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

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

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Page 1: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

CHF

Umer Ahmed, MS III Daniel Mehrhoff, MS III

Tazeen Al-Haq, MS III

Page 2: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 3: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Pathophysiology• Primary insults (myocyte loss,overload) -> pump

dysfunction, which leads to remodeling (dilation, hypertrophy) and neurohumoral activation->necrosis 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-> hypertrophy.

Page 4: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Pathophysiology

Increased end-diastolic ventricular volume (volume overload) e.g. aortic regurgitation

->cardiac dilationSystemic 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

Page 5: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 6: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 7: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 8: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

High Output Systolic Heart Failure • Occurs with peripheral shunting with large AV fistulas, large hepatic hemangiomas, and Paget’s 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

Page 9: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 10: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Causes of Low Output Systolic HF

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

Page 11: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Pathophysiology of Heart Failure

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

Page 12: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 13: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Classifications of Heart Failure by Myocardial Abnormality

Myocardial Abnormalities Ischemic Hypertensive Dilated Restrictive Hypertrophic

Page 14: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Ischemic Cardiomyopathy

• Caused by coronary disease• By far the most common cause of

heart failure• Characterized on echo by

segmental wall motion abnormalities.

.

Page 15: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 16: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 17: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 18: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 19: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Restrictive Cardiomyopathy < 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.

Page 20: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 21: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 22: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 23: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 24: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 25: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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 .

Page 26: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 27: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 28: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 29: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

CHF Diagnosis

Tazeen Al-Haq

Page 30: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

CHF Diagnosis

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

Page 31: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 32: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 33: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 34: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Physical Examination

• Left heart failure – Venous congestion (backward)

• Dyspnea• Orthopnea• Paroxysmal nocturnal dyspnea• Cough• Crackles

Page 35: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 36: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Physical Examination

• Right Heart failure– Venous congestion (backward)

• Peripheral edema• Elevated JVP with abdominal jugular reflex • Kussmaul’s 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

Page 37: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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)

Page 38: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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 (<100 pg/mL) is most useful for ruling out heart

failure

Page 39: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 40: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Investigations

• Chest X-Ray– HERB-B

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

Page 41: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Chest X-Ray

Page 42: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Chest X-Ray

Cardiomegaly

Page 43: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

CHF Treatment

Umer Ahmed

Page 44: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 45: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

General Principles in the Treatment of CHF

Mild CHF (NYHA Class I to II) • Mild restriction of sodium intake (no-added-

salt diet of <4 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.

Page 46: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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 β-blocker if moderate disease (class II or

III) is present and the response to standard treatment is suboptimal

Page 47: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 48: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Monitoring a Patient with CHF

• Weight—unexplained 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)

Page 49: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 50: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III
Page 51: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 52: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III
Page 53: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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.

Page 54: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

SurgeryHeart 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.

Page 55: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 56: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

SurgeryMyectomy. 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.

Page 57: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

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

Page 58: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Two Questions

Page 59: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III
Page 60: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III
Page 61: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III
Page 62: CHF Umer Ahmed, MS III Daniel Mehrhoff, MS III Tazeen Al-Haq, MS III

Thank you