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Heart failure

Tamás Fenyvesi MD3rd Department of Medicine

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Circulatory failure

Heart

Insufficient oxygen and nutrient supply to the tissues,and cells+ insufficient removal of the metabolic endproducts

causes:cardiac extracardiac

1.decreased venous return2.increased vascular capacity3.decreased oxyhemoglobin

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Heart failure:the heart is unable to pump sufficient blood , provided the

venous return is normal

mechanical myocardial1. pressure overload 1. ischaemic heart disease

AS, hypertension diffuse or segmental2. volume overload 2. myocardial disease

valvular regurg.,shunts

3. insufficient fillingmitral or tricuspid

stenosis4. Pericardial disease

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Classifications of impaired ventricular fuction

1. Forward failure vs backward failure2. Left heart failure vs right heart failure3. Systolic vs diastolic dysfunction4. Acute vs chronic5. Low output vs high output

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“Backward” failure

James Hope 18321. ventricular volume and pressure2. atrial volume and pressure behind the failing ventricle3. atrial contraction4. venous pressure 5. capillary pressure6. transsudation into the interstitial tissue7. extracellular fluid volume

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“Forward failure”Sir James Mackenzie 1913

decreased cardiac output:kidneys sodium retention

(RAS activation)liver dysfunctionmuscular weakness, fatiguebrain confusion

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„left” or „right” heart failure

This is implicitly „backward failure”congestion behind the originally failing ventricle

left ventricle pulmonary congestion,pulm edema

right ventricle liver and peripheralcongestion oedema etc

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Acute heart failure

The sudden development of the syndromeno time for compensatory mechanisms to activate

massive myocardial infarctionheart block with very slow ventricular rate< 35/mintachyarrhythmia with very rapid rate > 180/minrupture of a valveocclusion of a large segment of pulmonary artery

sudden reduction of cardiac output

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stroke volume

symp PRA

catechol vasoconstr AII

prostaglandin bradykinin vasopressin aldosteronedilate dilate constr constr

constrictor > dilatator

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Low-output vs high-output failure

1. Low output is the typical: most of the heart diseasesimpaired peripheral circulation, cold, pale or cyanotic extremities

2. High output: cardiac output is high before the developmentof failure

anaemia, hyperthyroidismAV shunts, Paget’s disease, Beriberi (B1 vit defic)gravidityhot, hyperemic extremities

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Compensatory mechanismsExtracardiac cardiacpreload

afterloadnatriuresis

volume decomp atrial dilat vasodilat

vasoconstr cardiac output ANP

RASsymp,ADH

RBF GFR FFsodium retention

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ACC Heart Failure GuidelinesSlide Deck

Based on the ACC/AHA 2005 Guideline Update

for the Diagnosis and Management of Chronic Heart Failure in the Adult

January 2006

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Definition of Heart Failure

HF is a complex clinical syndrome that canresult from any structural or functionalcardiac disorder that impairs the ability ofthe ventricle to fill with or eject blood.

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“Heart Failure” vs. “Congestive Heart Failure”

Because not all patients have volume overload atthe time of initial or subsequent evaluation, theterm “heart failure” is preferred over the older term “congestive heart failure.”

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Causes of HF in Western World

For a substantial proportion of patients, causes are:

1. Coronary artery disease

2. Hypertension

3. Dilated cardiomyopathy

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Class I —No limitation: Ordinary physical activity does notcause undue fatigue, dyspnea, or palpitation.

Class II —Slight limitation of physical activity:Such patients are comfortable at rest.Ordinary physical activity results in fatigue, palpitation dyspnea, or angina.

Class III —Marked limitation of physical activity:Although patients are comfortable at rest, less than ordinary activity will lead to symptoms.

Class IV —Inability to carry on any physical activity without discomfort: Symptoms of congestivefailure are present even at rest. With any physical activity, increased discomfort isexperienced.

NYHA Classification of HF

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Stages of Heart Failure

At Risk for Heart Failure:

STAGE A High risk for developing HF

STAGE B Asymptomatic LV dysfunction

Heart Failure:

STAGE C Past or current symptoms of HF

STAGE D End-stage HF

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Stage A

Patients at High Risk for Developing Heart Failure

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Stage B

Patients with Asymptomatic LV Dysfunction

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Stage C

Patients with Past or CurrentSymptoms of Heart Failure

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Stage D

Patients with Refractory End -Stage HF

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Stage D Therapy

Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies.

Discussion of Options for End-of-Life Care

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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Stages of Heart Failure

COMPLEMENT, DO NOT REPLACE NYHA CLASSES

• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)

• Stages - progress in one direction due to cardiac remodeling

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Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms

• Incorrect diagnosis of HF• Inaccurate measurement of

LVEF• Primary valvular disease• Restrictive (infiltrative)

cardiomyopathies• Amyloidosis, sarcoidosis,

hemochromatosis• Pericardial constriction• Episodic or reversible LV

systolic dysfunction• Severe hypertension,

myocardial ischemia

• HF associated with high metabolic demand (high-output states)

• Anemia, thyrotoxicosis, arteriovenous fistulae

• Chronic pulmonary disease with right HF

• Pulmonary hypertension associated with pulmonary vascular disorders

• Atrial myxoma• Diastolic dysfunction of

uncertain origin• Obesity

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BNP - echodyspnea

BNP - echodyspnea

EKG, RTG, BNP

<100 100-500 >500 pg/ml

HF echo: LVD HF 95%unlikely COPD echo

PE

EKG, RTG, BNP

<100 100-500 >500 pg/ml

HF echo: LVD HF 95%unlikely COPD echo

PE

Maisel Rev CV Med 2003;4:S3-12Maisel Rev CV Med 2003;4:S3-12

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Systolic vs diastolic heart failure

Implicit in the physiological definition the defect to pumpadequate volume of blood is a systolic heart failure

the abnormality may be caused by a defect ofventricular filling i.e. diastolic heart failure

slowed or incomplete ventricular relaxation possible causes:

acute or chronic ischaemiaconcentrical hypertrophyrestrictive cardiomyopathy

most clinical manifestations are combined

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Diastolic dysfunctionFibrosis Cellular dysarray PassiveHypertrophy chamber

stiffnessAsynchrony DiastolicAbnormal loading pressureIschemia RelaxationAbnormal Ca++ flux

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Diastolic heart failure became a centralissue of cardiology.

Diastolic heart failure is heart failure with preserved systolic functionor normal ejection fraction (HFNEF)EF>50%

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Systole and diastole

“So that the coming together,

depends on the going apart,

the systole depends on the diastole;

the flow depends on the ebb.”

DH Lawrence

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Symptoms of heart failure

1.dyspnea2.fatigue and weakness

hypoperfusion of the sceletal musculaturehyponatremia caused by diuretics

3.nocturiaredistribution of cardiac output at night: RBF

4.liver distensionepigastrial dyscomfort

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General mechanisms of dyspnoe:left atrial pressure

pulmonary capillary pressure

interstitial fluid volume in the lungs

elasticity of the lung

increased work of breathing low cardiac output impaired perfusion of the respiratory

muscles fatigue sensation of dyspnoe

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Physical signs of heart failure1

•visible dyspnoe •gray color of the face•cold extremities and acrocyanosis •decreased pulse pressure•extension of the veins (jugular) •palpable liver •symmetrical edema (pitting)

ankle-sacral-generalized•ascites•hydrothorax •rales „moist” at the end of inspiration

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Physical signs of heart failure 2

tachycardiapulsus alternans ?

auscultation of the heartS3 gallopaccentuated P2syst murmur- tricusp regurg

cardiac cachexia

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Pulsus alternans

this is just an interesting possibility

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Framingham criteria for congestive heart failure

Major criteria:paroxysmal nocturnal dyspnea or orthopneaneck vein distensionralescardiomegalyacute pulmonary edemaS3 gallopincreased venous pressure > 16cm H2Ocirculation time > 25 sechepatojugular reflux

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Framingham criteria for congestive heart failure

Minor criteria: ankle edemanight coughdyspnea on exertionhepatomegalypleural effusionvital capacity 1/3 from maximumtachycardia > 120/min

Minor or major criterion:weight loss > 4,5 kg in 5 days in

response to treatment

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The main causes of heart failureIschaemic heart disease !!

myocardial infarction necrosisremodeling

Systemic hypertension LV hypertrophy

Valvular heart disease pressure load, ASvolume load AI

Cardiomyopathies obstructivedilatativerestrictive

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Algoritm of diagnostic approach to HF

Suspition of HF

EKG,,RTG, BNP if available

Dg. rejected

abnormal

echocardiography

Cause,type,severity?

abnormal

therapy

additional Workup, eg.

coronarography

norm

norm

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Epidemiology of heart failure~ 4 million pts in the USA

yearly incidence > 400.000 hospitalization 1000 000

most prevalent cause of death > 300.000Hospital mortality 30-50% / yearin the mixed population

5 years survival afterdiagnosis only 25% in men and

38% in womenyearly cost 22billion $

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Annual incidence of heart failure per 1000 population in

Framingham

1 2 35 6

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13

17

2831

0

5

10

15

20

25

30

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45-54 55-64 65-74 75-84 85-94

femalemale

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Prevalence of heart failure

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Prevalence of HFPrevalence of HF

4,8 4,25,1

3,14,5

2,91,7 1,23 1,5

0

3

6

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Nether.Rotter.2,1

Nether.Rotter.2,1

USAOlmsted2,2

USAOlmsted2,2

PortugalEPICA4,2

PortugalEPICA4,2

SpainAsturias4,9

SpainAsturias4,9

Den.Copen.6,4

Den.Copen.6,4

SvedenVästeras6,7

SvedenVästeras6,7

EnglandPoole7,5

EnglandPoole7,5

FinlandHelsinki8,2

FinlandHelsinki8,2

USACHS8,8

USACHS8,8

Age(years) 66-103 75-86 70-84 75 ≥50 >40 >25 >44 55-95Mean 78 - 76 75 - 60 68 63 65

Age(years) 66-103 75-86 70-84 75 ≥50 >40 >25 >44 55-95Mean 78 - 76 75 - 60 68 63 65

proportion with preserved

LV systolic function

proportion with preserved

LV systolic function

Hogg JACC 2004; 43:317Hogg JACC 2004; 43:317

Overall 2.5% in the communitySenni, Circ 1998; 98:2282

Overall 2.5% in the communitySenni, Circ 1998; 98:2282

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