CONGESTIVE HEART FAILURE NOTES ....PPT.
- 1. Congestive Heart Failure & Cor Pulmonale @komu dot mzito
- 2. Heart failure - Definition Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs Not a disease but a “syndrome” 2
- 3. Heart Failure Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure). 3
- 4. Heart Failure (HF) - Key Concepts CO = SV x HR-becomes insufficient to meet metabolic needs of body SV- determined by preload, afterload and myocardial contractility *Classifications HF Systolic failure- decreased contractility Diastolic failure- decreased filling Mixed 4
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- 6. Factors Affecting Cardiac Output Heart Rate In general, the higher the heart rate, the lower the cardiac • E.g. HR x SV = CO • 60/min x 80 ml = 4800 ml/min (4.8 L/min) • 70/min x 80 ml = 5600 ml/min (5.6 L/min) But only up to a point. With excessively high heart rates, diastolic filling time begins to fall, thus causing stroke volume and thus CO to fall 6
- 7. Preload Volume of blood in ventricles at end diastole Depends on venous return Depends on compliance Afterload •Force needed to eject blood into circulation •Arterial B/P, pulmonary artery pressure •Valvular disease increases afterload Factors effecting heart pump effectiveness 7
- 8. Heart Failure Etiology and Pathophysiology Primary risk factors Coronary artery disease (CAD) Advancing age Contributing risk factors Hypertension Diabetes Tobacco use Obesity High serum cholesterol African American descent Valvular heart disease Hypervolemia 8
- 9. HF Pathophysiology Cardiac compensatory mechanisms Tachycardia Ventricular dilation - Starling’s law Myocardial hypertrophy Hypoxia leads to decreased contractility 9
- 10. Types of Heart Failure Low-Output Heart Failure Systolic Heart Failure: • Decreased cardiac output • Decreased Left ventricular ejection fraction Diastolic Heart Failure: • Elevated Left and Right ventricular end-diastolic pressures • May have normal LVEF High-Output Heart Failure • Seen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism, beri-beri, carcinoid, anemia • Often have normal cardiac output Right-Ventricular Failure • Seen with pulmonary hypertension, large RV infarctions. 10
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- 13. Clinical staging of Heart Failure symptoms New York Heart Association (NYHA) Class I – symptoms of HF only at levels that would limit normal individuals. Class II – symptoms of HF with ordinary exertion Class III – symptoms of HF on less than ordinary exertion Class IV – symptoms of HF at rest 13
- 15. Clinical Presentation of Heart Failure Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea (PND) Due to reduction in cardiac ouput: Fatigue (especially with exertion Weakness 15
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- 17. Physical Examination in Heart Failure S3 gallop - Low sensitivity, but highly specific Cool, pale, cyanotic extremities Have sinus tachycardia, diaphoresis and peripheral vasoconstriction Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites,Hepatomegaly,Splenomegaly Displaced Apex beat - Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement. 17
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- 19. Measuring Jugular Venous Pressure 19
- 20. JVD 20
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- 23. Lab Analysis in Heart Failure CBC • Since anemia can exacerbate heart failure Serum electrolytes and creatinine • before starting high dose diuretics Fasting Blood glucose • To evaluate for possible diabetes mellitus Thyroid function tests • Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF. Iron studies • To screen for hereditary hemochromatosis as cause of heart failure. ANA • To evaluate for possible CTD e.g lupus if suspected Viral studies • If viral mycocarditis suspected 23
- 24. Laboratory Analysis (cont.) BNP • With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures • Usually is > 400 pg/mL in patients with dyspnea due to heart failure. 24
- 25. Chest X-ray in Heart Failure Cardiomegaly Cephalization of the pulmonary vessels Kerley B-lines Pleural effusions 25
- 26. Cardiomegaly 26
- 27. Pulmonary Edema due to Heart Failure 27
- 28. Cardiac Testing in Heart Failure Electrocardiogram: May show specific cause of heart failure: • Ischemic heart disease • Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular block • Amyloidosis: pseudo-infarction pattern • Idiopathic dilated cardiomyopathy: LVH Echocardiogram: Left ventricular ejection fraction Structural/valvular abnormalities 28
- 29. Management of Systolic HF Correction of systemic factors • Thyroid dysfunction • Infections • Uncontrolled diabetes • Hypertension Lifestyle modification • Lower salt intake • Alcohol and smoking cessation • Medication compliance Maximize medications • Discontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers) 29
- 30. Order of Therapy 1. Loop diuretics 2. ACE inhibitor (or ARB if not tolerated) 3. Beta blockers 4. Digoxin 5. Potassium sparing diuretcs 6. Hydralazine, Nitrate 30
- 31. Diuretics Loop diuretics • Furosemide, bumetanide • For Fluid control, and to help relieve symptoms Potassium-sparing diuretics • Spironolactone, eplerenone • Help enhance diuresis • Maintain potassium • Shown to improve survival in CHF 31
- 32. ACE Inhibitors Improve survival in patients with all severities of heart failure. Begin therapy low and titrate up as possible: • Enalapril – 2.5 mg po BID • Captopril – 6.25 mg po TID • Lisinopril – 5 mg po QDaily If cannot tolerate, may try ARB 32
- 33. Beta Blocker therapy Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV. Contraindicated: • Heart rate <60 bpm • Symptomatic bradycardia • Signs of peripheral hypoperfusion • Asthma • PR interval > 0.24 sec, 2nd or 3rd degree block 33
- 34. Hydralazine plus Nitrates Dosing: Hydralazine Started at 25 mg po TID, titrated up to 100 mg po TID Isosorbide dinitrate Started at 40 mg po TID/QID Decreased mortality, lower rates of hospitalization, and improvement in quality of life. 34
- 35. Digoxin Given to patients with HF to control symptoms such as fatigue, dyspnea, exercise intolerance Shown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality. 35
- 36. Other important medication in Heart Failure Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease. Some studies have shown a possible benefit specifically in HF with statin therapy • Improved LVEF • Reversal of ventricular remodeling • Reduction in inflammatory markers (CRP, IL-6, TNF-alphaII) 36
- 37. Meds to AVOID in heart failure NSAIDS -Can cause worsening of preexisting HF Thiazolidinediones • Include rosiglitazone and pioglitazone • Cause fluid retention that can exacerbate HF Metformin - people with HF who take it are at increased risk of potentially lethal lactic acidosis 37
- 38. Heart Failure Complications Pleural effusion Atrial fibrillation (most common dysrhythmia) Loss of atrial contraction (kick) -reduce CO by 10% to 20% Promotes thrombus/embolus formation increase risk for stroke Treatment may include cardioversion, antidysrhythmics, and/or anticoagulants 38
- 39. Heart Failure Complications **High risk of fatal dysrhythmias (e.g., sudden cardiac death(V. fibrillation, ventricular tachycardia) with HF and an EF <35% HF lead to severe hepatomegaly, especially with RV failure • Fibrosis and cirrhosis - develop over time Renal insufficiency or failure 39
- 40. Heart Failure (ADHF) Pneumonic (emergency mgmt) U Upright Position N Nitrates L Lasix O Oxygen A ACE, ARBs, Amiodorone D Digoxin, Dobutamine M Morphine Sulfate E Extremities Down 40
- 41. Right heart failure / Cor Pulmonale •Results from diseased right ventricle •Blood backs up into right atrium and venous circulation •Causes LVF Cor pulmonale RV infarction 41
- 42. Cor Pulmonale Right Sided Heart Disease, secondarily caused by abnormalities of lung parenchyme, airways, thorax, or respiratory control mechanisms. No evidence of other heart conditions, May be Acute or Chronic 42
- 43. Etiology of Cor Pulmonale Lung and Airways COPD Asthma Bronchiectasis ILD Pulmonary tuberculosis Vascular Occlusion Multiple Emboli Schistosomiasis Filariasis Sickle Cell P. Pulmonary Hypertension 43
- 44. Thoracic Cage Kyphosis > 100 o Scoliosis > 120 o Thoracoplasty Pleural fibrosis N-M Disease Polio Myelitis Myasthenia Gravis ALS Muscular Dystrophy Etiology of Cor Pulmonale 44
- 45. Abnormal Respiratory Control Idiopathic hypoventilation Syndrome Obesity hypoventilation syndrome (Pick-Wickian syndrome) Cerebrovascular disease Etiology of Cor Pulmonale 45
- 46. Pathophysiology Pulmonary disease can produce physiologic changes that in time affect the heart and cause the right ventricle to enlarge and eventually fail. Any condition that deprives the lungs of oxygen can cause hypoxemia and hypercapnia resulting in ventilatory insufficiency. 46
- 47. Pathophysiology.. Hypoxemia and hypercapnia cause pulmonary arterial vasoconstriction and possibly reduction of the pulmonary vascular bed e.g in COPD or pulmonary Embolism. Right ventricular hypertrophy may result, followed by right ventricular failure. 47
- 48. Pathophysiology.. In summary, cor pulmonale results from pulmonary hypertension, which causes the right side of the heart to enlarge because of the increased work required to pump blood against high resistance through the pulmonary vascular system. . 48
- 49. Natural History Several months to years to develop All ages from child to old people Repeated infections aggravate RV strain into RV failure Initially responds well to therapy but progressively becomes refractory 49
- 50. Clinical features of RHF/Cor pulmonale Fatigue, lethergy, anorexia Venous congestion • Peripheral edema • Weight gain • Ascites • Hepatomegaly • Splenomegaly • Jugular venous distension Rx – mainly diuresis 50
- 51. Lab. Findings X-Ray : Prominent pulmonary hilum pulmonary artery dilatation Rt MPA > 20 mm EKG : P- pulmonale, RAD, RVH Echocardiography : RVH, TR, Pulm. Hypertension ABG : Hypoxemia, Hypercapnea, Respiratory acidosis CBC : polycythemia Cardiac catheterization 51
- 52. Treatment of Cor Pulmonale Treat Underlying Disease : COPD Tx, Steroid, Infection control, theophylline, B2 adrenergic agonists, medroxyprogesterone, Continuous O2 : < 2-3L/min Diuretics Phlebotomy Digoxin : controversial Pulmonary Vasodilators Anticoagulation Reduce Ventilation/Perfusion imbalance : Amitrine bimesylate 52
- 53. Prognosis 1960-1970 : 3 yr mortality 50-60% Recent times : survival 5 - 10 years or more 53
Editor's Notes
- #5: An ejection fraction (EF) is one of the measurements used by physicians to assess how well a patient’s heart is functioning. “Ejection” refers to the amount of blood that is pumped out of the heart’s main pumping chamber during each heartbeat. “Fraction” refers to the fact that, even in a healthy heart, some blood always remains within this chamber after each heartbeat. Therefore an ejection fraction is a percentage of the blood within the chamber that is pumped out with every heartbeat. An EF of 55 to 75 percent is considered normal. A higher than normal ejection fraction could indicate the presence of certain heart conditions, such as hypertrophic cardiomyopathy. A low ejection fraction could be a sign that the heart is weakened.