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02/03/17 1
Introduction
Heart failure is the pathological
process in which the systolic
or/and diastolic function of the
heart is impaired, and as a result,
cardiac output decreases and is
unable to meet the metabolic
demands of the body.
02/03/17 2
Cardiac Physiology
HR: parasympathetic
and sympathetic
Stroke Volume Heart Rate
tone
SV: preload,
afterload, Cardiac Output
contractility
02/03/17 3
Stroke Volume
PRELOAD : Passive stretch of muscle prior
to contraction function of LVEDP
AFTERLOAD : Force opposing/stretching
muscle after contraction begins
measured by SVR (Systemic Vascular
Resistance)
CONTRACTILITY : ability of the muscle to
contract at a given force for a given
stretch, independent of preload or
afterload forces
02/03/17 4
Frank Starling Mechanism
02/03/17 5
Pathophysiolog
y
Systolic dyfunctions : Dysfunction of myocardium :
The contractile state of
Myocardial damage :
the myocardium
myocardial infarction;
The preload of the Cardiomyopathy;
ventricle Myocarditis
Metabolic disturbance :
The afterload applied to
ischemia and hypoxia;
the ventricle
diabetes
The heart rate
Overload for myocardium :
Pressure overload (afterload) : Hypertension, aortic stenosis;
Pulmonary hypertension
Volume overload (preload) : Mitral regurgitation
Restriction of cardiac dilation : Pericardial effusion
02/03/17 7
Ventricular
Remodeling
Ventricular remodeling is the process by which
mechanical, neurohormonal, and possibly genetic
factors alter ventricular size, shape, and function.
Its hallmarks include hypertrophy, loss of myocytes,
and increased interstitial fibrosis.
Clas % of Symptoms
s patient
s
I 35% No symptoms or limitations in
ordinary physical activity
II 35% Mild symptoms and slight
limitation during ordinary
activity
III 25% Marked limitation in activity
even during minimal activity.
Comfortable only at rest
IV
02/03/17 5% Severe limitation. Experiences11
Stages of heart failure
Think FACES...
Fatigue
Activities limited
Chest congestion
Edema or ankle swelling
Shortness of breath
Modified Framingham
Criteria Diagnosis for Heart
Failure
Major criteria Minor criteria
Neck vein distension Bilateral ankle
Orthopnea edema
Cardiomegaly on CXR Night cough
CVP > 12 mm Hg Dyspnea on exertion
Left Ventricular Hepatomegaly
dysfunction on EKG Pleural effusion
Weight loss Tachycardia (> 120
Acute pulmonary beats/min)
edema
02/03/17 19
Clinical Data
HEART SOUNDS!!!
Systolic Murmurs
Mitral Regurgitation
Aortic Stenosis
Diastolic Murmurs
Mitral Stenosis Mitral Stenosis
Aortic Insufficiency
S3: Rapid filling of a diseased ventricle
02/03/17 21
Clinical Data
CXR(Chest X-Ray)
Kerleys lines : A and B
Pulmonary Edema
Cephalization
Pleural Effusions (bilateral)
EKG(Electrocardiogram)
Left atrial enlargement
Arrhythmias
Hypertrophy (left or right)
02/03/17 22
Clinical Data
Laboratory Data
Chemistry
Renal Function: Be Wary
02/03/17 23
Treatment Strategies of
HF
Etiology therapy
Treatment of etiology causes
Treatment of precipitating causes
Improve life-style
Lessen cardiac load
Rest
Limitation of salt intake
Water intake
Diuretics
Drug treatment for CHF
Diuretics, ACE
inhibitors
Reduce the number of sacks
on the wagon
Diuretics
Indicated in patients with symptoms of fluid
retention
Benefits :
Improves symptoms of congestion
Can improve cardiac output
Limitations :
Excessive volume depletion
Electrolyte disturbance
ACE Inhibitor
All patients with symptomatic heart failure and
functional class I with reduced LV function, unless
contraindicated or not tolerated
Should be continued indefinitely and titrate to
optimal dosage in the absence of symptoms or
adverse effects on end-organ perfusion
Increases exercise capacity and improves functional
class
Attenuation of LV remodeling post MI
Beta-blockers
Limit donkeys speed, thus
saving energy
Symptomatic despite
optimal medical therapy
QRS 130 msec
LVEF 35%
Treatment Strategies of
HF
Aldosterone antagonist:
RALES, serious HF
Angiotensin receptor
blocker: substitute, not
replace
TripleTherapy
TripleThe rapyfor
for
most patients ACE,
B-Blocker and MRA
Heart failure:
More than just drugs.
Dietary counseling
Patient education
Physical activity
Medication compliance
Aggressive follow-up
Sudden death assessment
Questions to determine
therapeutic strategy in CHF
patients
Is heart failure present?
Intra atrial pressure recordings reveal two peaks and two descents. The a waveis the
atrial pressure generated during atrial systole immediately preceding ventricular systole.
The peak atrial pressure recorded during ventricular systole before the tricuspid and
mitral valves open is the v wave.
120 mmHg
80 mmHg
Aortic Pressure