Heart failure
E.C. Ejim (MBBS, FMCP, FESC, FACC,FNCS)
Professor of Medicine/Consultant Cardiologist
University of Nigeria/Teaching Hospital
Ituku-Ozalla Campus
Outline
• Learning objectives
• Definitions, causes and precipitants
• Pathophysiology
• Classifications
• Clinical features
• Investigations
• Treatment
• Prognosis
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LEARNING OBJECTIVES
• Distinguish heart failure from circulatory failure, cardiac
arrest and myocardial failure.
• Understand the concept of systolic failure and diastolic
failure, and distinguish the pathophysiologic mechanisms
underlying them.
• Understand heart failure with preserved ejection fraction
and heart failure with reduced ejection fraction
• Understand the basis for the clinical features of heart
failure.
• Know the common causes of heart failure in our
environment.
• Understand the basic investigations and principles of
management of heart failure
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Definitions
• Heart failure or cardiac failure is a
pathophysiologic state in which the heart is
unable to pump blood at a rate
commensurate with the metabolic demands
of the body, or does so from an elevated filling
pressure
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Definitions
• It can also be defined as a complex clinical
syndrome that can result from any structural
or functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject
blood.
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Definitions
• More recently, there is a universal definition
of heart failure as a clinical syndrome with
symptoms and/or signs caused by a structural
and/or functional cardiac abnormality, and
corroborated by elevated natriuretic peptide
levels and/or objective evidence of pulmonary
or systemic congestion
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Definitions
• From the definitions above, heart failure may
be systolic – reduced contractility with
reduced cardiac output, or diastolic - reduced
ventricular relaxation or compliance with
elevated filling pressures.
• In heart failure there is a functional
impairment (systolic or diastolic or both)
usually due to a structural cardiac problem.
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Definitions
• The commonest structural problem is
myocardial injury(or failure).
• However in some cases of heart failure the
ventricular myocardium is perfectly normal
e.g., mitral stenosis, tricuspid stenosis,
constrictive pericarditis, acute valvular
regurgitation.
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Definitions
• Therefore myocardial failure is the commonest
mechanism underlying heart failure, but all
heart failures are not due to myocardial
failure.
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Definitions
• Circulatory failure (shock) may result from
severe heart failure (cardiogenic shock), but
many non-cardiac conditions also cause shock
- anaphylaxis, hypovolaemia etc.
• Therefore, circulatory failure can occur even
with a normally functioning heart
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Definitions
• Cardiac arrest is the sudden cessation of all
mechanical cardiac activity and is
characterized by a crash of blood pressure to
zero and disappearance of the pulse
• The commonest mechanism underlying
cardiac arrest is ventricular fibrillation
• Ventricular asystole and electromechanical
dissociation are other mechanisms
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Aetiology
• In our environment the causes of heart failure
vary in the different age groups.
• Hypertension is the commonest cause of heart
failure in middle–aged Nigerians.
• In young adult Nigerians, rheumatic heart
disease is the commonest cause.
• In the elderly population, degenerative
valvular diseases are quite common
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Aetiology
• Cardiomyopathies • Myocarditis
(including peripartum • Endocarditis
cardiomyopathy) • Pericardial diseases
• Cardiotoxins like alcohol, • Tachycardia-induced
cobalt
• Congenital heart diseases • Micronutrient
like ASD which are seen in deficiencies (selenium,
adults. phosphate, Vitamin B1)
• Diabetes mellitus • Infilterative heart muscle
diseases (amyloidosis,
• Anaemia multiple myeloma)
• Thyrotoxicosis
• Ischaemic heart disease
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Precipitants of Heart Failure
• In patients with • Systemic infection
established structural • Infective endocarditis
heart disease but in • Myocardial ischaemia
stable state, heart failure
may be precipitated by • Medication – NSAIDS,
• Arrhythmias like atrial oestrogen,
fibrillation, heart block nondihydropyridine
calcium channel
• Anaemia antagonists, anthracycline
• Thyrotoxicosis compounds, some beta
• Pregnancy blockers, anabolic
• Physical or emotional steroids, chloroquine,
stress amphetamine
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Classifications of Heart Failure
• Acute heart failure e.g. perforated mitral valve
leaflet or aortic valve cusp in infective
endocarditis and acute extensive myocardial
infarction.
• Chronic heart failure such as in rheumatic
heart disease or hypertensive heart disease or
the cardiomyopathies.
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Classifications of Heart Failure
• Right or left heart failure or biventricular
failure.
• Systolic or diastolic heart failure.
• High-output cardiac failure.
• Heart failure with reduced ejection
fraction/mid-range ejection
fraction/preserved ejection fraction
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Pathophysiology
• In systolic heart failure, there is a drop in
cardiac output and the body responds acutely
by employing mechanisms aimed at increasing
the cardiac output –
• Increased sympathetic activity
(vasoconstriction of arteries, tachycardia)
• Increased preload (venoconstriction, high
venous pressure)
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Pathophysiology
• Other neuroendocrine substances (ADH,
endothelin, natriuretic peptides)
• Rennin–Angiotensin- Aldosterone System
(increased blood volume)
• Myocardial remodeling
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Pathophysiology
• Shunting of blood away from non- vital
organs (kidney, skin, gut, skeletal muscle),
leads to cold skin with sweating, and oliguria.
• Endothelial dysfunction is present in heart
failure and exercise induced vasodilatation at
the extremities is attenuated
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Pathophysiology
• In heart failure, energy consumption of the
myocardium is increased despite a depression
of contractility
• Noradrenaline , adrenaline, aldosterone
damage the myocardium directly, causing
hypertrophy and fibrosis in addition to sodium
and water retention.
• The actions of these substances are countered
by ANP and BNP.
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Pathophysiology
• In diastolic heart failure there is impaired
ventricular relaxation or compliance resulting
in pulmonary and systemic congestion with
the attendant symptoms or sign in the
presence of normal or almost normal systolic
function
• Tachycardia shortens diastole more than
systole, and may worsen symptoms of
diastloic heart failure
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Ejection Fraction
• Ejection fraction is the fraction of the end-
diastolic volume each ventricle pumps out per
beat
• It is measured as part of an echocardiographic
examination, or during cardiac catheterization
• Patients with heart failure could have either
reduced, preserved or mid-range ejection fraction
• Classification of heart failure could therefore be
based on ejection fraction
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Ejection fraction
• Normal ejection fraction is from about 50-80%
• Heart failure patients with ejection fraction of
≤40% are classified as reduced ejection fraction
while those with ejection fraction ≥50% are
classified as preserved ejection fraction, and in
between mid-range ejection fraction
• These classifications are not exactly same as
systolic heart failure (reduced EF) and diastolic
heart failure (preserved EF)
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Epidemiology
• In the USA, 6.5 million adults are known to have
heart failure, while 1 in 8 deaths were related to
heart failure in a 2017 study.
• Prevalence increases with age, 1-2% (for people
aged 45-54yrs) and 10% for people > 75yrs.
• In Nigeria, the Nigerian cardiac society has
recently introduced a heart failure registry and
hopes to come up with figures on prevalence and
incidence soon.
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Symptoms (left sided)
Breathlessness
• Exertional dyspnoea
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Trepopnoea
• Cyclical breathing (Cheyne-Stokes breathing)
Cough
• Sputum production
• Haemoptysis
Easy Fatiguability
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Symptoms (left sided)
• Nocturia
• Oliguria
• Confusion
• Light headedness
• Presyncope
• Memory loss
• Delirium
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Symptoms (right sided)
• Dependent leg swelling
• Abdominal distension
• Upper abdominal pain
• Easy satiety
• Parotid fullness
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Signs
• General
• Respiratory distress
• Tachypnoea
• Intercostal / supra-clavicular recessions
• Visible pulsations in neck
• Cyanosis, jaundice, leg oedema, digital
clubbing
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Signs
• Cardiovascular
• Pulse- Tachycardia (SVR,NVR, irregular ,pulsus
alternans).
• Bp- variable (Normal, high, low).
• JVP- Elevated + Abdominojugular reflux.
• Displaced apex beat (systolic heart failure).
• Left parasternal heave
• Palpable P2 , loud P2
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Signs
• Heart sound – variable
• Murmur – maybe present
• Hepatomegaly
• Basal crepitations
• Weight loss
• Low grade fever due to peripheral
vasoconstriction
• Asterixes
• Abnormal response to Valsalva manoeuvre
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Framingham Criteria
Major
• Neck vein distension
• Increased venous pressure 15cm H20
• Hepatojugular reflux
• PND
• Basal crepitations
• Radiographic cardiomegaly
• S3 gallop
• Increased circulation time
• Acute pulmonary oedema
• Loss of 4.5kg of weight after 5 days of therapy
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Framingham Criteria
Minor
• Bilateral ankle oedema
• Hepatomegaly
• Nocturnal cough
• Breathlessness on ordinary exertion.
• Pleural effusion
• Tachycardia ≥ 120/min
• Decreased vital capacity by 1/3 from maximal
value recorded.
• Loss of 4.5kg of weight after 5 days of therapy
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New York Heart Association
Functional Classes of Heart Failure
• Class 1 – Patient with heart disease but no
symptoms
• Class 2 – Patient with heart disease and
symptoms on moderate to marked levels of
activity
• Class 3 – Patient with heart disease and
symptoms on mild activity
• Class 4 – Patient with heart disease and
symptoms at rest
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Investigations
1 Electrolytes
• Dilutional hyponatraemia or diuretic-induced
• Hypokalaemia may be diuretic–induced.
• Hyperkalaemia may also result from
ACEI/Aldosterone antagonists
• Hypophosphataemia and hypomagnesaemia may
also result
2 Urinalysis
• Proteinuria
• High specific gravity
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Investigations
3 LFT
• Elevated liver enzymes/ bilirubin especially if
cardiac sclerosis is present
• Hypoalbuminaemia
4 ESR
• Usually low due to enythrocytosis and
impaired synthesis of fibrinogen by the liver
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Chest X-ray (PA view)
• Cardiomegaly (enlarged cardiac silhouette)
• Mitralization of the left heart border
• Prominent hilar vessels
• Perivascular cuffing
• Upper lobe diversion
• Congested lung fields
• Pleural effusion
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ECG
• Always abnormal in heart failure
• Sinus tachycardia, Arrhythmias
• First degree AV block, 2nd Degree AV block
• Bundle Branch Blocks
• Wide QRS complexes
• Repolarisation abnormalities
• Hypertrophies
• QTc abnormalities
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Echocardiography
• Dilated heart chambers
• Regurgitant valves
• Wall motion abnormalities
• Systolic dysfunction
• Diastolic dysfunction
• Pulmonary hypertension
• Shunts
• Pericardial abnormalities
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Other Investigations
8 B-type Natriuretic peptides (BNP) levels
- levels below 100pg/ml indicate no failure
- 100-300pg/ml suggest heart failure
- above 300pg/ml indicate mild heart failure
- above 600pg/ml indicate moderate failure
- above 900pg/ml indicate severe failure
9 N-terminal Pro-BNP
- above 450pg/ml in those less than 50 years old
- above 900pg/ml in those more than 50 years
old
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Other Investigations
10 Serum ferritin and Transferrin saturation
(Iron deficiency in heart failure is defined as ferritin < 100 microgram/ml or
ferritin of 100-299 with a transferrin saturation of < 20%)
10 Chest CT scan
11 Cardiac MRI
12 Radionuclide ventriculography
13 Myocardial/Endocardial/Pericardial biopsies
14 Coronary angiography
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Treatment
• Drug treatment of HF
• Treatment of decompensated heart failure
• Treatment of chronic stable HF
• Goals of drug treatment
• Decompensated HF – stabilize patient, restore
organ perfusion, return filling pressures to
optimal levels, begin conversation to chronic
therapy
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Goals of treatment in chronic stable
heart failure
• Relieve symptoms and improve quality of life
• Slow disease progression
• Reduce the need for emergency room visits
and hospitalization
• Prolong life
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Drug Treatment (diuretics)
1. Loop duiretic (Ca and Mg loss also occurs).
• Frusemide, Bemetanide, Piretanide, Ethacrynic
acid, Torsemide.
2. Thiazide and thiazide-like diuretic (chlorothiazide,
hydrochlorothiazide, trichloromethiazide,
chlorthalidone, metolazone, indapamide).
3. Type 1 mineralocorticoid receptor Antagonists (K+
sparing diuretic)
• Spironolactone, Eplerenone(Reduce mortality
when given with ACE inhibitors
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Drug Treatment (diuretics)
4. Epithelial Na channel inhibitiors (K+ sparing
diuretic)
• (Amiloride, Triamterene)
5. ADH- antagonists
• (Tolvaptan, Conivaptan)
6. Carbonic Anhydrase Inhibitors
• Acetazolamide, Methazolamide
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Drug Treatment (vasodilators)
1. Nitrovasodilators (organic nitrates,
Nitropruside)
2. Direct vasodilators (hydralazine)
3. Hydralazine- Isosoibide dinitrate combination
are used in people intolerant of ACE inhibition
or as an add-on.
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Drug Treatment (vasodilators)
4. Natriuretic Peptides
• Nesiritide (human brain natriuretic peptide)
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Drug Treatment (positive ionotropes)
Cardiac glycosides (digoxin, digitoxin)
• Digoxin also has antiadrenergic properties
• Low dose digoxin reduces mortality in heart
failure (serum level of 0.5- 1.0nglml)
• Hyperkalaemia attenuates some of the toxic
effects of digoxin
• Useful is HFrEF and in the presence of atrial
fibrillation with rapid ventricular response
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Drug Treatment (positive ionotropes)
Adrenergic Agonists
• Intravenous infusion of Dobutanine,
Dopamine, Isoprenaline, Noradrenline,
adrenaline
• Useful in acute heart failure, sudden
deterioration of chronic heart failure or in
patients awaiting cardiac transplant
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Drug Treatment (positive ionotropes)
Phosphodiesterase inhibitors (type 111)
• Milrinone
• Amrinone
• Enoximone
• Pimobendan
• Vesnarinone
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Drug Treatment (neurohumoral
inhibitors)
1. Inhibition of RAAS
• Angiotensin Converting Enzyme inhibitors
(Captopril, Enalapril, Lisinopril, Ramipril)
• Angiotensin II Antagonists (Losartan,
Valsartan, Candesartan, Telmisartan,
Olmesartam)
• Aldosterone Receptor Antagonists
(Spironolactone, Eplerenone)
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Drug Treatment (neurohumoral
inhibitors)
2. Antiadrenergic Agents
• Beta Blockers (Metoprolol, Carvedilol,
Bisoprolol, Bucindolol, Nebivolol)
• Useful in heart failure with reduced ejection
fraction (HFrEF)
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Drug treatment
• Ivabradine is a selective inhibitor of ‘funny current’ in
the SA nodal cells. It reduces heart rate without
compromising contractile function (unlike beta
blockers and calcium channel blockers).
• Used in heart failure (sinus rhythm), with LVEF less
than 35% and heart rate 70-75/minute or more
• It could be used in combination with beta blockers or
alone
• Sick sinus syndrome is a contraindication to its use
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Drug treatment
• Angiotensin receptor/neprilysin inhibitor
combination (valsartan/sacubitril). Neprilysin
degrades natriuretic peptides, and its
inhibition makes these peptides available
resulting in increased natriuresis, urine cGMP
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Drug Treatment
• Sodium Glucose Co-Transporter 2 (SGLT2)
➢Useful in treatment of heart failure (HFrEF)
➢Both diabetic and non-diabetic patients with
heart failure
➢Causes diuresis, with loss of mainly
electrolyte-free water
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Drug Treatment
Soluble guanylate cyclase stimulator
• Vericiguat reduces the risk of cardiovascular
death or heart failure hospitalization in
patients with chronic heart failure and
ejection fraction less than 45%
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Drug Treatment
• Cardiac Myosin Activator
Omecamtiv Mecarbil is used in patients with
HFrEF with severe disease to improve
contractility
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Drug Treatment
Adjuvant Therapy
• Antiarrhythmic agents
• Anticoagulants (Heparin, LMWH, NOAC)
• Treatment of pulmonary hypertension
(prostacyclin analogues, Endothelin receptor
antagonists, PDE-5 inhibitors)
• Intravenous iron
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Treatment
Device Therapy
• Implantable Cardioverter-Defibrillator (ICDs)
• Cardiac pacemakers, particularly biventricular
pacing (cardiac resynchronization therapy)
• Ventricular assist devices (As a bridge for
cardiac transplant)
• Artificial heart
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Treatment
Surgical Therapy
• Valve surgeries (replacement, repair)
• Annuloplasty
• Closure of defects
• Ventricular assist devices
• Cardiac transplant
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Treatment
Exercise
• Bed rest is no longer recommended, and
exercise now appears to be promising as a
treatment in heart failure
• Input / Output chart aimed at maintaining a
negative fluid balance in oedematous patients
• Daily weighing
• Nursing in the most comfortable position
• Cardiac rehabilitation
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Differential Diagnosis
• Pulmonary hypertension
• Chronic obstructive airway diseases
• Tracheal obstruction
• Chronic asthma
• Intracardiac tumour
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Prognosis
• Mortality from heart failure is high
• When treatment is started early, and cause
appropriately addressed, prognosis is very good
• Despite advances in therapy, the life expectancy
for patients with chronic heart failure is worse
than for any of the common cancers (except lung
cancer) and is associated with a comparable
number of expected life-years lost. In Scotland
the five-year survival rate is approximately 25%
for both sexes after diagnosis.
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Predictors of Mortality
• Glomerular filtration rate
• Ejection fraction
• Functional status
• Hyponatraemia
• Diuretic resistance
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