SESION 24 Heart failure

CMT05210 INTERNAL MEDICINE

 Learning objectives
At the end of this session each participant should be able to
• Define Heart failure
• Explain epidemiology of Heart failure
• Describe pathogenesis of Heart failure
• Explain clinical features of Heart failure
• Explain functional classification
• Describe management of Heart failure
• Provide measures to prevent and control of Heart failure
 Heart failure
• Heart failure Is a complex syndrome caused by structural or
functional cardiac disorder that impairs the ability of the heart to
pump blood and support physiological circulation. Characterised
by; shortness of breath, fatigue and Signs of fluid retention.
• inability of the myocardium to pump blood to meet the metabolic
demands of the body, or consistently elevated filling pressures in
the chambers of the heart
• The failure may be either myocardial failure or circulatory failure.
• Heart failure may be either
• compensated (when the patient is stable) or
• decompensated (when the patient suddenly gets worse)
• There are three types of Heart failure;
• Right sided heart failure
• Left sided heart failure
• Congestive heart failure (Bilateral cardiac failure)
 Causes of Heart failure
Systolic Dysfunction Diastolic Dysfunction
(Inability to expel blood) (Abnormal filling)
• Hypertension • Hypertension
• Idiopathic cardiomyopathy • Fibrosis
(like HIV) • Ischemia
• Valvular disease • Aging process
• Ischemic heart disease • Constrictive pericarditis
• Alcoholic cardiomyopathy (like TB)
• Drug‐associated • Restrictive pericarditis
cardiomyopathy (endomyocardio fibrosis)
• Myocarditis • Hypertrophic
cardiomyopathy
 Pathophysiology
• Decreased cardiac output triggers the baroreceptors in the LV,
carotid sinus and the aortic arch. This leads to: stimulation of the
cardio ‐ respiratory center in the brains. increased ADH release
(causing peripheral vasoconstriction and increases renal salt
and water absorption) and
• Increased sympathetic stimulation (activating renin – angiotensin
‐ aldosterone system, promoting more water retention and
peripheral vasoconstriction).
• These lead to:
• LV dilatation and hypertrophy (poor ejection fraction),
• Increased peripheral vascular resistance (high afterload) and
• Retention of fluid (high preload).
• Most patients present with left heart failure which can
progresses to right heart failure. Themost common cause of right
heart failure is left heart failure but it can also be caused by
pulmonary hypertension (corpulmonale.
 Clinical Features
• Depending on acuteness and severity Signs and symptoms,
include;
• From history the patient may have; Exertion Dyspnea,
Orthopnea, Paroxysmal Nocturnal Dyspnea, Dyspnea at
Rest, edema, Congestive hepatomegaly, anorexia, bloating,
nausea, and constipation.

• On physical examination the patient may have; Edema,

finger clubbing, anxious, malnourished, Tachycardia,
Hepatomegaly, Pallor, Peripheral cyanosis, Pulmonary
rales, Jugular venous distention, positive Hepatojugular
reflux, Hydrothorax (pleural effusion), Ascites,
Cardiomegaly
 Investigations
Diagnosis is based on medical history and symptoms but
imaging and blood tests are also done
• Echocardiogram
• Baseline echocardiogram to evaluate LV/RV function,
valvular function, pericardial disease
• Echocardiogram yearly if possible to monitor cardiac
function
• Electrocardiogram - for ischemic disease, arrhythmias
• Full blood picture and HB level - evaluate anemia
• Blood chemistry - renal and liver function, electrolytes,
• Lipid panel - assess for hyperlipidemia
• CXR - usually in the acute inpatient setting to evaluate for
pulmonary edema, cardiomegaly, pleural effusion
• Urine analysis for proteins
 The New York heart association
(NYHA) functional classification
• The New York heart association (NYHA) functional
classification
• Class I: no limitation in physical activity
• Class II: slight limitation of physical activity (fatigue, SOB)
• Cass III: marked limitation of activity( comfortable at rest but
slight exertion causes symptoms)
• Class IV: symptoms at rest
 Framingham Criteria for CCF
Validated CHF with 2 major criteria or 1 major and 2 minor

Major criteria: Minor criteria:

• 1. Paroxysmal nocturnal • 1. Nocturnal cough
dyspnea or orthopnea, • 2. Dyspnea on ordinary exertion
• 2. Weight loss of 4.5 kg in 5 • 3. Pleural effusion
days in response to treatment • 4. Tachycardia (rate of 120 bpm)
• 3. Neck vein distension • 5. Bilateral ankle edema
• 4. Central venous pressure • 6. A decrease in vital capacity by
>16cm of water 1/3rd the maximal value
• 5. Hepatojugular reflux recorded
• 6. Pulmonary rales
• 7. Acute pulmonary edema
• 8. S3 gallop
• 9. Circulation time of 25
seconds
• 10. Radiographic cardiomegaly
 Management
• Lifestyle modifications – critically important to maximize
cardiac function and exercise tolerance
• low or no salt diet → to decrease fluid retention
• fluid restriction → usually 1-2 L of total fluid intake daily
• daily weights → monitor for signs of fluid overload nd
allows self-adjustment of medications
• for signs of fluid overload

• Limit the use of NSAIDs as they can worsen fluid retention

and lead to worsening renal function
 Management of CCF
• Pharmacological Management– Ideally CCF patients should be
managed with a multi-drug regimen consisting of:
• ACE inhibitor or angiotensin receptor blocker (ARB) -
to decrease Ventricular remodeling
• Captopril 12.5 – 25mg PO BD or TDS,
• Lisinopril 10 – 40 mg PO OD
• Diuretic - for symptomatic relief and to decrease fluid
retention e.g. furosemide 20 – 80mg PO OD or BD
• Beta blocker - to decrease myocardial oxygen demand,
decrease LV remodeling
• carvedilol 6.25mg PO BD, up to 25mg PO BD
• atenolol 12.5mg PO OD, up to 100mg PO OD
• propanolol 40mg PO BD, up to 320mg PO BD
• Digoxin for Class II‐III- symptomatic improvement, but
no mortality benefit. Dose 0.125 – 0.25mg PO OD
• NOTE; Due to resource limitations and financial constraints,
not all medications may be possible. At the minimum an ACE
inhibitor and diuretic should be used. But additional drugs will
add further benefit.
 Causes of CHF exacerbation
Decompensating in failure : FAILURE
• F: forgot to take medication, ran out of medication
• A: arrhythmias (especially atrial fibrillation)
• I: ischemia / infarction / infection
• L: lifestyle (poor diet)
• U: up‐regulation (high cardiac output i.e. pregnancy, thyroid)
• R: renal failure (fluid overload)
• E: embolism / endocarditis
 Management of Decompensated
Congestive Cardiac Failure (CCF)
• Diuresis (the mainstay of treatment, 1st dose should be given stat)
• Monitor urine output, daily weights (+/‐ Foley catheter if needed)
• Oxygen therapy for 02 sat < 90% on room air
• Treat exacerbating conditions (such as infection, afibrilation)
• Treat reversible causes of cardiomyopathies (anemia and Thyroid)
• Stop the patient's medications that don’t support improvement
• Low sodium diet
• Symptomatic management of pulmonary edema:
• Cardiac Posture
• Morphine: initially 3‐5mg IV or IM PRN for shortness of
breath
• Nitrates: If BP tolerates, add isosorbide mononitrate after
other agents have been prescribed
• If urine low output, give furosemide 20 , 40 to 80 mg IV TDS &
• consider ICU transfer for lasix drip, If MAP<65, consider ICU
transfer for inotropic assisted diuresis w/ dopamine by protocol
• captopril at 6.25mg PO BD, increase as tolerated
 Evaluation
• Define Heart failure
• Explain clinical features of Heart failure
• Describe management of Heart failure
• Provide measures to prevent and control
of Heart failure
 References
• Davidson, S, (2014) - Principles and Practice of
Medicine, 22nd Edition, Churchill Livingstone.
• Longmore, M, et al, (1999), Oxford Handbook of
Clinical Medicine, 6th Edition, Oxford
• Swash, M., & Glynn, M. (2007). Hutchinson’s Clinical
Methods: An Integrated Approach to Clinical Practice:
22nd Edition. Philadelphia, PA: Saunders Elsevier
• Trouse, (2000) Short textbook of Medicine University
Press
• MoHCDGEC Standard treatment guidelines & national
essential medicines list tanzania mainland 2017
• MoHCDGEC/ NACTE (2016). Curriculum for
Technician Certificate (NTA Level 5) Curriculum,
Dodoma.