Congestive heart failure

The heart does not pump efficiently

The heart is not able to move as much blood as it should with each
beat
Organs in the body do not get enough oxygen rich blood that they
need to work well.
• Results from any structural or functional abnormality that impairs
the ability of the ventricle to eject blood (Systolic Heart Failure) or
to fill with blood (Diastolic Heart Failure).
CHF occurs when the heart cannot generate sufficient
output to meet the metabolic demands of the tissue.
In the United state 5million persons are affected
resulting in more than 1 million hospitalization and
300,000 death each year.
The Vicious Cycle of Congestive Heart Failure

LV Dysfunction causes Decreased Blood Pressure and

Decreased cardiac output Decreased Renal perfusion

Stimulates the Release

of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure
Causes Heart Failure?
Coronary Artery Disease
♥ Untreated High Blood Pressure
♥ Faulty Heart Valves
♥ Cardiomyopathy
♥ Lung Disease
♥ Diabetes
♥ Infections
♥ Alcoholism
♥ Toxic Drugs
 2 Types of Heart Failure
Systolic Dysfunction
(Contraction) 2/3 of Patients

♥ The heart becomes weak and enlarged

♥ The weakened heart muscle can’t contract

♥ Not enough blood is pumped from the chambers

Diastolic Dysfunction
(Relaxation)

♥ Chambers don’t fill up so less blood goes to the lungs and

body

♥ Stiff heart muscle can’t relax

♥ Not enough blood fills the chambers

Clinical Presentation of Heart Failure
• Due to excess fluid accumulation:
– Dyspnea (most sensitive symptom)
– Edema
– Hepatic congestion
– Ascites
– Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)
• Due to reduction in cardiac ouput:
– Fatigue (especially with exertion)
– Weakness
pathogenesis
Decrease cardaic output(forward failure)
decrease cardaic output due to decreased heart function results in
diminished filling of arterial tree. therefore blood supply of the
organ is reduced which may lead to ischemia.
Damming of blood(backward failure)
Heart become fail to pump the whole blood coming to it (venous
return) resulting in blood damming back into the venous system.
accumulation of deoxgenated blood in the tissue venous system
may produce disturbed organ function.
compensatory mechanisms
As the heart begin to fail , a number of local compensatory
mechanisms are activated in an attempt to maintain normal
cardaic output these mechanism are
Increased sympathetic activity
it,s lead to increase heart rate and increased force of contraction of
cardaic muscles that lead to increased cardaic output.
Hypertrophy and dilatation of heart chambers.
Myocardail hypertrophy develops in respone to pressure overload
and there is dilatation of ventricles as a compensatory mechanism.
According to the frank starling law increase length of the cardaic
muscle fibers increase their force of contraction.
Left sided heart failure
Left sided heart failure is characterized by reduction in effective left
ventricular output for a given pulmonary venous or left atrial
pressure.
An acute increase in left atrial pressure may cause pulmonary
congestion or pulmonary edema.
In chronic left ventricualar failure decreased cardiac output results in
decreased tissue perfusion. Decrese renal blood flow stimulates
renin angiotensin system and aldosterone formation which causes
sodium and water retension from kidney. This sodium and water
retension increase blood volume, therefore increasing venous return
to already weak heart resulting in congenstion of lungs.
causes
ischemic heart disease( commonest)
systemic hypertension
mitral and aortic valve diseases
cardiomyopathies
symptoms

Dyspnea
Dyspnea on exertion
Orthopnea
Dyspnea on lying position is called orthopnea. It result from
increased amount of venous return to thorax from lower
extremities when patient is in lying position. Heart is unable to
pump all of this venous return that leads to lung congestion and
dyspnea
paroxysmal nocturnal dyspnea
dyspnea during sleep which awakens the patient with severe
breathlessness, accompanied by a choking sensation and coughing
is called paroxysmal noctural dsypnea. It aslo result from increased
venous congestion as the patient is lying on bed.
SIGN
Tachycardia
cardiomegaly
chronic dilation of left atrium may also occur which may be
associated with atrial fibrillation.
Right sided heart failure
Reduction of right ventricular output for an increased atrial pressure
is called right sided heart failure.
In acute right ventricular failure occurs in massive pulmonary
embolism. It,s occure when massive pulmonary embolus become
impacted in and obstruct the outflow tract of the right ventricale
and main pulmonary artery. This result in arrest of the circulation
and sudden death.
Cardaic temponade.
Acute right ventricular failure occure when fluid accumulated in
pericardial cavity that interferes the right ventricular diastolic
filling , resulting in decreased right ventricular output, the
condition is called cardaic temponade.
chronic right ventricular failure.
chronic right ventricular failure most commonly occurs secondry to
left ventricular failure and is manisfested clinically by systemic
venus congestion such as.
liver is enlarged and tender. enlargment due to congestion and
tenderness due to stretching of liver capsule.
peripheral edema. occuring in dependent area the ankles in
ambulatory pts, pleural effusion and pericardial effusion or ascites.
clinical feature

• Elevated jugular venous pressure( DNV)

• Lower extremity edema
• Ascites
• Hepatomegaly
• Splenomegaly
• Sudden death
• Edema in dependent parts
Lab Analysis in Heart Failure
• CBC
– Since anemia can exacerbate heart failure
• Serum electrolytes and creatinine
– before starting high dose diuretics
• Fasting Blood glucose
– To evaluate for possible diabetes mellitus
• Thyroid function tests
hypothyroidism can result HF.
• Viral studies
– If viral mycocarditis suspected
X-RAY

• Cardiomegaly
• Pleural effusions
Classification of Heart Failure

• New York Heart Association (NYHA)

– Class I – symptoms of HF only at levels that would limit
normal individuals.
– Class II – symptoms of HF with ordinary exertion
– Class III – symptoms of HF on less than ordinary exertion
– Class IV – symptoms of HF at rest
Order of Therapy

1. Loop diuretics
2. ACE inhibitor
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs
Diuretics

• Loop diuretics
• Furosemide, buteminide
• For Fluid control, and to help relieve symptoms
• Potassium-sparing diuretics
• Spironolactone, eplerenone
• Help enhance diuresis
• Maintain potassium
• Shown to improve survival in CHF
Beta Blocker therapy
• Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve
overall and event free survival in NYHA class II to III HF, probably in class
IV.
• Contraindicated:
– Heart rate <60 bpm
– Symptomatic bradycardia
– Signs of peripheral hypoperfusion
– COPD, asthma
Digoxin

• Given to patients with HF to control symptoms such

as fatigue, dyspnea, exercise intolerance
• Shown to significantly reduce hospitalization for
heart failure, but no benefit in terms of overall
mortality.
 What Can we Do To Prevent Progression of the
Disease?

♥ Become Conscious of Lifestyle Choices!

♥ Make Better Choices…
☺ Quit Smoking
☺ Reduce Weight
☺ Avoid Excess Alcohol and Drugs
☺ Exercise
☺ Take Medication
Self Care Strategies

♥ Keep high blood pressure under control

♥ Salt restrictions
♥ Daily weights and record
♥ Health Buddy
♥ Look for swelling
♥ Manage stress
THANK YOU