2. CARDIAC FAILURE 1 TOPICS INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE Brian Angus Pathology Department University of Newcastle upon Tyne Return to Cardiovascular Pathology Index Page

3. CARDIAC FAILURE 2 INTRODUCTION very common clinical problem due to many types cardiac disease prognosis poor - median survival 3 yrs

4. CARDIAC FAILURE 3 SIDE OF HEART AFFECTED The heart works as a unit with both ventricles contracting in unison. Heart failure usually involves both the right and left sides, giving symptoms and signs related to both - congestive cardiac failure. Sometimes left or right heart failure predominates, for example RHF in chronic obstructive airways disease, and acute LVF in myocardial infarction. In the ensuing slides we will consider right and left heart failure separately.

5. CARDIAC FAILURE 4 SIDE OF HEART AFFECTED LEFT pulmonary congestion and oedema - breathlessness RIGHTperipheral oedema hepatic congestion raised JVP CONGESTIVE : R & L Note: chronic LHF leads to RHF

6. CARDIAC FAILURE 5 CAUSES OF CARDIAC FAILURE ischaemic heart disease systemic hypertension valvular heart disease congenital heart disease lung disease COAD (cor pulmonale) Rarities e.g. cardiomyopathy

7. CARDIAC FAILURE 6 LEFT HEART FAILURE: EFFECTS Acute LHF -Pulmonary oedema Frothy blood stained sputum Chronic LHF - Dyspnoea on exertion Poor renal perfusion - Renin- angiotensin system activated

8. CARDIAC FAILURE 7 LEFT HEART FAILURE: THE RENIN-ALDOSTERONE- ANGIOTENSIN SYSTEM Poor renal perfusion is sensed by the juxtaglomerular apparatus, which secretes renin. Renin converts angiotensinogen in the blood to angiotensin1. This in turn is converted by ACE (angiotensin converting enzyme) to angiotensin2, which increases blood pressure directly by vasoconstriction and by increasing adrenal secretion of aldosterone. ACE inhibitors are used to treat heart failure as well. as hypertension. Diuretic drugs are another mainstay of treatment.

9. CARDIAC FAILURE 8 THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM ACE ACE INHIBITORS JGA RENIN ADRENAL ALDOSTERONE ANGIOTENSINOGEN ANGIOTENSIN 1 ANGIOTENSIN 2 VASOCONSTRTICTS Na RETENTION INCREASED BP

10. CARDIAC FAILURE 9 INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

11. CARDIAC FAILURE 10 RIGHT HEART FAILURE: EFFECTS Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities

12. CARDIAC FAILURE 11 RIGHT HEART FAILURE: EFFECTS 1 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows the “nutmeg” liver of chronic venous congestion

13. CARDIAC FAILURE 12 RIGHT HEART FAILURE: EFFECTS 2 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows pitting oedema of the ankle. An indentation has been left by firm digital pressure

14. CARDIAC FAILURE 13 RIGHT HEART FAILURE: EFFECTS 3 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows bilateral pleural effusions.

15. CARDIAC FAILURE 14 PLEURAL EFFUSIONS

16. CARDIAC FAILURE 15 RIGHT HEART FAILURE: COR PULMONALE Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.

17. CARDIAC FAILURE 16 CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

18. CARDIAC FAILURE 17 CONGESTIVE CARDIACFAILURE: EFFECTS Congestive = Combined R & L Most cases are congestive but sometimes features of R or L CF predominate

19. CARDIAC FAILURE 18 CONGESTIVE CARDIACFAILURE: CLINICAL FEATURES SUMMARY dyspnoea oedema venous congestion raised JVP mild hepatomegaly

20. CARDIAC FAILURE 19 CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

21. CARDIAC FAILURE 20 CARDIAC FAILURE DIAGNOSIS History Examination Chest X-RAY ECG Echocardiography BNP BNP = B type natriuretic peptide. Hormone released into plasma by steressed myocytes in CF

22. CARDIAC FAILURE 21 CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

23. CARDIAC FAILURE 22 DYSPNOEA Dyspnoea (breathlessness) occurs in left heart failure. At first the pulmonary vascular beds become congested. Later fluid builds up in the interstitium (the space between capillary endothelial cells and alveolar lining cells), and this is known as interstitial oedema. Finally fluid enters the alveoli giving pulmonary oedema as shown in the radiograph.

24. CARDIAC FAILURE 23 PULMONARY OEDEMA

25. CARDIAC FAILURE 24 In the early stages of pulmonary oedema, crepitations (fine crackles) are heard on auscultation. In severe pulmonary oedema frothy sputum can be produced. Occaisionally this can be bloodstreaked, for example in pulmonary oedema due to mitral stenosis. DYSPNOEA

26. CARDIAC FAILURE 25 On lying down dependent vascular and extravascular fluid enters the central circulation. In heart failure the heart cannot cope with the increase load and pulmonary congestion and oedema result DYSPNOEA: SPECIAL TYPES

27. CARDIAC FAILURE 26 The two clinical syndromes associated with this are: Orthopnoea: dyspnoea on lying down flat. Paroxysmal nocturnal dyspnoea: intermittent attacks of dyspnoea while in bed. The patient typically goes to an open window gasping for breath and waits for recovery. DYSPNOEA: SPECIAL TYPES

28. CARDIAC FAILURE 27 CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

29. CARDIAC FAILURE 28 CARDIAC FAILURE: AGE DIFFERENCES Babies and old people sometimes do not give classical symptoms and signs of heart failure. Babies typically show rapid breathing (tachypnoea), rapid heartbeat (tachycardia) and poor feeding. Old people can simply be lethargic with nausea and vomiting.

30. CARDIAC FAILURE 29 CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

31. CARDIAC FAILURE 30 CARDIAC FAILURE: HIGH OUTPUT FAILURE In most cases of heart failure the cardiac output is low. In rare situations, there may be no intrinsic heart disease, but the heart is put under such a high load that it cannot cope and eventually fails. This is known as high output failure. Examples of this include very severe anaemia and hyperthyroidism. Massively enlarged thyroid gland in hyperthyroidism.

32. CARDIAC FAILURE 31 Return to Cardiovascular Pathology Index Page END OF PRESENTATION