CHF

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CHF

• Umer Ahmed, MS III
• Daniel Mehrhoff, MS III
• Tazeen Al-Haq, MS III

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Definitions

• Forward Heart Failure heart unable to maintain
  adequate cardiac output to meet systemic demands
  and/ or able to do so only by elevating filling
  pressure.
• Backward Heart Failure Heart unable to
  accommodate venous return resulting in vascular
  congestion (systemic or pulmonary)
• Heart Failure can involve left side of heart,
  right side of heart or both(biventricular
  failure)
• Components of ineffective filling (diastolic
  dysfunction)and/or emptying-systolic dysfunction
  
• Most cases of HF are associated with poor cardiac
  output(low-output HF)however HF may not be due
  to intrinsic cardiac disease,but due to increased
  demand-HOP

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Pathophysiology

• Primary insults (myocyte loss,overload) -gt pump
  dysfunction, which leads to remodeling (dilation,
  hypertrophy) and neurohumoral activation-gtnecrosis
  and apoptosis.
• Both pathways result in further damage
  (re-starting the cycle), edema, tachycardia,
  vasoconstriction, congestion
• Compensatory response to myocardial stress
• increased end-systolic ventricular
  pressure(pressure overload) e.g. aortic
  stenosis-gt hypertrophy.
  

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Pathophysiology

• Increased end-diastolic ventricular volume
  (volume overload) e.g. aortic regurgitation
• -gtcardiac dilation
• Systemic response to ineffective circulating
  volume results in activation of sympathetic
  nervous and renin-angiotensin-alsosterone systems
  which causes
• -Salt and water retention with intravascular
  expansion
  - increased heart
  rate and myocardial contractility - increased
  afterload

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Classification of Heart Failure by Hemodynamic
Abnormality

• Diastolic Heart Function
• About 30 of heart failure
• Characterize by impaired LV relaxation
• The hemodynamic abnormality is an elevated
  LVEDP normally it should relax down to around
  5-10 mmHg
• The elevated LVEDP causes increased left
  atrial
• and pulmonary capillary pressures

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Diastolic Heart Failure

• Fluid is transudated across the pulmonary
• Capillaries causing intestitial edema and
  dyspnea
• Systolic performance is initially normal or
  hyperdynamic, but later fails.
• Examples include hypertensive heart disease,
• HCM, and diabetic cardiomyopathy

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High Output Systolic Heart Failure

• Pure forms of systolic heart failure are
  uncommon and are characterize by
• A low LVEDP
• Normal or hyper dynamic left ventricular
  function
• Tachycardia
• And increased cardiac output

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High Output Systolic Heart Failure

• Occurs with peripheral shunting with large
• AV fistulas, large hepatic hemangiomas, and
  Pagets disease
• Occurs with decrease peripheral resistance, as in
  Gram negative sepsis
• Other causes are hyperthyroidism, beriberi,
• Carcinoid, anemia and pregnancy
• Note it is either due to a dramatic decrease in
  after load or an increase in preload. Basically
  High output heart failure- differs from the usual
  heart failure in that the heart may pump out its
  usual amount of blood, but that still may not be
  enough to meet the body's needs

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Low Output Systolic Heart Failure

• The vast majority of systolic failure involves
  both decreased systolic dysfunction and an
  elevated LVEDP
• Decreased forward output causes weakness,
  fatigue, fluid retention.
• Note which leads to increased LVEDP

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Causes of Low Output Systolic HF

• Coronary artery disease 40
• Dilated cardiomyopathy 30
• Valvular heart disease 15
• Hypertensive heart disease 10
• Restrictive cardiomyopathy - lt 1

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Pathophysiology of Heart Failure

• Decreases Stroke Volume -gt Decrease cardiac
  output gt decrease Renal perfusion gt increase
  Renin gt increased Angiotensin- gtincreased
  Angiotensin II gt increased Sodium retention gt
  increased water retention gt increased Preload gt
  increased Ventricular filling pressures gt
  Exacerbation of heart failure gt

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Morbidity and Mortality

• 50 die with progressive heart failure, 40 of
  sudden death due to VT/VF
• LVEF is closely associated with prognosis!
• Other markers of poor outcome include low sodium,
  high BUN, low potassium, high or low magnesium,
  high catecholamine levels
• Exercise tolerance does not predict outcome

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Classifications of Heart Failure by Myocardial
Abnormality

• Myocardial Abnormalities
• Ischemic
• Hypertensive
• Dilated
• Restrictive
• Hypertrophic

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Ischemic Cardiomyopathy

• Caused by coronary disease
• By far the most common cause of heart failure
• Characterized on echo by segmental wall motion
  abnormalities.
• .

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Hypertensive Cardiomyopathy

• Chronic HTN causes LVH, which increases LV
  stiffness and elevates LVEDP
• Systolic function may be normal, hyperdynamic, or
  eventually, decreased
• Characterized on echo by concentric LVH

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Dilated Cardiomyopathy

• 50 are idiopathic, presumably post viral
• Other causes include alcohol, cocaine, inhaled
  glue, chemotherapy, late hemochromotosis, and
  selenium and carnitine dificiencies
• Characterized on echo by four chamber cardiac
  enlargement

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Peripartum Dilated Cardiomyopathy

• Occurs from the beginning of the third trimester
  to six months postpartum
• There is predilection of older women in African
  Americans
• About two thirds resolve spontaneously
• There is increased risk of occurrence with
  subsequent pregnancies

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Dilated Cardiomyopathy and Embolization

• About 2 of patients form mural thrombi and can
  have arterial embolization
• Pulmonary emboli can arise from the RV
• Anticoagulation is indicated even if no mural
  thrombi can be detected

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Restrictive Cardiomyopathy lt 1

• Caused by infiltrative diseases, such as amyloid,
  sarcoid, hemochromotosis, and lipid storage
  diseases
• Presents with left and right heart failure,
  initially from diastolic dysfunction, but later
  from systolic failure also. HF from due to
  restrictive cardiomyopathy usually presents as
  refractory left and right sided heart failure.

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Restrictive Cardiomyopathy

• Characterized an echo by normal sized ventricles,
  huge atria, and (in Amyloidosis) by a sparkling
  appearance of the LV myocardium.
• The venticles cannot enlarge, because they have
  already been enlarged.

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Hypertrophic Cardiomyopathy

• There are disordered myocytes in the region of
  the hypertrophy, especially in the region of the
  upper ventricular septum
• Areas other than the septum can be affected
  Asians frequently have an apical form
• Occasionally there is a concentric LVH
• Sudden death is probably due to ventricular
  arrhythmias

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Hypertropic Cardiomyopathy

• Hypertrophic cardiomyopathy (HCM) is associated
  with sudden cardiac death, especially in
  exercising young people with the familial form
• The severity of the LV outflow gradiant is not
  related to the risk of sudden death
• There is no cure except heart transplant
• .

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New York Heart Association (NYHA)Functional
Classification of Heart Failur

• Class I ordinary physical activity does not
  cause symptoms of HF
• Class II comfortable at rest, ordinary physical
  activity results in symptoms
• Class III marked limitation of ordinary
  activity less than ordinary physical activity
  results in symptoms.
• Class IV inability to carry out any physical
  activity without discomfort symptoms may be
  present at rest.

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Acute Versus Chronic Heart Failure

• Acute heart failure is the patient who is
  entirely well but who suddenly develops a large
  myocardial infarction or rupture of a cardiac
  valve.
• Chronic heart failure is typically observed in
  patients with dilated cardiomyopathy or
  multivalvular heart disease that develops or
  progresses slowly

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Acute Versus Chronic Heart Failure

• Acute heart failure is usually largely systolic
  and the sudden reduction in cardiac output often
  results in systemic hypotension without
  peripheral edema.
• In chronic heart failure, arterial pressure tends
  to be well maintained until very late in the
  course, but there is often accumulation of
  peripheral edema .

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Backward versus forward heart failure

• Forward heart failure-Is the inability of the
  heart to pump enough blood to meet the needs of
  the body for oxygen during exercise or at rest.
• Backward heart failure-Is the inability of the
  heart to meet the oxygen needs of the body when
  heart filling pressures are too high

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Redistribution of Cardiac Output

• Finally, the redistribution of cardiac output is
  an important compensatory mechanism when cardiac
  output is reduced. This redistribution is most
  marked when a patient with HF exercises, but as
  heart failure advances, redistribution occurs
  even in the basal state.

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Demographics

• The most expensive medical problem in the US
• The most common diagnose in hospitalized elderly
  patients
• Note It is the most expensive medical problem,
  because in the later stages patient are
  hospitalized over and over again as the disease
  progressed with frequent exacerbations and
  remissions.

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CHF Diagnosis

• Tazeen Al-Haq

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CHF Diagnosis

• Four components involved in the diagnosis of CHF
• History
• Physical
• Labs
• Imaging

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History

• Classical manifestations of heart failure include
  
• Fatigue
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Fluid retention
• Older patients with heart failure often present
  with nonspecific symptoms
• Nocturia
• Insomnia
• Irritability
• Anorexia

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Physical Examination

• Left heart failure
• Low cardiac output (forward)
• Fatigue
• Syncope
• Systemic hypotension
• Cool extremities
• Slow capillary refill
• Peripheral cyanosis
• Pulsus alternans
• Mitral regurgitation
• S3 aka Kentucky gallop
• Occurs at the beginning of diastole after S2 and
  is lower in pitch than S1 and S2
• Will increase on expiration

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Pulsus Alternans

• Is a physical finding with arterial pulse
  waveform alternating strong and weak beats
• Almost always indicative of left ventricular
  systolic impairment and also occurs in aortic and
  mitral valve stenosis, hypertrophic and
  congestive cardiomyopathy, pericarditis and use
  of general anesthesia
• Carries a poor prognosis
• EF is decreased in left ventricular dysfunction
  which causes an increase in EDV
• In the next cycle of systolic phase, the
  myocardial muscles are stretched more than usual
  causing an increase in muscle contraction and a
  stronger systolic pulse

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Physical Examination

• Left heart failure
• Venous congestion (backward)
• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Cough
• Crackles

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Physical Examination

• Right heart failure
• Low cardiac output (forward)
• Can mimic most of the symptoms of forward left
  heart failure if decreased right ventricle output
  leads to left ventricle underfilling
• Tricuspid regurgitation
• S3 (right-sided)
• will increase on inspiration

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Physical Examination

• Right Heart failure
• Venous congestion (backward)
• Peripheral edema
• Elevated JVP with abdominal jugular reflex
• Kussmauls sign
• Rise in JVP with inspiration
• Usually JVP falls with inspiration due to reduced
  pressure in the expanding thoracic cavity
• Suggests impaired filling of the right ventricle
• Hepatomegaly
• Pulsatile liver
• Signifies severe tricuspid regurgitation or
  constrictive pericarditis

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Investigation

• Identify and assess precipitating factors and
  treatable causes of CHF
• HEART FAILED
• HTN (common)
• Endocarditis
• Anemia
• Rheumatic heart disease and other valvular
  disease
• Thyrotoxicosis
• Failure to take meds (very common)
• Arrhythmia (common)
• Infection/Ischemia/Infarction (common)
• Lung problems (PE, pneumonia, COPD)
• Endocrine (pheochromocytoma)
• Dietary indiscretions (common)

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Investigations

• Blood work
• CBC
• Electrolytes
• BUN and Creatinine
• TSH
• Ferritin
• Cardiac biomarkers
• B-type/Brain natriuretic peptide (BNP)
• Secreted by ventricles due to LV stretch and wall
  tension
• Sensitive marker of ventricular pressure and
  volume overload
• Higher levels are suggestive of heart failure
• Lower levels (lt100 pg/mL) is most useful for
  ruling out heart failure

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Cardiac Biomarkers

• Provide diagnostic and prognostic information
• Identify increased risk of mortality in acute
  coronary syndromes
• Troponin I and T
• Peak at 1-2 days and remain elevated up to 2
  weeks
• DDx MI, CHF, acute pulmonary embolism,
  myocarditis, chronic renal insufficiency, sepsis,
  hypovolemia
• CK-MB
• Peak at 1 day and remain elevated for 3 days
• DDx MI, myocarditis, pericarditis, muscular
  dystrophy, cardiac defibrillation

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Investigations

• Chest X-Ray
• HERB-B
• Heart enlargement/Cardiomegaly
• Pleural Effusion
• Re-distribution (alveolar edema)
• Kerley B-lines
• Bronchiolar-alveolar cuffing

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Chest X-Ray
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Chest X-Ray
Cardiomegaly
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CHF Treatment

• Umer Ahmed

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General Principals in the Treatment of CHF

• No one simple treatment regimen is suitable for
  all patients.
• The following are a general guideline, but the
  order of therapy may differ among patients and/or
  with physician preferences.

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General Principles in the Treatment of CHF

• Mild CHF (NYHA Class I to II)
• Mild restriction of sodium intake (no-added-salt
  diet of lt4 g sodium) and physical activity (aka
  Lifestyle Changes).
• Start a loop diuretic if volume overload or
  pulmonary congestion is present.
• Use an ACE inhibitor as a first-line agent.

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General Principles in the Treatment of CHF

• Mild to Moderate CHF (NYHA Class II to III)
• Start a diuretic (loop diuretic) and an ACE
  inhibitor
• Add a ß-blocker if moderate disease (class II or
  III) is present and the response to standard
  treatment is suboptimal

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General Principles in the Treatment of CHF

• Moderate to Severe CHF (NYHA Class III to IV)
• Add digoxin (to loop diuretic and ACE inhibitor)
• Note that digoxin may be added at any time for
  the relief of symptoms in patients with systolic
  dysfunction. (It does not improve mortality.)
• In patients with class IV symptoms who are still
  symptomatic despite the above, adding
  spironolactone can be helpful.

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Monitoring a Patient with CHF

• Weightunexplained weight gain can be an early
  sign of worsening CHF
• Clinical manifestations (exercise tolerance is
  key) peripheral edema
• Laboratory values (electrolytes, K, BUN,
  creatinine levels serum digoxin, if applicable)

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Medical Devices

• Ventricular assist device (VAD). When your
  weakened heart needs help pumping blood, surgeons
  may implant a VAD into your abdomen and attach it
  to your heart. These mechanical heart pumps can
  be used either as a "bridge" to heart transplant
  or as permanent therapy for people who aren't
  candidates for a transplant.

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Medical Devices

• Cardiac resynchronization therapy (CRT) device
  (biventricular cardiac pacemaker). It sends
  specifically timed electrical impulses to your
  heart's lower chambers. CRTs are suitable for
  people who have moderate to severe congestive
  heart failure and abnormal electrical conduction
  in the heart.

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Medical Devices

• Internal cardiac defibrillator (ICD). Doctors
  implant ICDs under the skin to monitor and treat
  fast or abnormal heart rhythms (arrhythmias),
  which occur in some people who have heart
  failure. The ICD sends electrical signals to your
  heart if it detects a high or abnormal rhythm to
  shock your heart into beating more slowly and
  pumping more effectively.

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Surgery

• Heart valve repair or replacement. Cardiologists
  may recommend heart valve repair or replacement
  surgery to treat an underlying condition that led
  to congestive heart failure. Heart valve surgery
  may relieve your symptoms and improve your
  quality of life.

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Surgery

• Coronary bypass surgery. Cardiologists may
  recommend coronary bypass surgery to treat your
  congestive heart failure if your disease results
  from severely narrowed coronary arteries.

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Surgery

• Myectomy. In a myectomy, the surgeon removes part
  of the overgrown septal muscle in your heart to
  decrease the blockage that occurs in hypertrophic
  cardiomyopathy. Surgeons may perform myectomy
  when medication no longer relieves your symptoms.

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Surgery

• Heart transplant. Some people who have severe
  congestive heart failure may need a heart
  transplant.

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Two Questions
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Thank you ?