Congestive Cardiac Failure presentation and diagnosis

Interventional Cardiologist at AFIC & NIHD Rawalpindi um Army
4. Dec 2014

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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. Ventricular remodeling
  23. Classifying Heart Failure • Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
  24. 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
  25. 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
  26. 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
  27. 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%
  28. 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
  29. 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
  30. 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
  31. 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
  32. Clinical Data • HEART SOUNDS!!! • Systolic Murmurs – Mitral Regurg – Aortic Stenosis • Diastolic Murmurs – Mitral Stenosis – Aortic Insufficiency • S3: Rapid filling of a diseased ventricle
  33. Symptoms
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  35. 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
  36. 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
  37. 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
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  39. What does this show?
  40. Can You Have RVF Without LVF? • What is this called? COR PULMONALE
  41. What is present in this extremity, common to right sided HF?
  42. 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
  43. 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
  44. 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
  45. Clinical Data • CXR – Kerley’s lines : A and B – Pulmonary Edema – Cephalization – Pleural Effusions (bilateral) • EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
  46. Cardiomegaly Pulm Oedema
  47. 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
  48. 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
  49. Transesophageal echocardiogram TEE
  50. But
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  52. 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