1. HEART FAILURE

2. Objectives:- Definition Epidemiology Aetiology Pathophysiology Staging
Symptoms & Signs
Investigations
Treatments
Complications

3. Definition :-
Inability to maintain a cardiac output adequate for the body’s need.
It is considered to be a clinical syndrome , because despite different causes , it is associated with cardiac dilation and impaired cardiac contractility .

4. Epidemiology :
It is Primarily a disease of old age , affecting 30% of people over 80 years.
Improvements in the managements of acute MI & chronic heart disease has led to more heart failure rates , because more patients survive to develop it later in life .

5. Aetiology:- - Causes of Left heart failure : Inadequate LV filling :
-Mitral stenosis .
-LV diastolic dysfunction (LVH)
Pressure overload :
-Aortic stenosis .
-Hypertension .
Volume overload :
-Aortic or mitral regurgitation .
-High output failure , e.g. anemia
LV muscle disease :
-Myocardial infarction .
-Cardiomyopathy.
-Myocarditis .

6. - Causes of Right heart failure :
Any Cause of LHF .
Pulmonary hypertension (lung disease) .
Atrial septal defect .

7. Pathophysiology :- 1 Cardiac Damage Cardiac output Neuroendocrine
activation
Fluid
retention
Peripheral
resistance 2
Ventricular dilatation

8. Table 1. Stages of HF Examples Description ٍStage A B C D
Systemic hypertension ; coronary artery disease ; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse:personal history of rheumatic fever:family history of cardiomyopathy:
Patients at high risk for developing HF because of the presence of conditions that are strongly associated with the development of HF .Such patients have no identified structural or functional abnormalities of the pericardium , myocardium , or cardiac valves and have never shown signs or symptoms of HF . A
Left ventricular hypertrophy or fibrosis:LV dilatation or hypocontractility :asymptomatic valvular heart disease:prevous MI.
Patients who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF. B
Dyspnea or fatigue due to LV systolic dysfunction ;asymptomatic patients who are undergoing treatment for prior symptoms of HF.
Patients who have current or prior symptoms of HF associated with underlying structural heart disease . C
Patients who are frequantly hospitalized for HF and cannot be safely discharged from the hospital;patients in the hospital awating heart transplantation;patients at home receiving continous IV support for symptom relieve or being supported with mechanical circulatory assist device.
Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized intervention. D

9. Symptoms & Signs : - Left Heart Failure : Symptoms : Signs :
- Shortness of breath .
- Orthopnea.
- PND.
Signs :
- Tachypnoea .
- Tachycardia .
- 3rd heart sound on aus .
- Bibasilar pulmonary crepitations .

10. - Right Heart Failure : Symptoms : Signs : - Anorexia . - Nausea .
Non specific such as :
- Fatigue .
- Anorexia .
- Nausea .
Signs :
JVP .
- Hepatomegly .
- Pitting edema (an kles and pedal) .
- Ascites .
- Functional tricuspid incompetence .

11. Investigations : ECG . Echocardiography . Chest x ray.
Nuclear isotope scanning .
24 hr ECG to investigate arrhythmias .

13. Treatment
General
Measures
Surgical
Medical

14. General Measures :. :. Treat the underlying cause .
Reduce salt and water intake .
Daily weight .
Treat HTN and CAD aggressively.

15. .: Medical Treatment :. Diuretics. ACE inhibitors .
Angiotensin II receptor antagonist.
B- blockers.
Digoxin .

16. Diuretics : 1 - Classified into :
(A) Loop diuretics e.g. furosomide , bumetanide.
- MOA : Inhibit Na reabsorption in the ascending limb of the loop of Henle.
- They are potent .
- S/E : - Marked renal k loss.
- Promote hyperuricemia.

17. (B) Thiazides e.g. bendroflumethiazide.
-MOA : Inhibit Na reabsorption in the distal renal tubule.
-Mild diuretics except metolazone which causes excess diuresis.
-S/E : -Hypokalemia.
- Hyperglycemia & hyperuricemia.
(C) K- sparing diuretics e.g. spironolactone.
-MOA :Increase Na secretion on the distal
nephron and inhibit K secretion.
-S/E :Gynaecomastia, nausea and abdominal pain.

18. ACE Inhibitors : 2 E.g. captopril , enalapril , lisinopril . MOA :
- Inhibit angiotensin II.
- Increase cardiac output by decreasing preload and afterload .
- Decrease vascular resistance and PCWP .
Common S/E :
- First dose hypotension .
- the dose of diuretics 24 hr before first dose .
- Start with low dose followed by gradual increase every 1-2 weeks .
- Other S/E angioedema and persistant cough.

19. Studies of LVD (SOLVD) .Enalapril.
- Decrease all cause mortality 16%
- Decrease mortality from HF 22%

20. Angiotensin 2 receptor antagonist :3
e.g. losartan ,valsartan.
- They block binding of angiotensin 2 with type 1 receptors.
- Do not produce cough.
B – blockers : 4
e.g. metoprolol, bisoprolol, carvedilol.
- Restricted to patients with chronic stable HF.
- ACC guidelines recommend that b-blockers should be routinely prescribed to patients with asymptomatic LV dysfunction unless they have contraindication. 5
Digoxin :
- Has +ve inotropic effect .
- No mortality benefit.

21. .: Surgery :. Cardiac transplantation .
Has 90% 1-year survival after surgery .
75% a live after 5 years.
Death usually due to :
1- operative mortality.
2- organ rejection.

22. Complications :
Thromboembolism AF
Ventricular arrythmia

23. Thank You

24. Questions What is New York HF classification ?
What are the C/I of ACE inhibitors ?