HEART FAILURE PROF. DR. MUHAMMAD AKBAR CHAUDHRY M.R.C.P.(U.K) F.R.C.P.(E) F.R.C.P.(LONDON) F.A.C.C. DESIGNED AT A.V. DEPTT F.J.M.C. BY RABIA KAZMI

HEART FAILURE Definitions Circulatory failure Heart failure C.C.F. Pump failure Myocardial failure High output failure Forward and backward failure Left & right heart failure Compensated heart failure Atrial failure

CLASSIFICATION OF PULMONARY EDEMA THE BASIS OF INITIATING MECHANISIM

CLASSIFICATION OF HEART FAILURE (NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION) 1.Patients with cardiac disease but without resulting limitations of physical activity.Ordinary physical activity does not cause undue fatigue,palpitations,dyspnea, or anginal pain. 2.Patients with cardiac disease resulting in slight limitation of physical activity.These patients are comfortable at rest. Ordinary physical activity causes fatigue,palpitations,dyspnea,or anginal pain. 3.Patients with cardiac disease resulting in marked limitation of physical activity. These patients are comfortable at rest.Less than ordinary physical activity causes fatigue,palpitations,dyspnea,or anginal pain. 4.Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest.If any physical activity is undertaken discomfort is increased.

CLASSIFICATIONS & DEFINITIONS OF COMMON TYPES OF HEART FAILURE Heart failure Clinical syndrome with classic symptoms that are attributable to impaired myocardial function. Congestive heart failure Similar but with features of circulatory congestion. Non cardiac circulatory congestion Clinically similar syndrome but without any structural heart disease. Systolic heart failure Clinical syndrome with classic symptoms of heart failure whereby dominant cardiac feature is dilated heart & impaired systolic performance Diastolic heart failure Heart failure whereby the dominant cardiac feature is impaired diastolic function. Right sided heart failure Clinical syndrome characterized by marked impairment of right ventricular systolic function,usually with right ventricular dilatation & severe tricuspid regurgitation.

RIGHT HEART FAILURE AND SYSTEMIC CONGESTION

LEFT HEART FAILURE AND PULMONARY CONGESTION

SYSTOLIC HEART FAILURE Large,dilated heart Normal or low blood pressure Broad age group; more common in men Low ejection fraction S 3 gallop Systolic & diastolic impairment by echo Treatment well established Poor prognosis Role of myocardial ischemia important in selected cases DIASTOLIC HEART FAILURE Small LV cavity, concentric LV hypertrophy Systemic hypertension Elderly women more common Normal or increased ejection fraction S 4 gallop Diastolic impairment by various Echo measurements Treatment not well established Prognosis not as poor Myocardial ischemia common THE DIFFERENTIAL DIAGNOSIS OF SYSTOLIC HEART FAILURE & HEART FAILURE WITH NORMAL SYSTOLIC FUNCTION (DIASTOLIC HEART FAILURE)

CLASSIFICATION OF CIRCULATORY FAILURE & CIRCULATORY OVERLOAD 1.Circulatry failure a)Heart (cardiac) failure b)Non cardiac (peripheral) circulatory failure 1.Decreased return of blood to heart, inadequate blood volume 2.Increased capacity of vascular bed 3.Peripheral vascular abnormalities 4.Inadequate oxyhemoglobin II.Circulatory congestion A.Cardiac circulatory overload 1.Heart (cardiac) failure B.Non cardiac circulatory overload 1.Increase in blood volume 2.Increase in venous return & /or decrease in peripheral vascular resistance

GENERAL CAUSES OF OVERALL HEART “PUMP” FAILURE A.Mechanical abnormalities 1. Increased pressure load a) Central (aortic stenosis, etc) b)Peripheral (systemic arterial hypertension,etc) 2.Increased volume load (valvular regurgitation,shunts, increased venous return.etc) 3.Obstruction to ventricular filling (mitral or tricuspid stenosis) 4.Pericardial constriction,tamponade 5.Endocardial or myocardial restriction 6.Ventricular aneurysm 7.Ventricular dyssynergy

GENERAL CAUSES OF OVERALL HEART “PUMP” FAILURE B.Myocardial (muscular) abnormalities or loss of myocytes 1.Primary abnormalities or loss of myocytes a.Cardiomyopathy b.Neuromuscular disorders c.Myocarditis d.Metabolic (diabetes mellitus. etc) e.Toxic (alcohol, cobalt. etc) f.Presbycardia

C. Secondary myocardial abnormalities or loss of myocytes a.dysdynamic (secondary to mechanical abnormalities) b.Ischemia (coronary heart disease) c.Metabolic d.Inflammation e.infiltrative diseases f.Chronic obstructive lung disease g.Myocardial depression due to drugs GENERAL CAUSES OF OVERALL HEART “PUMP” FAILURE

D. Altered cardiac rhythm or conduction disturbances 1.Standstill 2.Fibrillation 3.Extreme tachycardia or bradycardia 4.Electrical asynchrony, conduction disturbances GENERAL CAUSES OF OVERALL HEART “PUMP” FAILURE

`CARDIAC PUMP FAILURE Pressure overload Volume overload Myocardial abnormality Or loss others Myocardial dysfunction Myocardial failure Compensatory hypertrophy Of remaining myocytes Compensatory mechanism compensated Minimally Impaired survival decompensated Loss of ‘ myocytes arrhythmias Ventricular dilatation Diastolic dysfunction failure Diastolic pressure Pulmonary congestion Peripheral congestion Decreased survival Systolic Dysfunction failure Fixed Peripheral resistance Emptying Ejection fraction Skeletal Blood flow Exercise tolerance

COMPENSATORY MECHANISMS INITIATED BY LOW CARDIAC OUTPUT : c

COMPENSATORY MECHANISMS IN HEART FAILURE : A. Autonomic nervous system 1. Heart a.Increased heart rate b.Increased myocardial contractility c.Increased rate of relaxation 2. Peripheral circulation a.Arterial vasoconstriction (increased after load) b.Venous vasoconstriction (increased preload)

B. Kidney renin angiotensin- aldosterone Arterial vasoconstriction (increased afterload) Venous vasconstriction (increased preload) Sodium & water retention (increased preload & after load) Increased myocardial contractility COMPENSATORY MECHANISMS IN HEART FAILURE :