The KING in Medicine

Cardiology
Heart Failure
 Definition :- Failure of heart to pump adequate amount of blood which contain ( O2 &
nutrients ) that satisfy metabolic requirements of tissues at all times .
 Classification :-
A ) According to COP :-
1- Low COP failure :- COP < 5 L / min & Treatment :- digitalis & diuretics .
2- High COP failure :-
 COP > 5 L / min , but tissues need more .
 Hyperdynamic circulation   peripheral resistance   VR &  COP .
 Treatment :- of the cause to  tissue demands ( e.g. ttt of anaemia or Thyrotoxicosis ) .
B ) Anatomical classification :-
1- LSHF :- lung congestion .
2- RSHF :- systemic congestion .
3- Combined HF :- It is of 2 types :-
 Combined HF from the start :- occurring in ;
 Extensive myocardial infarction  symptoms of RSHF  LSHF .
 Cardiomyopathy .
 Congestive HF :- LSHF causing RSHF .
C ) According to onset :-
1- Acute HF :- Acute MI , Myocarditis & rupture valve ( NO ventricular enlargement ) .
2- Chronic HF :- Valvular heart diseases .
D ) According to cardiac cycle :-
1- Systolic HF :- Myocarditis & MI .
2- Diastolic HF :- Restrictive Cardiomyopathy .
 Aetiology :-
A ) Acute HF :- [ Ischemic , HTN & Thyrotoxicosis )
1- RSHF :- massive infarction , tension pneumothorax , massive pulmonary embolism
& acute lung collapse .
2- LSHF :- massive infarction , Malignant hypertension , acute MR ( low compliance ) &
acute AR ( present with pulmonary oedema ) .
3- Combined HF :- due to Acute myocarditis .
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B ) chronic HF :-
1- RSHF :-
 RA failure :- TS , TR , RA myxoma .
 RV failure :- either due to ;
 Pressure over load :- PS , pulmonary HTN , MS & LVF .
 Volume over load :- PR , TR , ASD , VSD & hyperdynamic circulation .
 Myocardial disease :- Ischemia ( MI ) , myocarditis ( Rh.fever ) & Cardiomyopathy .
2- LSHF :-
 LA failure :- MS & LA myxoma .
 LV failure :- due to either ;
 Pressure over load :- AS , Systemic HTN & Co-arcitation of aorta .
 Volume over load :- AR , MR ,VSD , PDA , Hyperdynamic circulation .
 Myocardial disease :- Ischemia , Myocarditis & Cardiomyopathy .
3- Iatrogenic :- [ Bi-ventricular HF ]
 In normal heart :- due to irradiation of tumour & adriamycin .
 In diseased heart :- due to side effects of ;
 β-blockers :- on long run . ( due to -ve inotropic effect  precipitate HF ) .
 Verapamil ( CCB ) .

N.B. :-
 The commonest cause of RSHF is LSHF .
by pulmonary HTN .
 The 2nd common cause of RSHF is cor-pulmonale .
 HF can occur without volume or pressure overload or myocardial disease , via Brenheim's effect
which means that [ Sever hypertrophy of Lt. ventricular septum  encroach Rt. Ventricular cavity 
HF in RV ] .
 General causes of HF :-
 Acute HF :- Acute MI , Rupture valve , Myocarditis & sever HTN .
 Chronic HF :- Healed MI , Valvular disease , Myopathy & HTN .

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The KING in Medicine
Cardiology

 Precipitating factors :-
 Value of precipitating factors :-
 They Precipitate HF in incipient cases .
  Manifestations in manifest cases .
 Make HF refractory to treatment .
 They involve the following precipitating factors :-
 History :- infections & Rheumatic fever .
 Patient :- stoppage of digitalis & Excessive salt intake .
 Wife :- physical & mental stress , Pregnancy (  load on heart ) .
 Doctor :-
 Excessive steroid therapy ( salt & water retention )
 Excessive fluid therapy ( volume over load ) .
 Condition :- Environmental heat and humidity .
 Diseases :-
 Lung :- RSHF ( Pulmonary HTN ) , LSHF ( HTN )
 CVS :-  Coronary blood flow & Arrhythmia .
 Endocrine :- Thyrotoxicosis .
 Blood :- Anaemia .
 Pathophysiology :-
 HF passes into 2 stages :-
 Incipient failure ( no C/P of HF ) , diagnosed by ejection fraction ( EF ) & Echo .
 Manifest failure .
 When the heart is subjected to increased load :-
 Certain compensatory mechanisms come into action .
 These mechanisms are either early or late ;
 Early mechanisms :-
 Tachycardia

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Cardiology
 Cardiac dilatation
 Cardiac hypertrophy .
 Late mechanisms :-  Pre-load &  After load .
A ) Early mechanisms [ Incipient failure ] :-
1- Tachycardia :-
 Cause :- COP = SV X HR & in diseased heart , SV is ed , so HR must  to maintain constant COP .
 Mechanism :-
 Marry's law :-  COP   BP & HR .
 Bainbridge reflex :- Stagnant blood in Rt. side  RA pressure   HR due to stimulation of
cardio-acceleratory center .
 Value :- keep COP constant by increased heart rate .
 Disadvantages :- Marked tachycardia  Marked shortening of diastole   filling   COP .

2- Cardiac dilatation :-
 Cause :- Volume over load .
 Mechanism :- [ Starling law ] ; Stretch of myocardial fibers with in limits  strong
contraction &  COP .
 Disadvantages :- Excessive dilatation  separation of actine & myosin inside the muscle  weak
contraction ( due to dis-engagement of actine & myosin ) .
3- Cardiac hypertrophy :-
 Cause :- Pressure over load .
 Value :- Compensation for diseased fibers   contractility .
 Disadvantages :- Hypertrophy is not associated with  coronary flow ( fixed blood supply )  ischemic (
weak ) muscle   performance , stiffness & compliance   Ventricular filling .
B ) Late mechanisms [ Manifest failure ] :-
 On Failure of the above mentioned mechanisms , this leads to  COP & it will stimulate 
preload & after load which in ( normal heart ) will lead to  COP ; but in ( failing heart ) will
lead to more exhaustion & over loading  accentuate HF .
1-  Preload :-
 Definition :- It is the ventricular end diastolic volume .
 Mechanism :-
 Salt & water retention .
  Catecholamine  Venoconstriction & Na & water reabsorption from PCT  shift blood to heart .

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The KING in Medicine
Cardiology
2-  after load :-
 Definition :- It is the myocardial wall stress during systole .
 Mechanism :-
 Excess secretion of caticolamines  peripheral VC   Cardiac wall stress during systole .
 Stimulate aldosterone   work of heart .
N.B :- Blood pressure = COP X Peripheral Vascular resistance .

 Clinical presentation :-
A ) Symptoms
1- LSHF :- Low COP , lung congestion , palpitation , pressure manifestation & Cardiac cachexia .
2- RSHF :- Low COP , systemic congestion , palpitation & pressure manifestations .
N.B. :-
 Low COP is due to forward failure & it is marked in acute cases .
 Lung & systemic congestion are due to backward manifestations & marked in chronic cases .
 Triade of RSHF  Pulsating neck veins , oedema L.L. & Enlarged tender liver .
B ) Signs
1- LSHF :-
 General signs :-
 Low COP signs .
 Lung congestion :- tachypnea , bilateral basal crepitations & wheezes ( cardiac asthma )
 Fever :- due to infection .
 Low systolic BP & high diastolic BP , due to salt & water retention .
 Pulsus alternans due to left ventricular strain .
 Cardiac signs :-
 Tachycardia .
 LV enlargement :- with criteria of left ventricular apex ( mention )
 Protodiastolic gallop on Mitral area due to vibration of flabby myocardium .
 Murmur :- Apical pan-systolic murmur due to functional MR .
2- RSHF :-
 General signs :-
 Low systolic blood pressure .
 Low COP signs .
 Systemic congestion signs ( jaundice , enlarged tender liver & splenomegally , …. )
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The KING in Medicine
Cardiology
 Congested pulsating neck veins .
 Pulmonary HTN & pleural effusion .
 Cardiac signs :-
 Tachycardia .
 Protodiastolic gallop on tricuspid area .
 Right ventricular apex :- mention its criteria .
 Murmur :- Pan-systolic murmur due to Functional TR .

N.B. :-
 S3  Proto-diastolic gallop = Ventricular gallop .
 S4  Pre-systolic gallop = Atrial gallop .
 LV apex show parasternal retraction with each apical bulge  LV rocking .
 Murmur of MR or TR is soft if both are functional & hursh if organic .
 In LSHF ; there is weak pulse volume , due to
  Diastolic BP ; due to salt & water retention .
  Systolic BP ; due to previous HTN with low COP  Decapitated HTN .
 Why dyspnea in HF is very minimal ???
 In RSHF , there is  in pulmonary blood flow  No dyspnea as there is no more blood to be
oxygenated .
 Marked dyspnea with heart failure means  Pleural effusion .

 Investigations of HF :-

1- X-ray :-
 Enlarged cardiac chambers .
 Lung congestion .
 RSHF :- Pulmonary HTN & pleural effusion .
2- ECG :-
 RSHF :- RVH & infraction .

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Cardiology
 LSHF :- LVH , infraction & electrical alternans .
3- Echo-cardiography :-
 It is used for diagnosis of the lesion .
 It shows chamber enlargement .
 It help in estimation of cardiac function , via measurement of EF .
 Ejection fraction ( EF ) :-
SV EDV – ESV
EF = ------------------------ = --------------------------------------------- = 0.60-0.75 %
Ventricular EDV Ventricular end diastolic volume

4- Catheterization :-
  end diastolic pressure .
 Circulation time :- ( Arm to lung = 5 sec. & Arm to tongue = 10 sec )
 In RSHF :-  arm to lung .
 In LSHF :-  arm to tongue with normal arm to tongue .
 In Bronchial asthma :- both are normal .
5- Pulmonary function tests :- Most of them are reduced .

N.B. :-
 2 patients with insomnia , how can you know the aetiology & what is the treatment ??
 If the patient is RSHF :-
 Insomnia is due to brain congestion .
 Treatment :- Diuretics .
 If patient is LSHF :-
 Insomnia is sue to lung congestion  patient can't sleep due to orthopnea .
 Treatment :- Digitalis .

Treatment of Heart Failure

( 6 Important Items )

1 ) Causal treatment :- e.g. ;

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Cardiology
 HTN :- Anti-hypertensive .
 AS :- Valvotomy or Valve replacement .

2 ) Correction of precipitating factors :- ( mention & ttt of each ) ,

e.g.
 Pregnancy :- No abortion or premature labour , but continue pregnancy with special care .

3 ) Symptomatic treatment :- ( enumerate symptoms & ttt of each ) , e.g. ;

 Insomnia :- sedatives .
 Constipation :- laxatives .

4 ) Treatment of Heart failure :- ( Rest , Diet & Drugs )

A ) Rest :-
 It must be :-
 Physical rest :- Semi-setting position or leg hanging down in sever cases .
 Mental rest :- Diazepam ( 2-5 mg , 1-2 times / day ) .
 Value :-  cardiac work ,  HR ,  VR &  metabolites handled by tissues .
 Complications :- If the rest is prolonged for 2-3 weeks ;
 Skin :- bed sores .
 Vessels :- DVT .
 Muscles :- skeletal ( wasting ) & smooth ( constipation & Urine retention ) .
 Bone :- Osteoporosis .
 Orthostatic pneumonia ( retained secretion in lung ) .
 Psychosis .
B ) Diet :-
  total calories :- to  metabolites .
  lipids
 Small frequent meals .
 No exercise after meals .
 Salt restriction :- by ;
 Removal of added salt to food .

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Cardiology
 Selection of food ( avoid meat & bread ) .
 Cation exchange resin ( salt chelating agent )  K-salts combine with Na  excreted in urine
i.e. it prevent Na absorption .
 Medicinal salts use  Salty taste & little Na .
 Aim of salt restriction :- keep salt intake ( 4-5 gm / d ) & in sever cases ( 2 gm / day ) to avoid
salt & water retention .
 K-supplementation :- to avoid hypokalaemia which precipitate digitalis toxicity .
 Fluid balance :- ( fluid intake [ Input ] = Output )
 Fluid intake [ Input ] = urine out put in previous day + 500 cm ( insensible water loss ) +
amount equal to diarrhea + amount equal to vomiting + 500 cm for each 1oC  in body
temperature above normal .
C ) Drugs in treatment of Heart failure :-
I ] Drugs to Cardiac work :- ( Dilators & diuretics )
1- Dilators :- they are either ;
 Venodilators (  preload ) :- Nitrites , Morphine & Lasix [ NML ] .
 Vasodilators (  afterload ) :- Hydralazine , Nifidipen & Diazoxide [ HND ] .
 Drugs  pre- & after load :- ANF , ACEIs & Na nitroprusside .
N.B. :- Morphine & lasix are venodilators which mainly  preload so , they are given in pulmonary oedema
even before micturition .

2- Diuretics :-
 Thiazide diuretics :-
 Action :-
 Prevent re-absorption of Na , K , Cl & HCO3 in DCT  excreted in urine .
 Anti-hypertensives .
 Examples :- Hydrochlorothiazide , Chlorothialidone ( hygroton ) , Nitolazone .
 Side effects :-
 Hyponatraemia , hypokalaemia , hypovolaemia & hypotension
 Hyperglycaemia & hyperuraecemia
 Low salt syndrome :- Salt restriction with use of diuretics  Salt excretion till body salt  so ,
diuretics will be ineffective , Treatment  stop diuretics , fluid restriction & Na is given in
sever cases .
 Loop diuretics :-
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Cardiology
 Action :- prevent re-absorption of Na , k , Cl , HCO3 from loop of Henle .
 Examples :- Frusemide ( lasix ) , ethacrinic acid & Bumetanide ( edemex ) .
 Side effects :- as Thiazides except  hypoglycaemia , ototoxicity & Alkalosis .

 K-retaining diuretics :-
 Action :- keep K on DCT with salt & water excretion , so used with Lasix to avoid digitalis toxicity .

 Examples :-
 Aldosterone antagonists :- Spironolactone ( Aldactone ) .
 Non-aldosterone anatagonists :- Triemtrine ( thiamterine ) & Ameloride .
 Side effects :-
 In RF :- Keep K  more hyperkalaemia .
 Gynaecomastia ( in Spironolactone only ) .
 Stone formation in kidney ( in Triemtrine only )

N.B. :-
 Causes of diuretic resistance :- Hyponatraemia , Impaired renal function ( oliguria ) ,
secondary hyperaldosteronism & hypoproteinaemia .
 Drugs causing Gynaecomastia :- Cimetidine , estrogen in males , spironolactone ,
digitalis & mareguana .

II ] Drugs  Cardiac contractility :- they are +ve inotropic drugs ;

1- Digitalis :- ( will be described below ) .

2- β-Agonists :-
 Isoprenaline :- 1mg infusion , sympathomymetic & cause arrhythmia .
 Dopamine :- β1 agonist , 25 µg / kg / min ; infusion .
 Dobutamine :- β1 agonist , 2.5-10 µg / kg / min ; infusion .
3- Phospho-di-esterase inhibitors (  c-AMP ) :-
 Aminophyllin :-  contractility , bronchodilator , vasodilator & diuretic .
 Amrinone :- Oral , 50 mg / 6 h ,  c-AMP  cause thrombocytopenia .
 Milrinone :- 5 mg / 6h  NO thrombocytopenia .
4- Glucagone :- Pancreatic extract .

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The KING in Medicine
Cardiology

DIGITALIS
 Action of digitalis :- ( 2  , 2  , ECG & on kidney )
  Cardiac contractility ( +ve inotropic effect ) :-
 It inhibit Na-K ATPase  prevent Na pump outside myocardial cell  Na accumulate inside
cells  Na-Ca exchange carrier system   intracellular Ca  combine with tryponine ( which
inhibit sliding of actine over myosin )  promote sliding of actine over myosin  myocardial
contractility .
  Cardiac Excitability :- It enhance cardiac automaticity  Dysarrhysthmia ( in toxic dose ) .
  Conduction of impulses :- leads to prolonged refractory period in AV node by ;
 Direct action .
 Vagal stimulation .
 Blocking of cholinesterase enzymes  acetylcholine  bradycardia  protect ventricle from
ectopic impulses   filling time   COP .
  Heart rate :- by ;
 Inhibitory action on SAN either by direct action or vagal stimulation .
 Elimination of compensatory tachycardia by correction of COP & congestion .
 Effect of digitalis on ECG :-
 Prolonged P-R interval .
 Depressed sagging of S-T segment with normal g-point
 Inverted T-wave .
 Ventricular premature beats  Pulsus bigeminus .
 In toxicity :- any type of arrhythmia can occur except sinus tachycardia , as it inhibit SAN .
 Effect of digitalis on kidney :- ( Diuretic effect )
 Digitalis  VC in normal heart , while it produce VD in HF ; due to  COP  elimination of
sympathetic constrictor activity  RBF  (  GFR → diuresis ) & (  renin   aldosterone 
diuresis ) .
 Indications of digitalis :-
 Heart failure ( supra-ventricular tachycardia )

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Cardiology
 AF :- to protect ventricles from high atrial rate by AV node inhibition .
 Heart failure with AF .
 Contraindications :-
 Absolute CI :-
 Digitalis toxicity .
 Ventricular tachycardia ; as it  excitability , so  ventricular fibrillation  death .
 Partial heart block :- Digitalis converts it into complete HB .
 IHSS :- it  contraction   obstruction ( treatment is β-blockers )
 Wolf Parkinson's White syndrome ( WPW syndrome ) .
 Relative Contra-Indications :-
 Premature beats as it  excitability  convert it into ventricular tachycardia .
 Nodal rhythm :- as it inhibits AVN .
 RSHF with Cor-pulmonale .
 Peptic ulcer :- vagal effect   HCl .
 Recent infarction as it  contractility  rupture heart .

 Drug interaction :- DON'T use the following drug with digitalis ;

 Ca ++  Synergism .
 Adrenaline  Arrhythmia .
 Atropine  Anti-vagal .
 Virapamile  Negative inotropic &  digitalis absorption   toxicity .
 All diuretics except K-retaining  hypokalaemia  precipitate for toxicity .
 β-blockers  -ve inotropic effect .
 Preparations of digitalis :-
 Digoxine ( Lanoxine ) :- tablet ( 0.25 mg ) , ampule ( 0.5 mg ) ; metabolized in kidney .
 Digitoxine :- tablet ( 0.1 mg ) , ampule ( 0.2 mg ) ; metabolized in liver & GIT .
 Cedilanid :- ampule ( 0.4 mg ) ; metabolized in kidney .
 Oubain :- ampule ( 0.5 mg ) metabolized in kidney & GIT , rabid onset & short duration .
 Dose of digitalis :-

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 Therapeutic serum level of digitalis = 0.5 ng / ml ( measured by radio-immuno assay ) , if it
 to 2.5 ng/ml  toxicity .
 There are 2 doses for digitalis :-
 Digitalizing dose :- 1.25 mg , till reach the therapeutic serum level .
 Maintenance dose :- 0.5-1 tablet ( about 0.25 mg )
 There are 2 methods to give digitalis :-
 Non-Digitalizing method :- ( in chronic stable HF )
 Begin with maintenance dose & digitalis will reach therapeutic level in 2 weeks .
 Digitalizing method :- ( In acute HF & paroxysmal atrial tachycardia )
 It can be given either I.V. or oral .
 In I.V. method :-
 Give 2-3 ampoules in one day ( 1mg / 1/2h ) then continue by maintenance dose after end
of digitalization .
 It is important for patient not to take digitalis 2 weeks before digitalization to avoid toxicity .
 In Oral method :- It is given on 1 , 3 or 7 days , as follow ;
digitalizing dose + ( maintenance X No. of days )
Digitalization dose / day = ----------------------------------------------------------------
No. of days ( 1 , 3 or 7 )
 Criteria of response to digitalis :-
 Improvement of symptoms & signs .
 Clearing of congested lung bases .
 Diuresis with loss of edema and  BW .
 Slowing of heart rate .
 Early manifestations of digitalis toxicity .
 Digitalis toxicity :-
 Predisposing factors :- ( 2 O , 4 H & 2 D )
 Old age & Over dose .
 Hypomagnisaemia .
 Hypothyroidism :- thyroxine  clearance of digitalis .

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Cardiology
 Hypokalaemia :- It potentiate action of digitalis  K is pushed outside cells .
 Hypocalcaemia :- It has synergetic effect .
 Diseases :- liver , renal disease & failure .
 Drugs :- Verapamile , quinidine , amiodarone & β-blocker .
 Clinical presentation :-
 GIT :- Anorexia ( 1st ) , nausea , vomiting & diarrhea .
 CVS :- Bradycardia ( 1st ) , Pulsus bigeminus or trigeminus ( pathognomonic ) , heart block
& any type of arrhythmia except sinus tachycardia .
 Occular :- Yellow vision blurring of vision & optic neuritis .
 CNS :- Headache , confusion & convulsions .
 Others :- Gynaecomastia & hyper-coagulability .
 Investigations to asses digitalis toxicity :-
 Pulse :-  in under-digitalization &  in over digitalization .
 ECG :- Electrical ( pulsus ) bigeminus .
 Radio-immuno assay :- detect serum level of digitalis .

 Treatment of digitalis toxicity :-

 Stop the drug .
 Stop any drug causing hypokalaemia ( laxatives , diuretics & steroids ) .
 Give KCl , I.V. , 1 gm , 3 times / day .
 Give Ca chelating agents :- as EDTA ; 4 gm / 500 cm glucose infusion .
 Symptomatic treatment :- for ;
 Vomiting & nausea :- chloropromazine ; 25 mg .
 Bradycadia :- atropine ; 1 mg / SC.
 Heart block :- artificial pace-maker .
 Cardiac arrest :- Intra-cardiac adrenalin , Cardiac massage & C-P resuscitation .
 Ventricular tachy-arrhythmia :- anti-arrhythmic drugs ( lidocaine & phenytoin ) .
 VF :- direct current cardioversion  depolarize all irritable areas except SAN .
 Digitalis antibodies :- FAB fragments from sheep RBCs ( recent & help digitalis excretion )
N.B. :- Digitalis is bound to tissues so , it is un-dialyzable .

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5 ) Treatment of Cardiogenic Pulmonary oedema ( Acute HF )
1- Hospitalization .
2- Semi sitting position with leg hanging down .
3- Aspiration of secretions .
4- Oxygen inhalation :- 5-6 L / min by mask or nasal tube .
5- Drugs :- ( in order )
 Morphine :-
 Action :-  Cardiac work , it is not given in non-cardiogenic pulmonary oedema .
 Dose :- 5-10 mg I.V. or S.C .
 Value :-  preload ,  dyspnea ,  agitation ,  VF & Analgesic .
 Lasix :- till 1 gm ( 40 ampoules ) , it  cardiac work .
 Vasodilators :-  pre- & after load .
 Dopamine & Dobutamine :- they have +ve inotropic effect .
 Aminophylin :- I.V. ; 250 gm slowly then 250 infusion ( if rapid  arrhythmia ) .
 Digitalis .
 Rotating tourniquet :- apply 3 tourniquets to 3 limbs & change their site to avoid ischemia .
 Correction of precipitating factors :- to  VR .
 Treatment of complication :- e.g. digitalis toxicity .

N.B. :-
 Medical venesection :- dilators & diuretics (  blood volume ) .
 Surgical venesection :- Small incision in vein to loose some blood ( not used now ) .
 Treatment of acute pulmonary oedema :- ( involve 2 items in answer )
 Treatment of Cardiogenic pulmonary oedema ( as before ) .
 Treatment of non-Cardiogenic pulmonary oedema :- ttt of the cause ( refer to G. medicine )

6 ) Treatment of refractory Heart failure ( Chronic HF - CHF )

 Definition of refractory HF :- HF resisting the normal line of treatment .
 Aetiology :- there are 4 groups of causes ;
 Disease :- Un-corrected causes & Un-corrected pre-disposing factors . ( mention )

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 Patient :- Un-compliance ( stop digitalis , excess salt & in-adequate rest ) .
 Doctor :- either ;
 Wrong diagnosis :- pregnancy , Pericardial effusion , obesity , constrictive pericarditis .
 Iatrogenic :- under dose of digitalis or diuretics , inadequate salt restriction , CCBs , COC ,
β-blockers & NSAIDs .
 Others :- Sever damage of heart ( advanced cardiomyopathy & extensive MI ) .
 Treatment :-
1- Treatment of the cause  example .
2- Treatment of precipitating factors  example .
3- Proper diagnosis of HF .
4- Proper dose of digitalis .
5- Improve compliance :-
 Adequate salt restriction ( 0.5-1 gm / day ) .
 Strict instructions to patient ( drugs given by nurse ) .
6- If No response :- add I.V. , Dobutamine , diuretics & Vasodilators .
7- Surgical repair :-
 Cardiomyoplasty :- using latissmus dorsi muscle to help heart in its work till cardiac
transplantation .
 Cardiac transplantation .
 Intra-aortic ballon counter pulsations :- it acts as peripheral heart which relax in systole &
contract in diastole ( it is filled with Helium ) .

 Important N.B. 
 Heart maybe enlarged & compensated without heart failure ( as in athletes ) ; so chamber
enlargement not mean HF .
 Cardiomegally may be absent in HF ( i.e. HF with normal sized heart ) in ;
 Acute HF .
 MS .
 Restrictive cardiomyopathy .
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 Constrictive pericarditis .
 Cor-pulmonale due to COPD because heart is compressed bilaterally by hyper-inflated lungs .
  severity of dyspnea in LSHF means  development of RSHF on top .
 Differential diagnosis of LSHF :-
 Other causes of dyspnea ( chest dyspnea ) .
 Cardiac asthma .
 DD of aetiology of HF .
Parameter Chest dyspnea Cardiac dyspnea
 Cough &  Early .  Late & positional .
expectoration :-  Not occur  Characteristic
 PN Dyspnea :-  late .  Early ,  when RSHF occur
 Orthopnea :-  Of RV    Of LV   .
 Ejection fraction :-
 Digitalis has no effect on normal heart .
 If cardiac edema progress & HF resist treatment  Nephrotic syndrome or protein loosing
enteropathy .

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