripheral vasoconstriction – cold extremities + cyanosis of the lips and nail
Increased adrenergic activity results in diaphoresis, pallor, peripheral cyanosis with pallor and coldness of the extremities
Jugular veins
- Jugular vein distension JVD
- Provides an estimation of right atrial pressure
- The jugular venous pressure (normal ≤8 cm of water ) = the height of the venous column of blood above the sternal angle in centimeters and then adding + 5 cm
Pulmonary examination
- Inspection: +/- tachypnea–Sitting upright or Feel uncomfortable (dyspnea, cough) when lying flat few minutes (NYHA IV)
- Auscultation: Pulmonary congestion rales (wet crepitant rales) due to fluid transudation into the alveoli
- Percussion: dullness due to Pleural effusions
(Hydrothorax)
often bilateral basal dullness in HF
If unilateral occur more frequently in the right pleural space
• Acute Pulmonary edema:
Expectoration of frothy, blood-tinged sputum
Rales may be heard widely over both lung fields and
May be accompanied by expiratory wheezing (cardiac asthma)
Physical Examination
- Cardiac examination
- Cardiac cachexia in advanced HF (anorexia from hepatic and intestinal congestion)
- Abdomen and extremities
- Peripheral edema
Cardiac examination
does not provide definitive information about HF severity
• Palpation, Percussion, Auscultation
‒ Pulsus alternans (during pulse palpation an alternation of one strong and one
weak beat without a change in the cycle length) Or
‒ The pulse may be weak, rapid, and thready; the proportional pulse pressure (pulse pressure/systolic pressure) may be markedly reduced
‒ If right heart =enlarged or hypertrophied -> sustained and prolonged left parasternal impulse extending throughout systole
• If cardiomegaly present
point of maximal impulse (PMI) is displaced usuallybelow the 5th intercostal
space and/or lateral to the midclavicular line
the impulse is palpable over 2 intercostal spaces
if Severe LV hypertrophy -> sustained PMI
• S3 may be audible and palpable at the apex in advanced HF
• Accentuation of the P2 heart sound is a cardinal sign of Pulmonary Artery Hypertension
• Murmurs of Mitral and Tricuspid Regurgitation may appear if there is biventricular heart enlargement
• Increased adrenergic activity results in Tachycardia
• Systolic arterial pressure may be reduced if cardiac output has declined acutely,
Abdomen and extremities
- Hepatomegaly = enlarged and tender liver that may pulsate during systole if tricuspid regurgitation is present
- The hepatojugular reflux HJR = secondary to manual pressure over the liver JVD increases; the patient’s torso should be positioned at a 45° angle. HJR occurs in patients with elevated left-sided filling pressures and reflects elevated capillary wedge pressure and congestive LV heart failure
- Ascites, a late sign
- Jaundice, also a late finding
Peripheral edema
= cardinal manifestation of HF But nonspecific
• usually absent in patients treated adequately with diuretics
• usually symmetric
• ambulatory patients: predominantly in the ankles and the pretibial region
• bedridden patients: the sacral area (presacral edema) and the scrotum
• indurated and pigmented skin if Long-standing edema
Patterns of Presentation
• Left sided Heart Failure
• Right sided Heart Failure
Biventricular Heart Failure
• Acute heart failure
Acute pulmonary edema
Cardiogenic shock
!Pts with very low EF may be Asymptomatic
while
Patients with preserved EF may be disabled by symptoms
Left sided Heart Failure
Left HF Symptoms Fatigue (generalized weakness) Exercise intolerance Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Anxiety, confusion, restlessness
Left HF Signs
Nocturia Palpitation due to Arrhythmia /Tachycardia Cough - Persistent +/- Pink sputum wheezing like (“cardiac asthma”) Increased respiratory rate-Tachypnea Cyanosis (late) Cardiomegaly Laterally displaced apical impulse Third heart sound (S3) Mitral regurgitation murmur
Right-sided Heart Failure
Systemic Signs & Symptoms
Jugular vein distension, hepato-jugular reflux
Edema (pedal, pre-tibial, sacral)
Hepatomegaly, Splenomegaly (20%)
Anasarca (generalized edema)
Fluid accumulation in body cavities (ascites, pleural,
pericardial effusion)
Weight gain
Palpitation- Tachycardia
Nausea, lack of appetite, early satiety, abdominal fullness
Classic Triad of pure Right Ventricular Failure:
- JVD
- Hypotension
- Clear Lungs (without rales)
Causes of right heart failure:
- LV failure
- Coronary artery disease (ischemia)
- Pulmonary hypertension
- Pulmonary valve stenosis
- Pulmonary embolism
- Chronic pulmonary disease
- Neuromuscular disease
Complications of RHF
Hepatic Cirrhosis
Effusive enteropathy
Nefrotic Syndrome
Renal Veins Thrombosis
HF- Framingham
Diagnostic criteria
For diagnosis: presence of
• 2 major criteria OR
• 1 major + 2 minor criteria
HF- Framingham
Major criteria comprise the following:
- Paroxysmal nocturnal dyspnea
- Weight loss of 4.5 kg in 5 days in response to treatment
- Jugular vein distention
- Hepatojugular reflux
- Rales
- Central venous pressure greater than 16 cm water
- Acute pulmonary edema
- S 3 gallop
- Circulation time ≥ 25 seconds
- Radiographic cardiomegaly
- Pulmonary edema/visceral congestion/ cardiomegaly at autopsy
HF- Framingham Minor criteria (never related to to another medical condition)
- Nocturnal cough
- Dyspnea on ordinary exertion
- A decrease in vital capacity by one third the maximal value recorded
- Pleural effusion
- Tachycardia (rate of 120 bpm)
- Hepatomegaly
- Bilateral ankle edema
Distinction between
• pure right ventricular failure and
• pure left ventricular failure
→ RV failure causes leg edema
→ LV failure causes pulmonary congestion
ACUTE HEART FAILURE
Definition
New onset or gradual or rapidly worsening HF signs and symptoms requiring urgent therapy
ACUTE HEART FAILURE
Pathophysiology
Structural substrate→ cardiac dysfunction
Neurohormonal activation
Renal dysfunction
Vascular and endothelial dysfunction
Inflammation and oxidative stress activated
Hemodynamic abnormalities
Classification models for AHF
European Society of Cardiology (ESC) - 6 patterns
(1) Pulmonary edema
(2) Cardiogenic shock
(3) Worsening or decompensated chronic HF
(4) Isolated right HF
(5) Hypertensive HF
(6) Acute coronary syndrome and HF
The ACC/AHA describes – 3 patterns
(1) Patients with volume overload (pulmonary and/or
systemic congestion)
(2) Patients with hypotension and severe reduction in CO
(3) Patients with combination cardiogenic shock and
congestion
Symptoms and signs in AHF
slide 18
Hemodynamic & clinical profiles in AHF
Profile A: Patients without congestion with adequate perfusion (“dry-warm”)
Profile B: Patients with congestion but adequate perfusion (“wet-warm”)
Profile C: Patients with congestion and hypoperfusion (“wet-cold”)
Profile L: Patients without congestion, with hypoperfusion (“dry-cold”)
*Congestion
evaluated by orthopnea, jugular venous distention, rales, hepatojugular reflux, ascites, peripheral edema
*Poor perfusion
evaluated by presence of narrow pulse pressure, pulsus alternans, symptomatic hypotension, cool extremities, and/or decreased mentation.
Cardiogenic Shock
Definition:
Cardiogenic shock is characterized by a severe generally systolic dysfunction, most often with diminished cardiac output
With inadequate tissue perfusion
• Most extreme form of pump failure
• Mortality is high even with treatment
Cardiogenic Shock
Mechanism:
myocardial dysfunction → the heart is unable to maintain adequate
cardiac output.→ clinical signs of low cardiac output, with adequate intravascular volume
Signs/Symptoms
SBP < 90 mmHg systolic or > 30mmHg drop below baseline
Cool, clammy skin
Pallor
Weak or absent extremity pulses
Tachycardia
Confusion, restlessness, anxiety, stupor, coma
Slow or absent capillary refill
• Evaluate signs of peripheral perfusion in addition to
BP
• BP is NOT the same as perfusion
• Shock can be present with a “normal” BP
Acute Pulmonary Edema
Definition
Acute pulmonary edema is defined as the sudden
increase in pulmonary capillary wedge pressure (usually >25 mm Hg) as a result of acute LV failure
Acute Pulmonary Edema
Symptoms
- Orthopnea
- Profound Dyspnea
- Anxiety
- Associated (prior)
- DOE (dyspnea of effort
- PND
- Fatigue
- Nocturia
- GI Symptoms
- Chest Pain
a true life- threatening emergency
Acute Pulmonary Edema
Physical Exam
SLIDE 21!!!!! SOS
- Diaphoresis
- Palor
- Tachypnea
- Confusion
- Edema
- Diaphoresis
- ±Hypertension
- Pink Frothy Sputum
- Cyanosis
- Specific Rales
- Tachycardia
- JVD
- S3 Gallop
- Rales –coarse rales, rhonchus
- Displaced PMI (point of maximal impulse)* if cardiomegaly present
HF precipitating/aggravating factors
Volume overload, Excessive fluid intake, Dietary sodium intake
Tachycardia, Arrhythmia (Atrial fibrillation, AV block)
Intercurrent illness (eg infection)
Anemia
Hypertension
Myocardial ischemia or acute infarction
Conditions associated with increased metabolic
demand (e.g. pregnancy, thyreotoxicosis, ↑physical
activity, Anemia, fever
Fluid retention (eg. NSAIDs, corticosteroids)
Medication noncompliance
Administration of drug with negative inotropic
properties
Alcohol intake
Acute Pulmonary Edema
Other Useful tools for DIAGNOSTIC (I)
Labs BNP (↑sensitivity) NTproBNP • Diagnosis of heart failure • level correlates well with NYHA class. • Useful in assessing response to therapy • Helpful in discharge timing • Discharge BNP =prognostic value
Acute Pulmonary Edema
Other Useful tools for DIAGNOSTIC (II)
Chest X-Ray (CXR) Cardiomegaly Prominent upper lobe vessels Bats wing pulmonary edema, Kerley B lines Pleural effusions
EKG
Arrhythmias ( Afib, VT); Conduction abnormalities
Echo
EF – helps distinguish systolic and diastolic HF
Diastolic pattern
Etiology: Regional wall motion abnormalities, Valvular disease
Related conditions: Pulmonary artery pressures
Coronary angiography- asses etiology
MRI (Arrh. RV dysplasia, myocardial viability assessment, infiltrative cmp)
HF-conclusions
HF is a clinical syndrome in which
patients have the following features:
Symptoms typical of HF
(breathlessness at rest or on exercise, fatigue,
tiredness, ankle swelling)
and
Signs typical of HF
(tachycardia, tachypnea, pulmonary rales, pleural
effusion, raised jugular venous pressure, peripheral
edema, hepatomegaly)
and
Objective evidence of a structural or functional
abnormality of the heart at rest
(cardiomegaly, third heart sound, cardiac murmurs,
abnormality on the echocardiogram, raised natriuretic
peptide concentration)
Acute Pulmonary Edema
Goals of treatment
- To ↓ disease Progression
- To ↓ Death risk and Hospitalization
- To improve symptoms and quality of life
QUANTITY OF LIFE is prolonged by:
- Beta-blocker
- ACE-Inhibitors
- MRA (Mineralocorticoid receptors Antagonists)
Doses based on clinical trials Only
QUALITY OF LIFE is ameliorated by
- Diuretics (loop diuretics)
- Digoxin (rate control in Afib)
