Congestive Heart Congestive Heart FailureFailure

Symptoms & signsSymptoms & signsBY : DR.F.SahebjameeBY : DR.F.Sahebjamee

CardiologistCardiologist

Heart Failure Incidence Heart Failure Incidence and Prevalenceand Prevalence

♥ ♥ PrevalencePrevalence Worldwide – 22 millionWorldwide – 22 millionUnited States – 5 millionUnited States – 5 million

♥ ♥ IncidenceIncidenceWorldwide – 2 million new cases yearWorldwide – 2 million new cases yearUnited States – 500,000 new cases yearUnited States – 500,000 new cases year

2 Types of Heart 2 Types of Heart FailureFailure

Systolic Systolic DysfunctionDysfunction

(Contraction) 2/3 of Patients(Contraction) 2/3 of Patients

♥ ♥ The heart becomes The heart becomes weak and enlargedweak and enlarged

♥ ♥ The weakened heart The weakened heart muscle can’t contractmuscle can’t contract

♥ ♥ Not enough blood is Not enough blood is pumped from the pumped from the chamberschambers

Diastolic Diastolic DysfunctionDysfunction

(Relaxation)(Relaxation)

♥ ♥ Chambers don’t fill up Chambers don’t fill up so less blood goes to so less blood goes to the lungs and bodythe lungs and body

♥ ♥ Stiff heart muscle Stiff heart muscle can’t relaxcan’t relax

♥ ♥ Not enough blood fills Not enough blood fills the chambers the chambers

Symptoms and signs of heart failureSymptoms and signs of heart failure

1.1. forward failure:forward failure: symptoms result from inability of the heart to pump enough symptoms result from inability of the heart to pump enough

blood to the peripheryblood to the periphery (from(from left heart), or to the lungs (from left heart), or to the lungs (from

the right heart)the right heart)

a) forward failure of left heart:a) forward failure of left heart:-- muscle weakness, fatigue, muscle weakness, fatigue, dyspepsia, oliguriadyspepsia, oliguria........

generalgeneral mechanism mechanism:: tissue hypoperfusiontissue hypoperfusion

b) forward failure of right heartb) forward failure of right heart:: - hypoperfusion of the - hypoperfusion of the lungs lungs disorders of gas disorders of gas exchangeexchange

- decreased blood supply decreased blood supply to the left heartto the left heart

2. backward failure:2. backward failure: – symptoms result from inability of the heart to accept symptoms result from inability of the heart to accept

the blood comthe blood commming from periphery and from lungsing from periphery and from lungs

a.a. backward failure of left heart:backward failure of left heart:

– – increased pulmonary capillary pressureincreased pulmonary capillary pressure dyspnea dyspnea

and tachypnoea, pulmonary edema (cardiac asthma) and tachypnoea, pulmonary edema (cardiac asthma)

arterial arterial hypoxhypoxemiaemia and hypercapnia and hypercapnia........

b. backward failure of right heart:b. backward failure of right heart:

– increased pressure in increased pressure in systemic systemic venous systemvenous system

peripheral edemas, hepatomegaly, ascites peripheral edemas, hepatomegaly, ascites nocturnalnocturnal diuresisdiuresis........

New York Heart New York Heart Association Functional Association Functional

ClassificationClassificationClass IClass I

No symptoms No symptoms with ordinary with ordinary activityactivity

Class IIClass II

Slight limitation Slight limitation of physical of physical activity results in activity results in fatigue, fatigue, shortness of shortness of breath, chest breath, chest pain or irregular pain or irregular heart beatheart beat

New York Heart New York Heart Association Functional Association Functional

ClassificationClassificationClass IIIClass III

Marked limitation Marked limitation of physical activity.of physical activity.

Comfortable at Comfortable at rest, but less than rest, but less than ordinary physical ordinary physical activity results in activity results in fatigue, irregular fatigue, irregular heart beat, pain or heart beat, pain or shortness of breathshortness of breath

Class IVClass IV

Unable to carry Unable to carry out any physical out any physical activity without activity without discomfortdiscomfort

All symptoms in All symptoms in class III even at class III even at restrest

Class II1.68 M(35%)

Class IV240 K(5%)

Class III1.20 M(25%)

Class I1.68 M(35%)

AHA Heart and Stroke Statistical Update 2009

Systolic Heart Failure by NYHA Systolic Heart Failure by NYHA ClassClass

100

75

50

25

0I II III IV

1

10

NYHA CLASS

An

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al S

urv

ival

Rat

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Ho

spit

aliz

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ns

/ ye

ar

.1

Deceased

Adapted from Bristow, MR Management of Heart Failure, Heart Disease: A Textbook of Cardiovascular Medicine, 6th edition, ed. Braunwald et al.

Survival RateHospitalizations

ununNatural History of Heart FailureNatural History of Heart Failure

Advanced Heart FailureAdvanced Heart Failure

N=200,000N=200,000age 65 (50%)age 65 (50%)# of meds (9)# of meds (9)# hosp (5)# hosp (5)$$$ (12 billion)$$$ (12 billion)Mortality (50%/yr)Mortality (50%/yr)Rx???Rx???

Symptoms and MortalitySymptoms and Mortality

0

20

40

60

80

0 20 40 60

Months

% M

ort

ality

REMATCH

CONSENSUS-I

PROMISE

VHeFT-I

SOLVD-Rx

SAVE

SOLVD-pre

Class IV

Class I

Class III-IVClass II-III

Early Symptoms of Heart Early Symptoms of Heart FailureFailure

♥ ♥ A weight gain or loss of 2 or more A weight gain or loss of 2 or more pounds in 1 day, or 4 pounds in 1 weekpounds in 1 day, or 4 pounds in 1 week

♥ ♥ Confusion, restlessness or lightheadedConfusion, restlessness or lightheaded♥ ♥ A feeling of fullness or bloating in your A feeling of fullness or bloating in your

stomachstomach♥ ♥ Cough, shortness of breath, swellingCough, shortness of breath, swelling♥ ♥ Fatigue, lose of appetite, or nauseaFatigue, lose of appetite, or nausea

Urgent Symptoms of Urgent Symptoms of Heart FailureHeart Failure

♥ ♥ Increased shortness of breath while Increased shortness of breath while resting or trouble sleepingresting or trouble sleeping

♥ ♥ Waking up suddenly at night due to Waking up suddenly at night due to difficulty breathingdifficulty breathing

♥ ♥ A need to sleep sitting up or a need for A need to sleep sitting up or a need for more pillows than usualmore pillows than usual

♥ ♥ A fast irregular heart beat, a racing A fast irregular heart beat, a racing heart that makes you feelheart that makes you feel dizzy, or like dizzy, or like you are going to pass outyou are going to pass out

♥ ♥ Coughing up pink frothy mucusCoughing up pink frothy mucus

DYSPNEADYSPNEA

Abnormally uncomfortable awareness of Abnormally uncomfortable awareness of breathingbreathingDyspnea after strenous activity- NORMAL Dyspnea after strenous activity- NORMAL INDIVIDUALINDIVIDUALDyspnea after moderate activity – Dyspnea after moderate activity – DECONDITIONED INDIVIDUALDECONDITIONED INDIVIDUALDyspnea becomes abnormal only if it Dyspnea becomes abnormal only if it occurs at rest or at a level of activity not occurs at rest or at a level of activity not expected to cause dyspneaexpected to cause dyspnea

DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF DYSPNEADYSPNEA

PULMONARYPULMONARY - Reactive airways disease- Reactive airways disease - COPD- COPD - pulmoary edema- pulmoary edema - pulmonary hypertension- pulmonary hypertension - infection- infection - pulmonary embolism- pulmonary embolism - pleural diseases- pleural diseases - interstitial lung disease- interstitial lung disease

DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF DYSPNEADYSPNEA

CARDIACCARDIAC

-ischemic heart dsease-ischemic heart dsease

- right sided heart failure- right sided heart failure

- arrhythmias- arrhythmias

- dilated cardiomyopathy- dilated cardiomyopathy

- hypertrophic cardiomyopathy- hypertrophic cardiomyopathy

- valve stenosis and regurgitation- valve stenosis and regurgitation

ACUTE DYSPNEAACUTE DYSPNEA

Sudden development of dyspneaSudden development of dyspnea

- pulmonary embolism- pulmonary embolism

- pneumonia- pneumonia

- airway obstruction- airway obstruction

- Spontaneous pnumothorax- Spontaneous pnumothorax

- Pulmonary Edema - Pulmonary Edema

CHRONIC DYSPNEACHRONIC DYSPNEA

Symptom progress slowly or gradualSymptom progress slowly or gradual

- HEART FAILURE- HEART FAILURE

- COPD- COPD(chronic obstructive pulmonary disease)(chronic obstructive pulmonary disease)

DYSPNEADYSPNEA

INSPIRATORY DYSPNEA- obstruction in INSPIRATORY DYSPNEA- obstruction in upper airwayupper airway

EXPIRATORY DYSPNEA- obstruction of EXPIRATORY DYSPNEA- obstruction of lower respiratory tractlower respiratory tract

EXCERTIONAL DYSPNEA- left ventricular EXCERTIONAL DYSPNEA- left ventricular failure or COPDfailure or COPD

FUNCTIONAL DYSPNEA- dyspnea at FUNCTIONAL DYSPNEA- dyspnea at rest and not during activityrest and not during activity

ORTHOPNEAORTHOPNEA

Inability to breath comfortably when lyingInability to breath comfortably when lying

Severe pulmonary venous congestion is Severe pulmonary venous congestion is the cause of orthopneathe cause of orthopnea

Usually seen in advance heart failure were Usually seen in advance heart failure were resting pulmonary venous pressure is resting pulmonary venous pressure is elevatedelevated

PAROXYSMAL NOCTURNAL PAROXYSMAL NOCTURNAL DYSPNEADYSPNEA

Interstitial or intera alveolar pulmonary Interstitial or intera alveolar pulmonary edema edema

Secondary to ventricular failureSecondary to ventricular failure

Symptom starts 2-4 hours after sleeping, Symptom starts 2-4 hours after sleeping, patient arise from sleep feeling short of patient arise from sleep feeling short of breathbreath

Symptom ameliorated by sitting on the Symptom ameliorated by sitting on the side of bed and take about 15-30 minside of bed and take about 15-30 min

Measuring Jugular Venous Pressure