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Nothing can happen unless you first dream 
Carl Sandburg
Congestive heart failure 
Presentation and Diagnosis 
The most common reason for hospitalization in 
adults >65 years old 
Dr Shahid Abbas 
Consultant Interventional Cardiologist
Road Map 
– Definition 
– Causes and pathophysiology 
– Types of heart failure 
– Compensatory mechanism of heart failure 
– Clinical manifestations 
– Classification of heart failure 
– Diagnostic evaluation 
– Management
Definition 
A clinical syndrome that develops when 
the heart cannot maintain an adequate 
cardiac output 
The heart pumps blood inadequately, 
leading to reduced blood flow, back-up 
(congestion) of blood in the veins and 
lungs Leading to 
Other changes that may further weaken 
the heart
5 
Etiology 
• A syndrome of Pulmonary and/ or Systemic 
congestion due to  C.O 
• Heart is unable to pump enough blood to 
meet tissues O2 requirements 
 Pulmonary pressure  fluid in alveoli 
(PULMONARY EDEMA) 
 Systemic pressure  fluid in tissues 
(PERIPHERAL EDEMA)
6 
Etiology 
• Heart failure is caused by systemic 
hypertension in 75% of cases 
• About one third of clients experiencing 
myocardial infarction also develop heart 
failure 
• Structural heart changes, such as valvular 
dysfunction, cause pressure or volume 
overload on the heart
Predisposing Cardiac Diseases 
• Myocardial infarction 
• Chronic ischemia 
• Cardiomyopathy 
• Arrhythmias 
• Diastolic dysfunction 
• Valvular diseases 
– Aortic Stenosis 
– Mitral Stenosis 
– Mitral Regurgitation
Causes of congestive heart failure 
(cont…) 
• Severe lung disease (pulmonary hypertension) 
• Severe anemia 
• Overactive thyroid gland (hyperthyroidism) 
• Underactive thyroid gland (hypothyroidism) 
• Abnormal heart rhythms ( atrial fibrillation) 
• Kidney failure
Cardiac Physiology 
(remember this?) 
• CO = SV x HR 
• HR: parasympathetic and sympathetic tone 
• SV: preload, afterload, contractility
Preload 
• Passive stretch of muscle prior to contraction 
• Measurement: Swan-Ganz 
– LVEDP 
• Really a function of LVEDV 
• Affected by compliance 
– Low compliance = higher LVEDP @ lower LVEDV 
– False high estimate of preload 
• Frank-Starling right?
Afterload 
• Force opposing/stretching muscle after 
contraction begins 
• Measurement: SVR 
• Really a function of: 
– SVR 
– Chamber radius (dilated cardiomyopathies) 
– Wall thickness (hypertrophy)
Contractility 
• Normal ability of the muscle to contract at a 
given force for a given stretch, independent of 
preload or afterload forces 
• In other words: 
– How healthy is your heart muscle? 
• Ischemia, Hypertrophy (?), Muscle loss
CHF: the heart muscle 
March 2013 ghennersdorf DGK ESC SES
CHF: the heart muscle sarcomere 
March 2013 ghennersdorf DGK ESC SES
Pathophysiology 
Renin + Angiotensinogen 
Angiotensin I 
Angiotensin II 
Peripheral 
Vasoconstriction 
 Afterload 
 Cardiac Output 
Heart Failure 
Salt & Water Retention 
 Plasma Volume 
 Preload 
 Cardiac Workload 
Edema 
Aldosterone Secretion 
Renin-angiotensin system
Heart Failure 
• Pathophysiology 
• A. Cardiac compensatory mechanisms 
– 1.tachycardia 
– 2.ventricular dilation-Starling’s law 
– 3.myocardial hypertrophy 
• Hypoxia leads to dec. contractility
Acute decompensated heart failure 
Pulmonary edema, often life-threatening 
• Early 
–Increase in the respiratory rate 
–Decrease in PaO2 
• Later 
–Tachypnea 
–Respiratory acidemia
Acute Decompensated Heart Failure 
(ADHF) Pulmonary Edema 
Pulmonary edema begins with an increased 
filtration through the loose junctions of the 
pulmonary capillaries. 
As the intracapillary pressure increases, normally 
impermeable (tight) junctions between the alveolar cells 
open, permitting alveolar flooding to occur.
END RESULT 
FLUID OVERLOAD > Acute Decompensated Heart Failure 
(ADHF)/Pulmonary Edema 
Medical Emergency!
Person literally drowning in 
secretions 
Immediate Action Needed
MMildild 
Heart Failure 
(progression) 
Drugs 
Diet 
Fluid 
Restriction 
Cardiogenic shock 
Cardiomyopathy 
CDHF(Pulmonary Edema) Severe End Stage 
Irreversible 
Needs new ventricle 
VAD 
IABP 
VAD 
IABP 
Heart Transplant 
Control With 
Emergency-Upright, O2, morphine, etc
Ventricular remodeling
Classifying Heart Failure 
• Anatomically 
– Left versus Right 
• Physiologically 
– Systolic versus Diastolic 
• Functionally 
– How symptomatic is your patient?
Congestive heart failure 
Types 
• Left-sided heart failure 
There are two types of left-sided heart failure 
Systolic dysfunction 
Diastolic dysfunction 
• Right-sided heart failure
Left versus Right Failure 
Left Heart Failure 
- Dyspnea 
- Dec. exercise tolerance 
- Cough 
- Orthopnea 
- Pink, frothy sputum 
Right Heart Failure 
- Dec. exercise tolerance 
- Edema 
- HJR / JVD 
- Hepatomegaly 
- Ascites
Systolic versus Diastolic 
Systolic– “can’t pump” 
– Aortic Stenosis 
– HTN 
– Aortic Insufficiency 
– Mitral Regurgitation 
– Muscle Loss 
• Ischemia 
• Fibrosis 
• Infiltration 
Diastolic- “can’t fill” 
– Mitral Stenosis 
– Tamponade 
– Hypertrophy 
– Infiltration 
– Fibrosis
Classification of heart failure 
New York Heart Association (NYHA) Functional Classification 
Class % of patients Symptoms 
No symptoms or limitations in ordinary 
physical activity 
I 35% 
Mild symptoms and slight limitation 
during ordinary activity 
II 35% 
Marked limitation in activity even 
during minimal activity. Comfortable 
only at rest 
III 25% 
Severe limitation. Experiences 
symptoms even at rest 
IV 5%
Heart Failure 
Clinical Manifestations 
• Acute decompensated heart 
failure (ADHF) 
• Physical findings 
• Orthopnea 
• Dyspnea, tachypnea 
• Use of accessory muscles 
• Cyanosis 
• Cool and clammy skin 
•Physical findings 
•*Cough with frothy, 
blood-tinged sputum 
•Breath sounds: Crackles, 
wheezes, rhonchi 
•Tachycardia 
•Hypotension or 
hypertension
ADHF/Pulmonary Edema 
(advanced L side HF) 
When PA WEDGE pressure is approx 30mmHg 
– Signs and symptoms 
• wheezing 
• pallor, cyanosis 
• Inc. HR and BP 
• S3 gallop 
• Rales,copious pink, frothy sputum
Congestive heart failure 
Clinical manifestations 
– Symptoms (back up of blood and fluid) 
– Dyspnea 
– Orthopnea 
– Reduced exercise tolerance, lethargy, 
fatigue 
– Nocturnal cough 
–Wheeze 
– Ankle swelling 
– Anorexia
Congestive heart failure 
Clinical manifestations ( cont…) 
–Signs 
– Cachexia and muscle wasting 
– Tachycardia 
– Pulsus alternans 
– Elevated jugular venous pressure 
– Crepitations or wheeze 
– Third heart sound 
– Oedema 
– Hepatomegaly (tender) 
– Ascites
Clinical Data 
• HEART SOUNDS!!! 
• Systolic Murmurs 
– Mitral Regurg 
– Aortic Stenosis 
• Diastolic Murmurs 
– Mitral Stenosis 
– Aortic Insufficiency 
• S3: Rapid filling of a diseased ventricle
Symptoms
37
38 
PULMONARY EDEMA 
Rapid fluid accumulation in lung spaces that 
has leaked from engorged pulmonary 
capillaries 
Etiology – most common cause is sudden 
deterioration of LV function
39 
Cardiogenic Shock 
Significant reduction in SV & CO causes drop in 
pressure & poor tissue perfusion a/r/o LV MI 
• Clinical signs: 
–  BP,  pulse,  peripheral pulses 
– confusion/ agitation (cerebral hypoxia) 
– cold/ clammy skin 
–  urine output 
– Resp distress 
– Chest pain
41 
(R) SIDED HF 
Blood “BACKS UP” into venous circulation. High 
oncotic pressure pushes fluids into tissues. 
CLINICAL SIGNS: 
 CVP SUDDEN WT. GAIN 
 JVD DEPENDENT EDEMA 
FATIGUE LIVER CONGESTION 
LETHARGY ASCITES 
ORTHOPNEA ANOREXIA
42
What does this 
show?
Can You Have RVF Without LVF? 
• What is this called? 
COR PULMONALE
What is present in this extremity, common to right sided HF?
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 inc. 
risk for stroke 
– Treatment may include cardioversion, 
antidysrhythmics, and/or anticoagulants
Heart Failure 
Complications 
• **High risk of fatal dysrhythmias (e.g., sudden 
cardiac death, 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
Heart Failure 
Diagnostic Studies 
• Primary goal- determine underlying cause 
– History and physical examination( dyspnea) 
– Chest x-ray 
– ECG 
– Lab studies (e.g., cardiac enzymes, BNP- (beta 
natriuretic peptide- normal value less than 100) 
electrolytes 
– EF
Clinical Data 
• CXR 
– Kerley’s lines : A and B 
– Pulmonary Edema 
– Cephalization 
– Pleural Effusions (bilateral) 
• EKG 
– Left atrial enlargement 
– Arrhythmias 
– Hypertrophy (left or right)
Cardiomegaly Pulm Oedema
Cardiomegaly/ventricular remodeling occurs as heart overworked> changes in size, shape, and function 
of heart after injury to left ventricle. Injury due to acute myocardial infarction or due to causes that inc. 
pressure or volume overload as in Heart failure
Clinical Data 
• Laboratory Data 
• Chemistry 
– Renal Function: Be Wary 
• BNP 
– Used in ER departments the world over 
– Good negative correlation 
– Need baseline for positivity 
– Pulmonary versus cardiac dyspnea
Transesophageal 
echocardiogram 
TEE
But
56
Goals of Treatment-ADHF/Pulmonary Edema) 
MAD DOG 
• Improve gas exchange 
– Start O2/elevate HOB/intubate 
– Morphine –dec anxiety/afterload 
– A- (airway/head up/legs down) 
– D- (Drugs) Dig not first now- but drugs as 
• IV nitroglycerin; IV Nipride, Natrecor 
– D- Diuretics 
– O- oxygen /measure sats; 
• Hemodynamics, careful observation 
– G- blood gases 
– Think physiology
Congestive Cardiac Failure presentation and diagnosis

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Congestive Cardiac Failure presentation and diagnosis

  • 1. Nothing can happen unless you first dream Carl Sandburg
  • 2. Congestive heart failure Presentation and Diagnosis The most common reason for hospitalization in adults >65 years old Dr Shahid Abbas Consultant Interventional Cardiologist
  • 3. Road Map – Definition – Causes and pathophysiology – Types of heart failure – Compensatory mechanism of heart failure – Clinical manifestations – Classification of heart failure – Diagnostic evaluation – Management
  • 4. Definition A clinical syndrome that develops when the heart cannot maintain an adequate cardiac output The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs Leading to Other changes that may further weaken the heart
  • 5. 5 Etiology • A syndrome of Pulmonary and/ or Systemic congestion due to  C.O • Heart is unable to pump enough blood to meet tissues O2 requirements  Pulmonary pressure  fluid in alveoli (PULMONARY EDEMA)  Systemic pressure  fluid in tissues (PERIPHERAL EDEMA)
  • 6. 6 Etiology • Heart failure is caused by systemic hypertension in 75% of cases • About one third of clients experiencing myocardial infarction also develop heart failure • Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart
  • 7. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases – Aortic Stenosis – Mitral Stenosis – Mitral Regurgitation
  • 8. Causes of congestive heart failure (cont…) • Severe lung disease (pulmonary hypertension) • Severe anemia • Overactive thyroid gland (hyperthyroidism) • Underactive thyroid gland (hypothyroidism) • Abnormal heart rhythms ( atrial fibrillation) • Kidney failure
  • 9. Cardiac Physiology (remember this?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility
  • 10. Preload • Passive stretch of muscle prior to contraction • Measurement: Swan-Ganz – LVEDP • Really a function of LVEDV • Affected by compliance – Low compliance = higher LVEDP @ lower LVEDV – False high estimate of preload • Frank-Starling right?
  • 11. Afterload • Force opposing/stretching muscle after contraction begins • Measurement: SVR • Really a function of: – SVR – Chamber radius (dilated cardiomyopathies) – Wall thickness (hypertrophy)
  • 12. Contractility • Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces • In other words: – How healthy is your heart muscle? • Ischemia, Hypertrophy (?), Muscle loss
  • 13. CHF: the heart muscle March 2013 ghennersdorf DGK ESC SES
  • 14. CHF: the heart muscle sarcomere March 2013 ghennersdorf DGK ESC SES
  • 15. Pathophysiology Renin + Angiotensinogen Angiotensin I Angiotensin II Peripheral Vasoconstriction  Afterload  Cardiac Output Heart Failure Salt & Water Retention  Plasma Volume  Preload  Cardiac Workload Edema Aldosterone Secretion Renin-angiotensin system
  • 16. Heart Failure • Pathophysiology • A. Cardiac compensatory mechanisms – 1.tachycardia – 2.ventricular dilation-Starling’s law – 3.myocardial hypertrophy • Hypoxia leads to dec. contractility
  • 17. Acute decompensated heart failure Pulmonary edema, often life-threatening • Early –Increase in the respiratory rate –Decrease in PaO2 • Later –Tachypnea –Respiratory acidemia
  • 18. Acute Decompensated Heart Failure (ADHF) Pulmonary Edema Pulmonary edema begins with an increased filtration through the loose junctions of the pulmonary capillaries. As the intracapillary pressure increases, normally impermeable (tight) junctions between the alveolar cells open, permitting alveolar flooding to occur.
  • 19. END RESULT FLUID OVERLOAD > Acute Decompensated Heart Failure (ADHF)/Pulmonary Edema Medical Emergency!
  • 20. Person literally drowning in secretions Immediate Action Needed
  • 21. MMildild Heart Failure (progression) Drugs Diet Fluid Restriction Cardiogenic shock Cardiomyopathy CDHF(Pulmonary Edema) Severe End Stage Irreversible Needs new ventricle VAD IABP VAD IABP Heart Transplant Control With Emergency-Upright, O2, morphine, etc
  • 22.
  • 24. Classifying Heart Failure • Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
  • 25. Congestive heart failure Types • Left-sided heart failure There are two types of left-sided heart failure Systolic dysfunction Diastolic dysfunction • Right-sided heart failure
  • 26. Left versus Right Failure Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - HJR / JVD - Hepatomegaly - Ascites
  • 27. Systolic versus Diastolic Systolic– “can’t pump” – Aortic Stenosis – HTN – Aortic Insufficiency – Mitral Regurgitation – Muscle Loss • Ischemia • Fibrosis • Infiltration Diastolic- “can’t fill” – Mitral Stenosis – Tamponade – Hypertrophy – Infiltration – Fibrosis
  • 28.
  • 29.
  • 30. Classification of heart failure New York Heart Association (NYHA) Functional Classification Class % of patients Symptoms No symptoms or limitations in ordinary physical activity I 35% Mild symptoms and slight limitation during ordinary activity II 35% Marked limitation in activity even during minimal activity. Comfortable only at rest III 25% Severe limitation. Experiences symptoms even at rest IV 5%
  • 31. Heart Failure Clinical Manifestations • Acute decompensated heart failure (ADHF) • Physical findings • Orthopnea • Dyspnea, tachypnea • Use of accessory muscles • Cyanosis • Cool and clammy skin •Physical findings •*Cough with frothy, blood-tinged sputum •Breath sounds: Crackles, wheezes, rhonchi •Tachycardia •Hypotension or hypertension
  • 32. ADHF/Pulmonary Edema (advanced L side HF) When PA WEDGE pressure is approx 30mmHg – Signs and symptoms • wheezing • pallor, cyanosis • Inc. HR and BP • S3 gallop • Rales,copious pink, frothy sputum
  • 33. Congestive heart failure Clinical manifestations – Symptoms (back up of blood and fluid) – Dyspnea – Orthopnea – Reduced exercise tolerance, lethargy, fatigue – Nocturnal cough –Wheeze – Ankle swelling – Anorexia
  • 34. Congestive heart failure Clinical manifestations ( cont…) –Signs – Cachexia and muscle wasting – Tachycardia – Pulsus alternans – Elevated jugular venous pressure – Crepitations or wheeze – Third heart sound – Oedema – Hepatomegaly (tender) – Ascites
  • 35. Clinical Data • HEART SOUNDS!!! • Systolic Murmurs – Mitral Regurg – Aortic Stenosis • Diastolic Murmurs – Mitral Stenosis – Aortic Insufficiency • S3: Rapid filling of a diseased ventricle
  • 37. 37
  • 38. 38 PULMONARY EDEMA Rapid fluid accumulation in lung spaces that has leaked from engorged pulmonary capillaries Etiology – most common cause is sudden deterioration of LV function
  • 39. 39 Cardiogenic Shock Significant reduction in SV & CO causes drop in pressure & poor tissue perfusion a/r/o LV MI • Clinical signs: –  BP,  pulse,  peripheral pulses – confusion/ agitation (cerebral hypoxia) – cold/ clammy skin –  urine output – Resp distress – Chest pain
  • 40.
  • 41. 41 (R) SIDED HF Blood “BACKS UP” into venous circulation. High oncotic pressure pushes fluids into tissues. CLINICAL SIGNS:  CVP SUDDEN WT. GAIN  JVD DEPENDENT EDEMA FATIGUE LIVER CONGESTION LETHARGY ASCITES ORTHOPNEA ANOREXIA
  • 42. 42
  • 43. What does this show?
  • 44. Can You Have RVF Without LVF? • What is this called? COR PULMONALE
  • 45. What is present in this extremity, common to right sided HF?
  • 46. 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 inc. risk for stroke – Treatment may include cardioversion, antidysrhythmics, and/or anticoagulants
  • 47. Heart Failure Complications • **High risk of fatal dysrhythmias (e.g., sudden cardiac death, 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
  • 48. Heart Failure Diagnostic Studies • Primary goal- determine underlying cause – History and physical examination( dyspnea) – Chest x-ray – ECG – Lab studies (e.g., cardiac enzymes, BNP- (beta natriuretic peptide- normal value less than 100) electrolytes – EF
  • 49. Clinical Data • CXR – Kerley’s lines : A and B – Pulmonary Edema – Cephalization – Pleural Effusions (bilateral) • EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
  • 51. Cardiomegaly/ventricular remodeling occurs as heart overworked> changes in size, shape, and function of heart after injury to left ventricle. Injury due to acute myocardial infarction or due to causes that inc. pressure or volume overload as in Heart failure
  • 52. Clinical Data • Laboratory Data • Chemistry – Renal Function: Be Wary • BNP – Used in ER departments the world over – Good negative correlation – Need baseline for positivity – Pulmonary versus cardiac dyspnea
  • 54. But
  • 55.
  • 56. 56
  • 57. Goals of Treatment-ADHF/Pulmonary Edema) MAD DOG • Improve gas exchange – Start O2/elevate HOB/intubate – Morphine –dec anxiety/afterload – A- (airway/head up/legs down) – D- (Drugs) Dig not first now- but drugs as • IV nitroglycerin; IV Nipride, Natrecor – D- Diuretics – O- oxygen /measure sats; • Hemodynamics, careful observation – G- blood gases – Think physiology