Congestive heart

failure
Dr. Tariku
 Heart failure
• is a complex clinical syndrome that arises from any structural or functional
cardiac disorders that impair the ability of the ventricles to fill with or eject
blood
Forms of Heart Failure
• left or right sided
• high output or low output
• acute or chronic
• Systolic or diastolic
Symptoms in Heart
Failure
Major Symptoms Minor Symptoms
• Dyspnea • Weight loss
• Orthopnea
• Cough
• Paroxysmal nocturnal dyspnea
• Ankle edema • Palpitations
• Pulmonary edema • Depression
• Fatigue • Nocturia
• Exercise intolerance
• Peripheral cyanosis
• Cachexia
Framingham clinical criteria for dx
of heart failure
•Major criteria
PND
Orthopnea
↑JVP
Pulmonary rales
S3
cardiomegally
pulmonary edema
wt loss≥4.5kg in fife days in response to treatment of heart failure
Con .Framingham

•Minor criteria
bilateral leg edema
nocturnal cough
dyspnea on ordinary exertion
hepatomegaly
pleural effusion
tacycardia≥120/min
wt loss≥4.5kg in fife days in response to treatment of heart failure
For dx heart failure
• 2 major criteria
• 1 major plus 2minor criteria
functional classification
the New York Heart Association

• Class I: no limitation is experienced in any activities; there are no symptoms from

ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with
mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.
 stages of heart failure

• Stage A : patients who are at high risk for developing HF but do not have
structural heart disease or symptoms of HF (e.g., patients with diabetes mellitus
or hypertension).
• Stage B : patients who have structural heart disease but do not have symptoms
of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction).
• Stage C : patients who have structural heart disease and have developed
symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)
• Stage D :patients with refractory HF requiring special interventions (e.g., patients
with refractory HF who are awaiting cardiac transplantation)
Causes of heart failure
Depressed Ejection Fraction
(<40%)
systolic heart failure
• Coronary artery disease
Myocardial infarction
Myocardial ischemia

• Dilated cardiomyopathy
Familial/genetic disorders
Nonischemic dilated cardiomyopathy
Infiltrative disorders
Toxic/drug-induced damage
Viral
Chagas' disease
Metabolic disorder

• Chronic pressure overload

Hypertension
Obstructive valvular disease
Con. Systolic heart failure

• Chronic volume overload

Regurgitant valvular disease
Extra cardiac shunting
Intra cardiac (left-to-right) shunting
• Disorders of rate and rhythm
Chronic bradyarrhythmias
Chronic tachyarrhythmias
Preserved Ejection Fraction
(>40–50%)

diastolic heart failure

• Pathologic hypertrophy
• Restrictive cardiomyopathy
• Primary (hypertrophic cardiomyopathies)
• Infiltrative disorders (amyloidosis, sarcoidosis)
• Secondary (hypertension)
• Storage diseases (hemochromatosis)
• Aging
• Fibrosis
• Endomyocardial disorders
Pulmonary Heart Disease

• Cor pulmonale
• Pulmonary vascular disorders
High-Output States
• Thyrotoxicosis
• Nutritional disorders (beriberi)
• Systemic arteriovenous shunting
• Chronic anemia
industrialized countries
• coronary artery disease (CAD) is responsible for 60–75% of cases of HF
• Hypertension
• diabetes mellitus
• Congenital heart disease
Developing countries

• Rheumatic heart disease : especially in the young

• Hypertension
 Basic Mechanisms of Heart
Failure

• LV remodeling - the changes in LV mass, volume, and shape and the

composition
 Diastolic Dysfunction

• Myocardial relaxation is ATP dependent process

• in ischemia, slow myocardial relaxation
• LV filling is delayed because LV compliance is reduced (e.g.,
from hypertrophy or fibrosis
Pathophysiology of
heart failure
pathogenesis
ROUTINE LABORATORY TESTS

• CBC to detect anemia and infection

• electrolyte disorders
• renal and liver function
• brain natriuretic peptide (BNP)
•t
BNP

• useful in distinguishing cardiac from noncardiac causes of dyspnea

• provides prognostic information in patients with chronic heart
failure and/or acute coronary syndromes
CXR

• Cardiomegaly
A cardiothoracic ratio more than 0.5
• acute heart failure have evidence of pulmonary hypertension and
interstitial and/or pulmonary edema
• Kerley B lines—linear densities of interlobular interstitial edema—
over the lower lobes are the typical findings in acute heart failure
CXR
ECG

• Ischemic heart disease

• Arrhythmia
• LVH
• Atrial enlargement
• Electrolyte imbalance
Echocardiography
ECHOCARDIOGRAPHY

General Findings
• Size and shape of the ventricle
• LV ejection fraction (LVEF)
• Regional wall motion
• synchronicity of ventricular contraction
• LV remodeling (concentric versus eccentric)
• LV or RV hypertrophy
• Morphology and severity of valve lesions
• Mitral inflow and aortic outflow properties
• RV pressure gradient
• Output state (low or high)
 ECHO

Systolic Dysfunction
• Reduced LVEF (<45%)
• Enlarged left ventricle
• Thin LV wall
• Eccentric LV remodeling
• Mild or moderate mitral regurgitation
• Pulmonary hypertension
• Reduced mitral filling
• Signs of increased filling pressure
ECHO

Diastolic Dysfunction
• Normal LVEF (≥45%-50%)
• Normal LV size
• Thick LV wall
• dilated atria
• Concentric LV remodeling
• No or minimal mitral regurgitation
• Pulmonary hypertension
• Abnormal mitral filling pattern
• Signs of increased filling pressure
 For strategies
• Treatment of the underlining cause
• Treatment of precipitating factors
• Treatment to prevent remodeling
• Symptomatic management
precipitating factors
• Dietary indiscretion: excess salt,alchol
• Myocardial ischemia/infarction
• Arrhythmias (tachycardia or bradycardia)
• Discontinuation of HF therapy
• Infection :endocarditis,pneumonia,pylonephritis,sepsis etc
• Anemia
• Initiation of medications
Calcium antagonists (verapamil, diltiazem)
Beta blockers
Nonsteroidal anti-inflammatory drugs
Antiarrhythmic agents [all class I agents, sotalol (class III)]
Anti-TNF antibodies
• Alcohol consumption
• Pregnancy
• Worsening hypertension
• Acute valvular insufficiency
• Emotion
• PTE
Precipitating factors
Symptomatic mx

• Activity
avoid heavy physical activity
routine modest exercise has been shown to be beneficial in patients
with NYHA class I–III HF
regular isotonic exercise such as walking or riding a stationary-bicycle
ergometer
Diet

• Dietary restriction of sodium (2–3 g daily) is recommended

• Further restriction (<2 g daily) may be considered in moderate to

severe HF
 Caloric supplementation for cardiac cachexia
Diuretics

volume expansion and congestive symptoms

loop diuretics :Furosemide
thiazides
 potassium-sparing diuretics :spironolactone
Diuretics

• Furosemide 20–40 mg qd or bid up to 400mg

• Hydrochlorthiazide 25 mg qd up to100 mg/d

• Spironolactone 12.5–25 mg qd up to 25–50 mg qd

Preventing Disease Progression

• Drugs that interfere with excessive activation of the RAA system and
the adrenergic nervous system
• ACE inhibitors and beta blockers
ACE Inhibitors

• used in symptomatic and asymptomatic patients with a depressed EF

(<40%)
• inhibiting the enzyme angiotensin I to angiotensin II
• inhibit kininase II upregulation of bradykinin
Angiotensin-Converting Enzyme
Inhibitors
• Captopril l6.25 mg tid 50 mg tid

• Enalapril 2.5 mg bid 10 mg bid

• Lisinopril 2.5–5 mg qd 20–35 mg qd

• Ramipril 1.25–2.5 mg bid 2.5–5 mg bid
Angiotensin Receptor Blockers
ARBs

• ARBs block the effects of angiotensin II on the angiotensin type 1

receptor
• For patients who are intolerant of ACE inhibitors because of cough,
skin rash, and angioedema
Angiotensin Receptor Blockers

• Valsartan 40 mg bid 160 mg bid

• Candesartan 4 mg qd 32 mg qd
• Irbesartan 75 mg qd 300 mg qd

• Losartan 12.5 mg qd 50 mg qd
Adverse Effects
ACIE
• Hypotention
• renal failure
• hyperkalemia
• nonproductive cough (10–15% of patients)
• angioedema (1% of patients)
Contraindication for ACEi or ARBs

• Pregnancy
• renovascular disease with unilateral kidney
• Hyperkalemia>5.5meq/ml
• Hypotension
Β-Adrenergic Receptor Blockers

• indicated for patients with symptomatic or asymptomatic HF and a

depressed EF <40%
• beta blockers should be initiated in low doses
followed by gradual increments in the dose if lower doses have been
well tolerated
• the titration of beta blockers should proceed no more rapidly than at
2-week intervals
• it is important to optimize the dose of diuretic before starting
therapy with beta blockers
β blockers

considered in all patients who have been stabilized on an ACE inhibitor,

digoxin, and a diuretic
but remain symptomatic (New York Heart Association classes II to IV)
• β-blocker therapy is generally withheld from patients with acutely
decompensated heart failure or significant volume overload
• Gradual up-titration of the dose improves the ability to tolerate these
drugs
 β- Receptor Blockers

• Carvedilol 3.125 mg bid 25–50 mg bid

• Bisoprolol 1.25 mg qd 10 mg qd
• Metoprolol succinate CR 12.5–25 mg qd Target dose 200 mg qd
 Adverse Effects
• bradycardia
• exacerbate heart block.
• Beta blockers are not recommended for patients who have asthma with
active bronchospasm
Aldosterone Antagonists

• spironolactone
• recommended for patients with NYHA class IV or class III HF who
have a depressed EF (<35%)
• Adverse Effects : hyperkalemia, gynecomastea
• Aldosterone antagonists are not recommended serum creatinine is
>2.5 mg/dL
serum potassium is >5 mmol/L
hydralazine and isosorbide dinitrate

• recommended as part of standard therapy in addition to beta

blockers and ACE inhibitors for African Americans with NYHA class II–
IV HF
• Effect due to the beneficial effects of NO on the peripheral circulation
Digoxin

• inhibiting the Na+,K+-ATPase pump in cell membranes

• increase in intracellular calcium concentration and hence increased
cardiac contractility
• increase in vagal tone :slow heart rate
COMPLICATIONS OF DIGOXIN USE

cardiac arrhythmias: heart block ectopic and reentrant cardiac

rhythms
neurological complaints : visual disturbances, disorientation, and
confusion;
gastrointestinal symptoms : anorexia, nausea, and vomiting.
Indication for digoxine

• Systolic heart failure

• Heart failure with superaventicular tachycardia
digoxin therapy

in the patient with left ventricular systolic dysfunction

who remains symptomatic after treatment with an ACE inhibitor and a
diuretic.
anticoagulation

recommended in heart failure patients with

• atrial fibrillation
• prior arterial embolic events
• mechanical heart valves
• an anterior myocardial infarction in the past 3 months
Refractory Heart Failure

• Dobutamine
• Milrinone
• sodium nitroprusside
• dopamine
Management of Cardiac Arrhythmias

• Most antiarrhythmic agents, with the exception of amiodarone and

dofetilide
• have negative inotropic effects
• are proarrhythmic
• implantable cardioverter-defibrillators (ICDs)
RESYNCHRONIZATION THERAPY

• Interventricular conduction delays, demonstrated as a prolonged QRS

duration
• have been associated with reduced exercise capacity and a poor
long-term prognosis
• Biventricular pacing or resynchronization therapy results in more
normal ventricular contraction and
improvement in cardiac output and LVEF.
CARDIAC RESYNCHRONIZATION

• manifest a QRS duration longer than 120 ms

• dyssynchronous ventricular contraction
suboptimal ventricular filling,
a reduction in LV contractility
prolonged duration of mitral regurgitation
paradoxical septal wall motion.
CRP

• for patients with severe heart failure and a widened QRS complex
who remain symptomatic despite optimal pharmacologic therapy
• for ambulatory patients with sinus rhythm and class III or IV
symptoms
CRP

Biventricular pacing
• stimulates both ventricles nearly simultaneously
• thereby improving the coordination of ventricular contraction
• reducing the severity of mitral regurgitation.
Recommendation for CRP

• sinus rhythm
• EF less than 35 percent
• QRS width more than 120 milliseconds
• who remain symptomatic (NYHA Class III or IV)
IMPLANTABLE CARDIOVERTER-
DEFIBRILLATOR(ICP)

• ICDs in NYHA Class II or III has been shown to reduce the incidence
of sudden cardiac death in patients with ischemic or nonischemic
cardiomyopathy.
ICD

• NYHA Class II or III HF

• depressed EF of less than 30 to 35
• On ACEI-ARB, beta blocker, and aldosterone antagonist
• highly effective in treating recurrences of sustained ventricular
tachycardia and/or ventricular fibrillation in HF patients with
recurrent arrhythmias and/or cardiac syncope
 pulmonary edema
• Diuretics
• Treatment of precipitating factors
• Vasodilators
• Inotropic Agents
• Vasoconstrictors
• intraaortic balloon counter pulsation,
• implanted LV assist devices
Treatment: Cor Pulmonale

• The primary treatment goal of cor pulmonale is to target the

underlying pulmonary disease
• decreasing work of breathing by using noninvasive mechanical
ventilation and bronchodilation
• treating any underlying infection
• Adequate oxygenation (oxygen saturation 90–92%)
• phlebotomy may be considered in extreme cases of polycythemia.
con

• Diuretics are effective but need causion

• Digoxin is of uncertain benefit in the treatment of cor pulmonale and
may lead to arrhythmias
If any indication it is given at low doses and monitored carefully
• Pulmonary vasodilators for isolated pulmonary arterial hypertension
is present