Basic understanding of heart failure at undergraduate level pathophysiology , etiology , clinical features, diagnosis and treatment

1. HEART FAILURE
ASWIN RM
20.08.2021

2. DEFINITION
Clinical syndrome that develops when the heart cannot
maintain adequate cardiac output, or can do so only at
the expense of elevated ventricular filling pressures
AHA
Complex clinical syndrome that results from structural or functional
impairment of ventricular filling or ejection of blood, which in turn leads
to the cardinal clinical symptoms of dyspnea and fatigue and signs of HF,
namely edema and rales.

3. EPIDEMIOLOGY
64.34 Mn
Current world wide prevalence
2%
Age > 65
6-10%
Developed countries
No 1
1in 5
Every Individual Life time risk
of developing Heart Failure
Cause of Hospitalization
25%
Rehospitalisation rate within 1
months of discharge

4. CLASSIFICATION
Left Sided
Heart
Failure
Right Sided
Heart
Failure
Biventricul
ar Failure
Reduced
EF
<40%
Preserved
EF
>50%
Mid Range
EF
40-49%
Systolic
Diastolic
Acute
Chronic
High
output
Low
Output

5. ETIOLOGY
HF WITH REDUCED EF ( <40%)
CAD
•Myocardial ischaemia
•Myocardial infarction
Chronic pressure overload
• Hypertension,
•Obstructive valvular disease
Chronic volume overload
•Regurgitant valvular disease
•Intra and extra cardiac shunt
Chronic lung disease
•Cor pulmonale,
•Pulmonary vascular disorders
Non ischaemic DCM
•Familial / genetic, infiltration disorders
•Toxic / drug induced - Metabolic, viral
Disorders of rate and rhythm
•Chronic bradyarrhthmias
•Chronic tachyyarrhthmias
HF WITH PRESERVED EF ( >40%)
Pathologic hypertrophy
•Primary (HCM),
•Secondary (Hypertension)
Aging
Restrictive cardiomyopathy
•Infiltrative disorders (amyloidosis, sarcoidosis),
•Storage disorders (Hemochromatosis)
Fibrosis
Endomyocardial disorders
HIGH OUTPUT HEART FAILURE
Metabolic disorders
• Thyrotoxicosis
Nutritional disorders (Beriberi)
Excessive blood flow requirements
•Systemic AV shunting,
•chronic anaemia

6. RIGHT SIDED HEART FAILURE
Cor Pulmonale
Tricuspid & Pulmonary Valve diseases
Carcinoid syndrome
Constrictive Pericarditis
RV endomyocardial Fibrosis
ARVD
 Most common cause left heart Failure
 Predominant right heart failure occur in some conditions

7. PATHOPHYSIOLOGY
Cardiac Output determined by 3 factors
Preload Afterload
Myocardial
Contractility
Depressed contractility is the primary factor mostly in heart
failure with reduced EF

8. PATHOPHYSIOLOGY
Compensatory Mechanism includes Activation of 3 systems
RAAS
Sympathetic
system
Endocrine
/Cytokine system

9. PATHOPHYSIOLOGY
Tachycardia
Increased Contractility
Adverse LV remodeling
Arrythmias
Vasoconstriction
Decreased peripheral circulation
Incresed SVR
Endothelial dysfunction
Sodium & Water Retention

10. PROGRESSIVE HEART FAILURE – A
VICIOUS CIRCLE

11. CLINICAL FEATURES
Chronic Heart Failure – A relapsing remitting course
With intermittent worsening episodes of systemic &
pulmonary congestion
Acute Heart Failure can be de novo or decompensation
of chronic heart failure
Clinical features caused by
Low Cardiac output
Elevated LV & LA pressures – pulmonary Venous Congestion
Elevated RV & RA pressures – systemic Venous Congestion

12. STAGES OF HEART FAILURE

13. SYMPTOMS
Dyspnea on Exertion
PND & Orthopnea
Fatigue
Edema/abdominal distension / Pain right hypochondrium
Increased frequency of micturition

14. NYHA FUNCTIONAL
CLASSIFICATION

15. CHRONIC HEART FAILURE-
OTHER SYSTEMS
Anorexia
Weight Loss – Cardiac cachexia
Cardiac cirrhosis
Renal Failure – Cardio renal syndrome

16. ACUTE HEART FAILURE
 Patients presents with Acute pulmonary edema or
cardiogenic shock
 Sudden Onset sever dyspnea associated with orthopnea
 Coughing with pink frothy sputum
 Autonomic symptoms like diaphoresis
 Altered sensorium due to hypoxia,
 Cyanosis
 Cheyne stokes breathing
 Cold clammy peripheries

17. CLINICAL FEATURES
 Not able to lie supine
 Tachypnea , accessory muscles for
respiration
 Pallor – due to low cardiac output
 Peripheral pitting edema
 Cold extremeties - hypoperfusion
 Tachycardia , Low volume pulse , Pulsus
alternans
 Systemic BP – Normal , Low or high
 Accelerated hypertension – causes acute
pulmonary edema

18. CLINICAL FEATURES
JVP elevated
Cardiomegaly may be present
LV 3rd heart sound
HFpEF – LV 4th heart sound
MR / TR murmurs
Basal Crepitations – severe cases can extent upto higher
lung fields
Features of pleural effusion
Tender hepatomegaly & ascites

19. INVESTIGATIONS
CBC
Renal function – Cause or consequence
Electrolytes (Hyponatremia Common)
Diabetes mellitus
Thyroid function

20. ECG
Previous MI
Features of LVH
Arrythmias
LBBB – May benefit from CRT

21. CXR
Cardiomegaly
Prominent upper lobe veins
Peribronchial cuffing
Kerly lines
Bat wing Appearance
Cotton wool apperarance
Pleural efussion
REDISTRIBUTION PHASE
PCWP 12-18 mm Hg
INTERSTITIAL EDEMA
PCWP 18-25 mm Hg
ALVEOLAR EDEMA
(A/C PULM EDEMA)
PCWP >25 mm Hg

24. ECHOCARDIOGRAM
Ejection Fraction
Diastolic dysfunction ( HFpEF)
Etiology
Valve lesions
Response to drug therapy

25. BIO MARKERS
BNP & NT pro BNP – markers of myocardial stretch
Useful in Diagnosis & Prognosis
Differentiate from Non cardiac causes of breathlessness &
edema

26. DIFFERENTIAL DIAGNOSIS
ARDS
COPD
Pulmonary embolism
Renal Dysfunction
Hepatic disease

27. COMPLICATIONS
Activity Limitation
Impaired Hepatic & Renal Function
Electrolyte abnormalities
Cardiac Cachexia
Thrombo embolism
Arrythmias
Sudden Cardiac death

28. MANAGEMENT-ACUTE
PULMONARY EDEMA
 Admission to ICU
 Propped up position
 O2 inhalation if hypoxia
 If oxygenation not improving or patient in severe distress – Non invasive
ventilation
 Intravenous Loop Diuretics as bolus / infusion – Frusemide (40-240
maintenance mg/day), torsemide 10-100 mg/day maintenance
 Frusemide – pulmonary venodilator also- sudden improvement before
diuresis
 Nitroglycerin infusion (20-200 mcg/kg/min) – with BP monitoring
 Dobutamine , milrinone – increases contractility & dilates systemic
vessels – increase cardiac output

29. MANAGEMENT-ACUTE
PULMONARY EDEMA
 Patient in shock – vasoconstrictors – Nor adrenaline , dopamine ,
adrenaline
 Persistent hypoxemia – mechanical ventilation
 Refractory shock – Circulatory assist devices
 Treatment of etiology

30. LONG TERM MANAGEMENT
General Measures
• Sodium intake : 2-3 g /d,
• Fluid restriction , periodic weight monitoring
• Nutritional supplementation
• Smoking : cessation
• Alcohol : <2 standard drinks/d  men , <1 standard drink /d  women
Drug Therapy
Device Therapy
Intervention & Surgical

31. DRUGS FOR HEART FAILURE
Drugs that decrease mortality
• ACE Inhibitors
• Angiotensin receptor blockers
• ARNI
• Beta Blockers
• Mineralocorticoid receptor
antagonists
• Isosorbide and hydralazine
• Ivabradine
• SGLT2 inhibitors
Drugs that may improve symptoms
without improving outcome
• Cardiac glycosides (digoxin)
• Loop diuretics
• Inotropes

32. MAJOR DRUG GROUPS FOR
HEART FAILURE
Drugs reducing Preload
• Diuretics
• Nitrates
• RAAS inhibitors  ACE-i/ARB/MRA
• SGLT2 inhibitors
Drugs reducing After load
• RAAS inhibitors  ACE-i/ARB/MRA
• Dobutamine / milrinone
• Arteriolar dilators -hydralazine
Drugs reducing Heart rate
• Beta blockers ( also reduces myocardial O2 demand )
• Ivabradine

33. MAJOR DRUG GROUPS FOR
HEART FAILURE
Drugs preventing Adverse cardiac remodeling
• RAAS inhibitors  ACE-i/ARB/MRA
• Beta blockers
• SGLT2 inhibitors
Drugs increasing contractility
• Cardiac glycosides
• Dobutamine
Vasopressors
• Nor adrenaline Dopamine
Antiarrhythmics
• Amiodarone
• Beta blockers

34. DRUGS FOR HEART FAILURE
Metoprolol
Carvedilol
Bisoprolol
Spiranolactone
elplerenone
Enalapril
Lisinopril
Ramipril
Perindopril
Etc..
Candesartan
Losartan
Valsartan
Telmisartan
Olmesartan
Etc..

35. NON PHARMACOLOGICAL
TREATMENT
DEVICE THERAPY
 Cardiac Resynchronization
therapy
 Implantable cardioverter
defibrillator
 Ventricular Assist devices – short
term & Long term
INTERVENTION & SURGERY
 PCI
 CABG
 Valve surgeries
 LV reconstruction surgeries
 Cardiac transplantation

36. CRT
• Cardiac Resynchronisation
theapy for HFrEF
• LBBB with wide QRS > 120,
• Non LBBB > 150
• Ensures simultaneous
contraction of different
segments of heart
ICD
• Implantable cardioverter
defibrillator- to prevent death
from lethal arrythmias
• HFrEF, HCM

37. VENO ARTERIAL ECMO (EXTRA-
CORPOREAL MEMBRANE OXYGENATION LV ASSIST DEVICE

38. PCI or CABG
• Post MI Heart Failure
• Ischemic Cardiomyopathy
heart failure
•
CARDIAC TRANSPLNTATION
• Only definitive treatment in
Advanced heart Failure

39. THANK YOU