Heart Failure Overview

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Heart Failure

Definition
Heart failure (HF) is a complex clinical syndrome resulting from any structural or functional
cardiac disorder that impairs the ability of the ventricle to fill or eject blood.

It is a common health issue, particularly in industrialized nations.

Etiology of Heart Failure

1. Intrinsic Pump Failure

Myocardial weakening leads to inefficient pumping.

Ischemic heart disease (e.g., myocardial infarction)

Myocarditis

Cardiomyopathies

Cardiac arrhythmias (e.g., atrial fibrillation, flutter)

2. Increased Workload on the Heart

A. Pressure Overload

Systemic or pulmonary hypertension

Valvular stenosis: mitral, aortic, pulmonary, tricuspid

Chronic lung diseases: ILD, COPD

B. Volume Overload

Valvular insufficiency: mitral and aortic regurgitation

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 Congenital shunts: ASD, VSD

High-output states: thyrotoxicosis, anemia, AV fistulas, beriberi

3. Impaired Ventricular Filling

Cardiac tamponade

Constrictive pericarditis

Precipitating Causes

Aggravate an already compromised heart:

Infections: Fever, tachycardia, increased O₂ demand

Arrhythmias: Tachyarrhythmias, AV dissociation

Excesses: Sudden physical exertion, emotional stress, high sodium intake, extreme temperatures

Drug-related:

Withdrawal: Antihypertensives, diuretics

Ingestion: NSAIDs

Myocardial infarction (new infarct)

Pulmonary embolism

Anemia

Thyrotoxicosis and pregnancy

Uncontrolled hypertension

Myocarditis

Infective endocarditis

Types of Heart Failure

1. Acute vs Chronic

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 Acute: Sudden drop in CO; hypotension; no edema
e.g., MI, valve rupture

Chronic: Gradual; BP maintained; peripheral edema

e.g., valvular disease, cardiomyopathy, hypertension

2. Left-sided vs Right-sided

Left-sided: Pulmonary congestion → dyspnea, orthopnea

Right-sided: Systemic congestion → JVP↑, hepatomegaly, ascites, pedal edema

Both sides: Congestive cardiac failure (CCF)

3. High-output vs Low-output

High-output: ↑CO but inadequate tissue perfusion

e.g., anemia, hyperthyroidism, AV fistula, pregnancy, beriberi, Paget’s disease

Low-output: ↓CO due to heart disease

e.g., IHD, hypertension, cardiomyopathy

4. Systolic vs Diastolic

Systolic HF: ↓Ejection due to impaired contraction

e.g., MI, cardiomyopathy

Diastolic HF: Impaired relaxation → poor filling

e.g., LVH, constrictive pericarditis, restrictive cardiomyopathy

Often coexist

Pathophysiology

1. Ventricular Dysfunction

Failing myocardium responds poorly to ↑EDV

→ ↓Contractility, flattened Frank-Starling curve

2. Compensatory Mechanisms

Neurohormonal activation:

↑Sympathetic activity

↑RAAS → ↑Angiotensin II & Aldosterone

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 ↑ADH (vasopressin)
→ Tachycardia, vasoconstriction, fluid retention

Effects:

Initially maintain BP and perfusion

↑Preload & CO (Frank-Starling)

Eventually cause worsening of HF due to ↑O₂ demand

Counter-regulation:

ANP, BNP, Prostaglandins (PGE₂, PGI₂), Nitric oxide (NO)

→ Natriuresis, vasodilation, RAAS inhibition

Clinical Features

Symptoms

1. Dyspnea

Exertional: Early symptom

Orthopnea: Dyspnea on lying down (fluid redistribution, diaphragm elevation)

Paroxysmal Nocturnal Dyspnea (PND): Sudden breathlessness during sleep, resolves upon waking
and sitting up

Acute pulmonary edema: Pink frothy sputum, wheezing, cyanosis, Cheyne-Stokes respiration

2. Fatigue

Due to reduced skeletal muscle perfusion

3. Cerebral Symptoms

Altered mentation, confusion, insomnia, headache

4. Abdominal Symptoms

Nausea, anorexia, abdominal pain (due to hepatic/portal congestion)

5. Urinary Symptoms

Oliguria: Daytime renal hypoperfusion

Nocturia: Nighttime diuresis due to recumbency-induced increased renal perfusion

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New York Heart Association (NYHA) Classification of Heart Failure

The NYHA classification is the most commonly used clinical tool to evaluate the functional limitation
caused by heart failure. It helps in prognosis and monitoring response to therapy.

Class Functional Capacity Description

I No limitation No symptoms of heart failure with ordinary activity (fatigue, dyspnea, palpitations).

II Mild limitation Symptoms occur with significant exertion. Comfortable at rest or with mild activity.

III Marked limitation Symptoms occur with mild exertion. Comfortable only at rest.

IV Severe limitation Symptoms occur even at rest. Any physical activity leads to discomfort.

Physical Signs of Heart Failure

Vital Signs
Pulse: Rapid and low volume; Pulsus alternans may be seen in left ventricular failure (LVF).

Blood Pressure: Often low in severe cases.

Respiratory Rate: Elevated due to pulmonary edema.

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General Examination
Dyspnea and orthopnea.

Cold peripheries, cyanosis.

Jugular Venous Pressure (JVP): Elevated with positive abdominojugular reflux.

Edema:

Pitting pedal edema (upright patients).

Sacral edema (bedridden patients).

Cardiac Cachexia: Weight loss due to chronic severe HF; associated with elevated cytokines.

Cardiovascular System (CVS)

Apex beat: Displaced down and out (cardiomegaly).

Heart sounds:

S1 may be soft.

S3 and S4 may be present.

Murmurs: Pansystolic murmurs due to functional mitral/tricuspid regurgitation from ventricular

dilation.

Respiratory System (RS)

Tachypnea.

Bilateral basal crepitations.

Rhonchi due to pulmonary edema.

Pleural effusion may be present, more commonly right-sided.

Abdominal Examination
Hepatomegaly: Congestive, tender liver.

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 Ascites due to systemic venous congestion.

CNS Symptoms
Confusion, memory disturbances due to cerebral hypoperfusion.

Investigations in Heart Failure

1. Chest X-Ray
Cardiomegaly: Cardiothoracic ratio >0.5 (especially >0.6).

Pulmonary edema:

Bilateral batwing (perihilar) pattern.

Generalized interstitial haziness.

Kerley B lines: Short horizontal lines at the lung bases.

Pleural effusion: Typically bilateral, more on the right.

2. Electrocardiogram (ECG)
Helps assess:

Cardiac rhythm.

Ischemia, old or recent myocardial infarction.

Left ventricular hypertrophy.

Conduction blocks, electrolyte abnormalities.

3. Echocardiography
Confirms and quantifies heart failure.

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 Evaluates:

Left and right ventricular size and function.

Regional wall motion abnormalities (ischemia/infarct).

Valve morphology and function.

Left atrial myxoma.

Pericardial effusion.

Ventricular hypertrophy.

4. Natriuretic Peptides
BNP (Brain Natriuretic Peptide) and ANP (Atrial Natriuretic Peptide) elevated in heart failure.

Useful in diagnosis and monitoring treatment.

5. Radionuclide Imaging
Non-invasive technique to evaluate:

Ventricular ejection fraction.

Ventricular volumes.

Wall motion abnormalities.

6. Cardiac Catheterization
Findings:

Increased end-diastolic pressure.

Decreased cardiac output and ejection fraction.

Coronary angiography: Determines the severity of coronary artery disease (CAD).

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TREATMENT OF HEART FAILURE

🧩 A. General Principles
Treat underlying cause (e.g. valvular surgery, MI management).

Address precipitating factors: infections, anemia, hyperthyroidism.

Lifestyle modifications:

Adequate rest (not necessarily bedrest).

Diet:

Adequate calories.

Sodium restriction: <6g/day salt.

Low-fat, low-calorie diet for obese.

Potassium-rich foods if on diuretics.

💧 B. Control of Excessive Fluid

Low-salt diet and fluid restriction help reduce symptoms.

Diuretics:

Reduce extracellular fluid volume and edema.

Types:

Loop: Furosemide, Torsemide.

Thiazides.

K-sparing: Spironolactone, Amiloride.

Combination therapy to avoid hypokalemia.

Watch for hyponatremia.

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🔧 C. Prevention of Myocardial Deterioration
1. RAAS Inhibitors

ACE Inhibitors (Captopril, Enalapril, Lisinopril, Ramipril, Perindopril):

↓ Afterload (vasodilation), inhibit tissue RAAS.

Prevent remodeling, enhance exercise tolerance.

↓ Mortality and hospital readmission.

Contraindicated in hypotension.

ARBs (Losartan, Telmisartan, Valsartan):

Alternative to ACEIs (cough, angioedema).

Similar benefits.

Aldosterone Antagonists:

Spironolactone: ↓ mortality and sudden death.

Eplerenone: More selective alternative.

2. Beta-Blockers (Atenolol, Metoprolol, Bisoprolol, Carvedilol)

↓ Mortality, sudden death, and hospitalizations.

Indicated in NYHA class II & III.

Contraindicated in:

Class IV HF.

Hypotension (SBP < 90 mmHg).

Severe fluid overload.

Bradycardia, AV block.

Recent IV inotropes or bronchospastic disease.

Initiate after ACEIs.

3. Vasodilators

For patients with systemic vasoconstriction despite ACEI.

↓ Afterload, ↑ cardiac output.

IV agents: Nitroprusside, Nitroglycerin, Nesiritide.

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 Oral: Hydralazine + Isosorbide dinitrate.

4. ARNI (Angiotensin Receptor-Neprilysin Inhibitor)

Sacubitril + Valsartan:

Sacubitril: Inhibits neprilysin → ↑ ANP & BNP.

Valsartan: Blocks angiotensin II.

Used in symptomatic patients after stopping ACEI/ARB.

Never use sacubitril alone (↑ angiotensin II).

5. Ivabradine

Slows heart rate by inhibiting If channel in SA node.

Used in sinus rhythm patients with HR ≥70 bpm despite BB, ACEI/ARB.

↓ hospitalization and cardiovascular death.

💪 D. Enhancement of Myocardial Contractility

1. Cardiac Glycosides (Digoxin)

↑ Intracellular Na⁺ → ↑ Ca²⁺ → ↑ contractility.

Improves symptoms but does not prolong survival.

Contraindicated in:

HCM, Mitral stenosis, Constrictive pericarditis, Diastolic HF.

2. Sympathomimetic Amines

Dopamine: Useful in HF with hypotension (α-adrenergic stimulation ↑ BP).

Dobutamine: Used in acute HF without hypotension (↓ BP).

IV infusion for short-term use in:

Refractory/severe HF.

MI + shock/pulmonary edema.

Bridge to transplant.

3. Phosphodiesterase Inhibitors (Amrinone, Milrinone)

↑ cAMP → ↑ contractility & vasodilation.

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 Used IV in:

Acute decompensated HF.

Bridge to transplant.

Similar indications to dopamine/dobutamine.

⏱ E. Cardiac Resynchronization Therapy (CRT)

For intraventricular conduction defects (e.g. LBBB).

Improves contractility by restoring synchrony.

Device with 3 leads: RA, RV, LV via cardiac vein.

🫀 F. Advanced Support
1. Circulatory Assist Devices

For class IV HF unresponsive to treatment and survival <1 year.

May be a bridge to cardiac transplant.

2. Cardiac Transplantation

Final option for end-stage HF.

⚡ G. Antiarrhythmics & Devices

Amiodarone: Preferred antiarrhythmic (class III) in HF.

ICD (Implantable Cardioverter Defibrillator):

For:

Resuscitated sudden death.

Syncope/presyncope due to VT/VF.

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🩸 H. Anticoagulants & Antiplatelets
Anticoagulants (e.g. warfarin):

Indicated if:

Atrial fibrillation.

History of thromboembolism.

Documented LV thrombus.

Not routine in patients in sinus rhythm.

Antiplatelets (e.g. aspirin):

Only for patients with coronary artery disease.

🫁 I. Treatment of Diastolic Heart Failure

Treat underlying cause (e.g. LV hypertrophy, fibrosis, ischemia).

Sodium restriction and diuretics for symptom relief.

Rest and dietary modifications as in systolic HF.

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