HEART FAILURE

DR MD SAZZAD HOSSAIN
FCPS (MEDICINE)
Associate Professor
Department of Medicine
ShTAMC
Objective
• Definition
• Classification
• Pathophysiology
• Aetiology
• Clinical features
• Investigations
• Management
• Prognosis
Purpose
• Students will be able to diagnose
and manage patients appropriately
who presented with heart failure.
 Introduction
Heart failure describes the clinical syndrome that
develops when the heart can not maintain adequate
output, or can do so only at the expense of elevated
ventricular filling pressure.

In mild to moderate forms of heart failure, symptoms

occur during exercise or stress.

In severe heart failure, symptoms may be present at rest.

Heart failure may be diagnosed when a patient with
significant heart disease develops

• Signs or symptoms of a low cardiac output,

• Pulmonary congestion or
• Systemic venous congestion

at rest or on exercise.
Classification
Three types of heart failure
a) Left heart failure
b) Right heart failure
c) Biventricular failure
Other types of classification

1) Systolic failure
2) Diastolic failure

1)Acute heart failure

2)Chronic heart failure

1)Low output cardiac failure

2)High output cardiac failure
 Left heart failure
• Reduction in left ventricular output
• Increase in left atrial and pulmonary venous
pressure.
• Rapid increase in left atrial pressure causes
pulmonary oedema.
• If the rise in atrial pressure is more gradual, as
occurs with mitral stenosis, there is reflex pulmonary
vasoconstriction, which protects the patient from
pulmonary oedema.
• However, the resulting increase in pulmonary
vascular resistance causes pulmonary hypertension,
which in turn impairs right ventricular function.
Right heart failure

Reduction in right ventricular output

Increase in right atrial and systemic venous pressure.
The most common causes are chronic lung disease,
pulmonary embolism and pulmonary valvular stenosis.
The term ‘cor pulmonale’ is used to describe right heart
failure that is secondary to chronic lung disease.
Biventricular heart failure

Both sides of the heart are affected.

Occur due to
• Dilated cardiomyopathy or
• Ischaemic heart disease, or
• Because disease of the left heart leads to chronic
elevation of the left atrial pressure, pulmonary
hypertension and right heart failure.
Pathogenesis
Heart failure occurs when cardiac output fails to
meet the demands of the circulation.
Cardiac output is determined by
• preload (the volume and pressure of blood in the
ventricles at the end of diastole),
• afterload (the volume and pressure of blood in
the ventricles during systole) and
• myocardial contractility.
Ventricular dysfunction

It is the most common cause of heart failure. Due to

• Impaired systolic contraction due to myocardial
disease,
• Or diastolic dysfunction where there is abnormal
ventricular relaxation due to a stiff, non-compliant
ventricle. This is most commonly found in patients with
left ventricular hypertrophy.
Systolic dysfunction and diastolic dysfunction often
coexist, particularly in patients with coronary artery
disease.
 Ventricular dysfunction reduces cardiac output, which, in
turn, activates the sympathetic nervous system (SNS)
and renin–angiotensin–aldosterone system (RAAS).
Under normal circumstances, activation of the SNS and
RAAS supports cardiac function but, in the setting of
impaired ventricular function, the consequences are
negative and lead to an increase in both afterload and
preload.
High-output failure

Sometimes cardiac failure can occur in patients without heart

disease due to a large arteriovenous shunt, or where there is an
excessively high cardiac output due to beri-beri , severe anaemia
or thyrotoxicosis.
Valvular disease

Heart failure can also be caused by valvular disease in which

there is impaired filling of the ventricles due to mitral or tricuspid
stenosis; where there is obstruction to ventricular outflow, as
occurs in aortic and tricuspid stenosis and hypertrophic
cardiomyopathy; or as the result of ventricular overload
secondary to valvular regurgitation
Clinical features
Heart failure may develop suddenly, as in MI, or gradually, as in
valvular heart disease.
The term compensated heart failure is sometimes used to
describe the condition of those with impaired cardiac function, in
whom adaptive changes have prevented the development of
overt heart failure.
However acute heart failure sometimes supervenes as the result
of a decompensating episode, on a background of chronic heart
failure; this is called acute-on-chronic heart failure.
 Acute left heart failure
Sudden onset of dyspnea at rest that rapidly progresses
to acute respiratory distress, orthopnoea and prostration.
Often there is a clear precipitating factor, such as an
acute MI, which may be apparent from the history.
The patient appears agitated, pale and clammy. The
peripheries are cool to the touch and the pulse is rapid,
but in some cases there may be an inappropriate
bradycardia that may contribute to the acute episode of
heart failure.
The BP is usually high because of SNS activation, but
may be normal or low if the patient is in cardiogenic
The jugular venous pressure (JVP) is usually elevated, particularly
with associated fluid overload or right heart failure.
In acute heart failure, there has been no time for ventricular
dilatation and the apex is not displaced.
A ‘gallop’ rhythm, with a third heart sound, is heard quite early in the
development of acute left-sided heart failure.
A new systolic murmur may signify acute mitral regurgitation or
ventricular septal rupture.
Chest examination may reveal crepitations at the lung bases if there
is pulmonary oedema.
There may be an expiratory wheeze.
Patients with acute-on-chronic heart failure may have additional
features of chronic heart failure .
 Chronic heart failure
Relapsing and remitting course, with periods of
stability and episodes of decompensation.
The clinical picture depends on the nature of the
underlying heart disease, the type of heart failure
that it has evoked, and the changes in the SNS and
RAAS that have developed .
Low cardiac output causes fatigue, listlessness and
a poor effort tolerance; the peripheries are cold and
the BP is low.
.
Poor renal perfusion leads to oliguria and uraemia.
Pulmonary oedema due to left heart failure
presents with dyspnoea and inspiratory crepitations
over the lung bases.
In contrast, right heart failure produces a high JVP
with hepatic congestion and dependent peripheral
oedema. In ambulant patients the oedema affects
the ankles, whereas in bed-bound patients it
collects around the thighs and sacrum. Ascites or
pleural effusion may occur .
Chronic heart failure is sometimes associated with marked weight
loss (cardiac cachexia), caused by a combination of anorexia and
impaired absorption due to gastrointestinal congestion, poor
tissue perfusion due to a low cardiac output, and skeletal muscle
atrophy due to immobility.
Complications of heart failure
• Renal failure
• Hypokalemia
• Hyperkalemia
• Hyponatremia
• Impaired LFT
• Thromboembolism
• Arrythmia
• Sudden death
Investigations
• CXR P-a view
• ECG
• Echocardiogram
• Serum urea, creatinine and electrolytes,
• Haemoglobin and thyroid function
• S. BNP/ S. Pro BNP
Echocardiography is very useful and should be considered in all
patients with heart failure in order to:

• determine the aetiology

• detect unsuspected valvular heart disease, such as occult
mitral stenosis, and other conditions.
• identify patients who will benefit from long-term drug therapy.
 Management
Acute heart failure with pulmonary oedema is a
medical emergency.
The patient should initially be kept rested, with
continuous monitoring of cardiac rhythm, BP and
pulse oximetry.
Intravenous opiates can be of value in
distressed patients but must be used sparingly,
as they may cause respiratory depression and
exacerbation of hypoxaemia and hypercapnia.
If these measures prove ineffective,
inotropic agents such as dobutamine (2.5–10
μg/kg/min) may be required to augment
cardiac output, particularly in hypotensive
patients.
Insertion of an intra-aortic balloon pump may
be beneficial in patients with acute cardiogenic
pulmonary oedema and shock.
Following management of the acute episode,
additional measures must be instituted to
control heart failure in the longer term.
 Management of chronic heart failure

The aims of treatment in chronic heart failure are

to improve cardiac function by

• increasing contractility,
• optimising preload or decreasing afterload,
• and controlling cardiac rate and rhythm.

This can be achieved by a combination of drug

treatment or non-drug treatments
• Drugs:
Diuretics
ACE inhibitors
ARB
Neprilysin inhibitors (sacubitril)
vasodilators(nitrates)
B blockers
Ivabradine, digoxine, amiodarone
• Non-pharmacological treatments
Implantable cardiac defibrillators
Resynchronisation devices
Coronary revascularization
ventricular assist device
cardiac transplantation.