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Heart Failure

Clinical definition of
:chronic HF
(.Symptoms of HF (at rest or during exercise(1
.Objective evidence of cardiac dysfunction(2
Response to TTT directed towards HF. (if Diagnosis is(3
(.in doubt
Failure of the H to pump blood (↓COP( at a rate
sufficient to the metabolizing tissues, with an ↑ in the
filling pr; resulting in cardiac and extracardiac
:compensatory responses
(.Hemodynamic, renal, neural, and hormonal (
:Acute HF
.Acute (cardiogenic( dyspnea : APEdema•
Cardiogenic shock (syndrome with: ↓ ABP, oliguria,•
:cool periphery(. Due to
:A) Systolic HF
Dilated V with poor contractility (due to CAD, DCM,
(.severe valve regurgitation, hyperdynamic state
:B) Diastolic HF
occur when symptoms of HFexist in presence of LVH,
preserved LV Systolic function; i.e. diastolic
LVdysfunction by echoDoppler, as in LVH( HTN, HCM,
.AS (, and with aging
:Left or right HF
Used when HF presents mainly by S,S of systemic or
. pulmonary venous congestion

Presentation of HF
):Acute HF (APO- 1
rapid ↑in LA pr (min to hours( as in: acute MI or MR due
to (CAD, rupture chordea, endocarditis, trauma(, acute
AR due to (dissection, endocarditis, trauma(, acute VSD
.due to (CAD, trauma(, hypertensive crisis
:DD or Non cardiac causes of Acute dyspnea
Acute severe bronchitis, acute bronchial asthma
pneumonia, pneumothorax, pulmonary embolism
Upper airway obstruction, aspirin overdose, acute toxic
...(.inhalation (chloride
Chronic HF: see next (DD: noncardiac causes of- 2
exercise intolerance: anemia, chest wall deformity,
:Acute decompensation on top of chronic HF- 3
Precipitating( potentially reversible( causes are : M
ischemia, rapid↑ BP, rapid AF, pulmonary embolism
anemia, pregnancy, infection, stress, thyrotoxicosis,
negative inotropic drugs, NSAIDs, bronchodilators,
cocaine, lack of compliance with medical or dietery
(. therapy (↑Na intake, alcohol consumption

Cardiogenic shock: -4
(Hypotension, tachycardia, low cardiac output and organ
( hypoperfusion
Caused by: large MI, acute VSD or valvular insufficiency
:Causes of left side failure
.Pressure overload: severe HTN, AS, Coarctation of Ao
Volume overload: Severe AR, MR VSD, PDA,
.arteriovenous fistula , hyperkinetic circulation
Myocardial causes: CAD, CM, Myocarditis (cytotoxic
.drugs, alcohol(, peripartum cardiomyopathy
.LA causes: tight MS, LA myxoma

Causes of right side HF

Pr overload: severe PS, PH
.Volume overload: severe PR, TR
Myocardial causes: CAD,CM
.RA causes: severe TS
Pericardial causes of HF
Constrictive pericaditis, Tamponade (causing impaired
(.venous return
Refractory (intractable or resistant) HF
Severe( valve disease, DCM, or CAD(, drug non
( compliance, electrolyte disturbance (↓Na,K,or Mg
Compensatory Mechanisms of HF
Sinus tachycardia- 1
LV dilatation (to ↑the preload(, in cases with volume- 2
LV hypertrophy (to ↑the afterload( in conditions with- 3
.pressure overload
A) Left side failure: ↑LVEDP, ↑LApr , ↑PVPr,
.(PVCongestion( : shortness of breath
.Grade І: dyspnea on more than ordinary activity
II: on ordinary activity
.III: less than ordinary activity
IV : at rest , PND , orthopnea , APO : severe
.distress , cough , frothy sputum , Hemoptysis
(.B) Right side failure: (Systemic Venous Congestion
( JVP, dependant pitting edema (LL swelling↑
Ascitis (↑ abdominal size(, Hepatomegaly,
.R.hypochondrial pain
.GIT congestion: dyspepsia, anorexia
.CNS congestion: insomnia
..(C( Low COP symptoms: (severe AS, DCM
(Cold, pale or bluish extremities: (peripheral VC *
(Easy fatigue (↓ muscular bld perfusion *
(Dizziness, syncope (↓ CNS perfusion *
( . Oliguria :(↓ renal perfusion *

:D( Other symptoms of HF

…Palpitation: sinus tachycardia, AF, PVCs
Chest pain: CAD ischemia or MI, or severe LVH as in
(. tight Aos( relative ischemia
Dysphagia: pr on oesophagus by huge LA
Physical Examination
Skin extremeties : cold , pale , or cyanosed , sweaty
:( VC in case of ↓ COP( ,or
Warm skin( in ↑ COP states: anemia, thyrotoxicosis,
…( Pagets disease
(.Respiration R≥ 20 ∕ m (dyspnea, orthopnea, hemoptysis
(,Pulse: rapid, regular, small volume (sinus tachycardia
(.Irregular (PVCs(, irregular irregularity (AF
(.Pulsus alternans in (severe HF
, Bp: may be ↑ (if uncontrolled HTN( causing HF
or ↓ ( In severe HF, cardiogenic shock, or taking too
(. much VD drugs, and Diuretics
.Hepatomegaly, R. hypochondrial tenderness
.Ascitis: shifting abdominal dullness , ↑ size
LL edema, pitting, starts in dependant parts, propagating
. upwards
(. On the back of sacrum( in bed ridden patients
DD(Other causes of edema(: hepatic or renal failure,
nutritional deficiency or malabsorbtion (↓protein(, drugs: NSAID, CCB, steroids
Cardiac cachexia: muscular wasting in chronic severe
. HF
Lung Auscultation
. Fine basal crepitations up to bubbling chest in APO
( .Wheezes( bronchiolar wall edema: cardiac asthma
(. Basal dullness,↓ breath sounds( pleural effusion: CHF

Cardiac Examination
(.Palpation: displaced apex (outside 5th left MCL line
(.Palpable gallop( S3 of systolic HF, S4 of diastolic HF
(.Hyperdynamic( V. overload (or heaving( Pr overload
(,Auscultation : ↓ H sounds, ± ↑ S2 ( PH
(.Functional (MR in LVF, or TR in RVF
…..Tachycardia ≥100 ∕ min, irregular PVCs, AF
:Framingham Criteria of HF
:-Major criteria
. PND *rales *APO*
.JVP(≥ CVP 16cm(, * Hepatojugular reflux↑ *
.S3, *Cardiomegaly*
Circulation time≥25 sec.,* Weight loss≥ 4.5 kg in 5d on*
.treatment starting

:-Minor criteria
Bilateral ankle edema, Hepatomegaly, Pleural effusion
Dyspnea on exertion , Nocturnal cough , HR ≥120
. major , or 1 major + 2 minor are needed for diagnosis 2
:A) To detect HF
CXR: cardiomegaly ( C/T>50%(, PVC (↑ p vasc- 1
markings up(, Kerley B lines (interstitial edema( , APO
(.(hilar opacities: alveolar edema
.(, Chamber enlargement (due to valve,myoc.dis
(Pleural effusion (in CHF
(NB: N size H does not R/O diastolic HF(conc.LVH
:ECHO: impaired LVF (EF < 50 %( as in- 2
.Systolic LVF:dilated LV(N 5.5cm(with poor contractility
Or Diastolic LVF: LVH with diastolic relaxation, or
(.restrictive anomaly (diagnosed by Doppler
. Cardiopulmonary exercise testing: to evaluate ex- 3
+Tolerance, max O2 uptake. (if art. Desaturation
(.CO2 retention = lung disease
B) Look for underlying cause
.ECG: signs of ischemia, LVH, arrhythmias- 1
ECHO: different valve or congenital disease and- 2
:severity, pericardial effusion or constriction, CAD
Less common causes : Thyroid dis. (TSH ( , -3
anemia(CBC(, amyloid dis.(s.electrophoresis, rectal
biopsy( , hypocalcemia , iron storage dis., sarcoid.
( (Kveim test
Cardiac catheterization : used rarely to DD restrictive-4
.CM vs. constrictive pericarditis
Coronary angiography if CAD suspected as a cause of-5
. HF
.( Rarely myocardial Biopsy (myocardial dis-6
C) Assess the severity of HF
LVEF by S,S,,response to ttt, EchoDoppler,
((Radionuclide angiography, ex.capacity testing

:D) Evidence of poor Prognosis

(.24h Holter monitor (serious V.arrhythmias- 1
Laboratory tests (impaired renal, liver functions,- 2
electrolyte changes:↓ Na,Mg,K ,↑ plasma noradrenaline
CXR cardiomegaly- 3
Echo: EF < 35%, restrictive pattern of diastolic- 4
(. dysfunction (Doppler
E-Complications of HF
Vascular: postural hypotension, peripheral embolisations
. Renal impairement ,failure
. GIT: congestion, dysfunction, malabsorption
. Musculoskeletal: easy fatigue wasting
Respiratory: P congestion → non asthmatic bronchial
.constriction, wheezes, resp. mus. weakness, PH, RVF
.Neurological: ↑ incidence of fainting, strokes, fits
. Arrhythmias: especially AF, VT→sudden death