Heart Failure

Noha Khalil , MD

Definition

Heart failure is a clinical syndrome usually due to left ventricular dysfunction, resulting in acute or chronic symptoms of cardiac pump failure.

Aetiology

The most common causes of heart failure are coronary heart disease, hypertension, alcohol abuse, and idiopathic dilated cardiomyopathy

Other causes are valvular and pericardial disease; or non-cardiac diseases causing high-output cardiac failure, such as anaemia, thyrotoxicosis, septicaemia, Paget's disease of bone, and arteriovenous fistulae.

Symptoms

DYSPNEA CHEST PAIN SYNCOPE PALPITATION EDEMA COUGH HEMOPTYSIS FATIGUE CYANOSIS

DYSPNEA Abnormally uncomfortable awareness of breathing Dyspnea after strenous activity- Normal Individual Dyspnea after moderate activity – Deconditioned

Individual Dyspnea becomes abnormal only if it occurs at rest

or at a level of activity not expected to cause dyspnea

DIFFERENTIAL DIAGNOSIS OF DYSPNEA

PULMONARY

- Reactive airways disease

- COPD

- Pulmoary edema

- Pulmonary hypertension

- Infection

- Pulmonary embolism

- Pleural diseases

- Interstitial lung disease

DIFFERENTIAL DIAGNOSIS OF DYSPNEA

CARDIAC

-Ischemic heart dsease

- Right sided heart failure

- Arrhythmias

- Dilated cardiomyopathy

- Hypertrophic cardiomyopathy

- Valve stenosis and regurgitation

ACUTE DYSPNEA

Sudden development of dyspnea

- Pulmonary embolism

- Pneumonia

- Airway obstruction

CHRONIC DYSPNEA

Symptom progress slowly or gradual

- HEART FAILURE

- COPD ( chronic obstructive pulmonary disease )

PAROXYSMAL NOCTURNAL DYSPNEA

Interstitial or interalveolar pulmonary edema Secondary to ventricular failure Symptom starts 2-4 hours after sleeping, patient

arise from sleep feeling short of breath Symptom ameliorated by sitting on the side of bed

and take about 15-30 min

ORTHOPNEA

Inability to breath comfortably when lying Severe pulmonary venous congestion is the cause

of orthopnea Usually seen in advanced heart failure were

resting pulmonary venous pressure is elevated

CHEST PAIN

Cardinal manifestation of coronary heart disease There are other structures that can casue chest

pain- Intrathoracic structures like aorta, pulmonary airway, pleura and mediastinum; tissue of the neck; thoracic wall and subdiaphragmatic structures

DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

PULMONARY

- pulmonary embolism

- pneumothorax

- pneumonia

NEUROMUSCULAR

- Degenerative joint disease of cervical area

- Costochondritis

- Herpes zoster

PSYCHOGENIC

- Anxiety

- Depression

GASTROINTESTINAL

- Cholecystitis

- Esophageal spasm

- GERD

QUALITY OF PAIN

Angina means tightening Unpleasant sensation which is describe as either

heaviness, pressing, squeezing or constricting

LOCATION

Anginal pain is substrenal in location Pain at times radiates to the jaw, left arm, or neck

DURATION

The pain of angina pectoris is usually brief and last between 2-10 minutes

Chest pain lasting for more than 15 minutes would fall into either UNSTABLE ANGINA OR MYOCARDIAL INFARCTION

COUGH Cough due to left ventricular failure is dry,

irritating , spasmodic and nocturnal It is due to pulmonary venous congention Cough of pulmonary disease is usually productive Cough follwed by dyspnea is usally pulmonary in

nature while dyspnea follwed by cough is cardiac in nature

HEMOPTYSIS

Expectoration of blood in sputum RBC escapes into aleveoli Rupture of bronchial vessel Necrosis and hemorrahge into the alveoli

FATIGUE

Patient with impaired cardiovascular function Decrease peripheral perfusion Muscle weakness

Chronic Heart Failure

The most specific signs are: Laterally displaced apex beat Elevated jugular venous pressure Third heart sound Less specific signs include: Tachycardia Lung crepitations Hepatic engorgement (tender hepatomegaly) Peripheral oedema

Investigations Electrocardiogram (ECG) may show acute ischaemia, arrhythmias,

left ventricular hypertrophy, left bundle branch block, or prior MI. Heart failure is unlikely if the ECG is normal, and the diagnosis

should be reconsidered in this situation. Chest X-ray (CXR)

pulmonary vascular congestion (upper lobe diversion), pulmonary oedema effusions cardiomegaly

Chronic Heart Failure

B-type natriuretic peptide (BNP) and its N-terminal fragment (NTproBNP)

New diagnostic test A raised concentration of either has been shown to have a

sensitivity of greater than 90% and a specificity of 80-90% for the diagnosis of heart failure.

Heart failure is unlikely if the level of BNP or NTproBNP is normal, especially if the ECG is also normal, and the diagnosis should be reconsidered in this situation.

Medication

Drug treatments should be initiated in the following order:

ACE inhibitor - with diuretic if needed - for NYHA Grades I-IV.

Angiotensin-II receptor antagonist - if intolerant of ACE inhibitor.

Beta-blocker - for NYHA Grades I-IV. Spironolactone - for NYHA Grades III-IV. Digoxin - for NYHA Grades II-IV.

Thank you