Congestive Heart Failure

Definition

Clinically defined as the inability of the heart at the

normal filling pressures to maintain an output adequate to
meet the metabolic demands of the body.
 Epidemiology
0,4 2 % population in europe has CHF
Half of these population will die in 4 years since dianosed
 Causes of CHF
Common
CHD
Conditions that cause pressure overload (e.g. hypertension, aortic
stenosis)
Idiopathic dilated cardiomyopathy

Less common
Volume overload (e.g. mitral valve regurgitation)
Uncontrolled arrhythmias (e.g. atrial fibrillation (AF)
Thyroid dysfunction (e.g. hyperthyroidism, hypothyroidism)
Other systemic illness (e.g. amyloidosis, sarcoidosis, scleroderma,
haemochromatosis, cryoglobulinaemia)
Pathophysiologi of CHF
Ventricular Remodeling after Infarction (Panel A) and in Diastolic and Systolic Heart Failure
(Panel B)

Jessup M and Brozena S. N Engl J Med 2003;348:2007-2018

 Clinical Manifestations of CHF
SYMPTOMS PHYSICAL SIGNS
Fluid overload Rales
Dyspnea Tachycardia
Orthopnea Displaced PMI
Paroxysmal nocturnal dyspnea S3 (ventricular gallop)
Cardiac asthma S4 (atrial gallop)
Cheyne-Stokes Respiration (aka Pulmonary HTN (loud P2)
cyclic respiration) Neck vein distention
Fatigue, weakness Hepatic enlargement
Exercise intolerance Peripheral edema
Decreased urine output Ascites
Confusion Pleural effusion
Lethargy Cardiac Cachexia
Nocturia Jaundice
Anorexia Skin cold and clammy
Pulsus alternans
 New York Heart Association classification of heart
failure.
Focuses on symptoms

Class I : No limitation of physical activity.

Class II : Slight limitation with ordinary exertion.
Class III : Marked limitation with less than ordinary exertion.
Class IV : Symptoms are present at rest.

ACC/AHA Classification
Emphasizes evolution and progression of heart failure.

Class A: At risk for CHF, but heart is structurally normal.

Class B: Structural abnormality of the heart, never had symptoms
Class C: Structural abnormality; current or previous symptoms.
Class D: End-stage symptoms; refractory to standard treatment.
 Management of Heart Failure

1. General measures
2. Correct underlying cause
3. Remove precipitating cause
4. Prevention of deterioration of
cardiac function
5. Control of congestive HF state

Jessup M and Brozena S. N Engl J Med 2003;348:2007-2018

 Nonpharmacologic therapy
Exercise training for stable HF patients increased exercise capacity,
decreased hospitalization rate, increased quality of life, decreased
symptoms.
Weight loss in obese patients
Dietary Na restriction ( 2 g/day)
Fluid and free water restriction ( 1.5 L/day) especially if hyponatremic
Minimize medications known to have deleterious effects on heart failure
(negative inotrops, NSAIDs, over-the-counter stimulants)
Oxygen
Fluid removal (dialysis, thoracentesis, paracentesis)
Stages of Heart Failure and Treatment Options for Systolic Heart Failure

Jessup M and Brozena S. N Engl J Med 2003;348:2007-2018

Pharmacologic therapy
 Treatment of HF exacerbation:
Parenteral agents

IV Vasodilators
- Nitroglycerine
- Nitroprusside
- Recombinant BNP (nesiritide)

IV Inotropic agents
- Dopamine
- Dobutamine
- PDE inhibitors (amrinone, milrinone)

IV Diuretics
- Furosemide
- Bumetanide
 Other management considerations
Anticoagulation. No RCT. Warfarin therapy may be considered in the
absence of contraindications for patients who are in sinus rhythm and
have EF <30%.

Ventricular resynchronization therapy. Survival benefit in patients

with NYHA class III-IV HF despite optimal medical therapy, who are in
sinus rhythm, have EF 35%, and a prolonged QRS ( 120 msec). CARE-
HF and COMPANION trial.

ICD. Based on the SCD- HeFT trial. Significant benefit in NYHA class II -
III HF and EF 35%. Class IV patients have not been studied.

Mechanical circulatory support.

Cardiac transplantation.
 Complication
Pleural efusion
Arhytmia
Atrial fibrilation
Ventrikel fibrilation