Heart failure

PhD, Assistant of the Department of Internal Medicine №2, Clinical Immunology

and Allergology named after academician L.T.Malaya
Tetiana Zaikina
 Heart failure is a clinical syndrome
characterized by the inability of the heart to
maintain adequate cardiac output in order to
provide the metabolic demands caused by
structural or functional cardiac abnormality.
Etiology of heart failure
Etiology of heart failure
Clinical presentation
Right-sided heart failure Left-sided heart failure

Symptoms: Symptoms:
• Ascites • Nocturnal paroxysmal
• Lower limb edema dyspnea
• Discomfort in the right • Orthopnea
subcostal area • Palpitation
• Breathlessness
• Fatigue

Objective signs: Objective signs:

• Jugular veins distention • Tachycardia
• Hepato-jugular reflux • S3,S4-gallop rhythm
• Esophageal varices • Bilateral pulmonary rales
Classification of the heart failure
 Classification of heart failure
According to the course of heart failure:
• Acute heart failure
• Chronic heart failure
According to the affected part of the heart:
• Right-sided heart failure
• Left-sided heart failure
• Two-sided heart failure
According to the impaired phase of cardiac cycle:
• Systolic heart failure (occurs when ventricular contraction is
impaired)
• Diastolic heart failure (occurs due to insufficient filling of one or
both ventricles leading to increased ventricular filling pressure in
the presence of normal systolic function)
• Systolo-diastolic heart failure
Functional classification of chronic heart failure by
New York Heart Association (NYHA)

• Class I: No symptoms and no limitation in ordinary physical activity,

e.g. shortness of breath when walking, climbing stairs
• Class II: Slight limitation of ordinary physical activity
• Class III: Marked limitation in activity due to symptoms, even during
less-than-ordinary activity, e.g. walking short distances (20—100 m),
patients feel comfortable only at rest;
• Class IV: Severe limitation. Symptoms are present even at rest.
Classification of heart failure depending on the stage of
its development (ACC/AHA)
• Stage A: patients have risk factors for heart failure (hypertension,
coronary heart disease, diabetes, obesity) but normal ventricular
function and no heart failure symptoms
• Stage B: patients have structural abnormality but no heart failure
symptoms
• Stage C: patients have ventricular dysfunction and symptoms of
inadequate cardiac output (exercise intolerance) and/or fluid
overload (congestion)
• Stage D: patients have advanced symptoms and severe disability
Classification of congestive heart failure depending on
the ejection fraction (ESC, 2016)
Diagnosis of chronic heart failure
 Blood tests

• CBC (inflammatory markers, anemia)

• Biochemical analysis (sodium,
magnesium, calcium, creatinine,
glucose, serum iron, ferritin)
• Endocrine panel (thyroid-stimulating
hormone, thyroxine, T4, parathyroid
hormone)
 Natriuretic peptides

• Types: ANP; BNP, CNP

• BNP˃35 pg/ml and NT-proBNP>125

pg/ml confirms heart failure
 Echocardiography

• Detection of the pathological

abnormalities (hypokinesis,
dyskinesis, akinesis, abnormal
functioning of the heart valves,
pericardial effusion)
• Assessment of systolic (EF) and
diastolic functions
 Electrocardiography

• Detection of the underlying cause

(myocardial infarction,
arrhythmias, heart blocks)
 Chest X-ray

• Signs of the pulmonary

congestion
• Cardiomegaly
• Exclusion of other causes of
dyspnea
 Coronary angiography

• Is recommended in patients with

HF who suffer from angina
pectoris resistant to medical
therapy
• Is recommended in patients with
HF who suffer from symptomatic
ventricular arrhythmias or heart
blocks
 Endomyocardial biopsy

• Detection of amyloid or any other

pathological deposits
Treatment of congestive heart failure
Pharmacological treatment of chronic heart failure
• Diuretics
• ACE inhibitors or ARBs
• Beta-blockers
• Mineralocorticoid receptor antagonist
• Neprilysin inhibitor
• Cardiac glycosides
• Inotropic agents
• If-channels blocker
Diuretics
ACE inhibitors or ARB II
Beta-blockers
Mineralocorticoid receptor antagonist
Alternative drugs for HF
 Non-pharmacological treatment of HF

• Heart pacing (HF NYHA III-IV with

LVEF≤35%; HF NYHA II-IV with LBBB
(QRS≥150 ms))
• Cardiac resynchronization therapy
(HF NYHA III-IV with QRS≥120 ms and
LVEF≤35%)
• Implantable cardioverter-defibrillator
• Heart transplantation
• Ultrafiltration
Acute failure
 Acute heart failure is rapid onset or
worsening of symptoms and signs of heart
failure. It may present as a first occurrence or,
more frequently, as a consequence of acute
decompensation of chronic heart failure.
Etiology of AHF
Classification of acute heart failure
 Clinical classification of AHF
Clinical classification of AHF is based on
bedside physical examination in order to detect the
presence of clinical symptoms/signs of congestion
(‘wet’ vs ‘dry’) and peripheral hypoperfusion (‘cold’ vs
‘warm’).
The combination of these options allows to
attribute a patient to one of four groups: warm and
wet (well perfused and congested) —most commonly
present; cold and wet (hypoperfused and congested);
cold and dry (hypoperfused without congestion); and
warm and dry (compensated, well perfused without
congestion).
 Pharmacological treatment of AHF depending on
patient’s hemodynamic profile

• Warm and dry: adjust oral therapy

• Warm and wet: diuretics, vasodilators
• Cold and wet: inotropic agents, diuretics,
vasodilators
• Cold and dry: inotropic agents, fluids infusion
Inotropes
Vasodilators
 Mechanical assist devices

• Intra-aortic balloon pump • Ventricular assist devices

 Classification of AHF caused by AMI (by Killip and
Kimball)
• Killip I: no clinical signs of AHF
• Killip II (cardiac asthma): rales over
less than 50% of lungs with S3 gallop
rhythm
• Killip III (pulmonary edema): rales
over more than 50% of lungs
• Killip IV (cardiogenic shock):
hypotension<90 mm Hg, oliguria,
cyanosis, diaphoresis