Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic

Heart Failure) or to fill with blood (Diastolic Heart Failure).

Approximately 4.9 million people have CHF More than 550,000 cases detected annually Account for 5 to 10% of all hospitalizations 250,000 deaths per year related to CHF Five year mortality as high as 60% in men & 45% in women Median survival is 3.5 years for men and 5.4 years women for

Low-Output Heart Failure

Systolic Heart Failure:

Decreased cardiac output Decreased Left ventricular ejection fraction

Diastolic Heart Failure:

Elevated Left and Right ventricular end-diastolic pressures May have normal LVEF Seen with peripheral shunting, low-systemic vascular resistance, hyperthryoidism, beri-beri, carcinoid, anemia Often have normal cardiac output Seen with pulmonary hypertension, large RV infarctions.

High-Output Heart Failure

Right-Ventricular Failure

Systolic Dysfunction
Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) Ischemic heart disease, perpartum, hypertension, HIV, connective tissue disease, substance abuse, doxorubicin

Hypertension Valvular Heart Disease

Diastolic Dysfunction

Hypertension Coronary artery disease Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy

Due to excess fluid accumulation:

Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)

Due to reduction in cardiac ouput:

Fatigue (especially with exertion( Weakness

S3 gallop

Low sensitivity, but highly specific Have sinus tachycardia, diaphoresis and peripheral vasoconstriction

Cool, pale, cyanotic extremities

Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI
Apical impulse that is laterally displaced past the midclavicular line is

usually indicative of left ventricular enlargement>

CBC

Since anemia can exacerbate heart failure before starting high dose diuretics

Serum electrolytes and creatinine Fasting Blood glucose Thyroid function tests Iron studies ANA
To evaluate for possible diabetes mellitus Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF. To screen for hereditary hemochromatosis as cause of heart failure. To evaluate for possible lupus If viral mycocarditis suspected

Viral studies

BNP
With chronic heart failure, atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures Usually is > 400 pg/mL in patients with dyspnea due to heart failure.

Cardiomegaly Cephalization of the pulmonary vessels Kerley B-lines Pleural effusions

Electrocardiogram:

May show specific cause of heart failure:

Ischemic heart disease Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular block Amyloidosis: pseudo-infarction pattern Idiopathic dilated cardiomyopathy: LVH

Echocardiogram:
Left ventricular ejection fraction Structural/valvular abnormalities

Exercise Testing

Should be part of initial evaluation of all patients with CHF. Should be performed in patients presenting with heart failure who have angina or significant ischemia Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina. Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.

Coronary arteriography

Endomyocardial biopsy
Not frequently used Really only useful in cases such as viral-induced

cardiomyopathy

Major

Minor

Bilateral leg edema Paroxysmal nocturnal dyspnea Nocturnal cough Orthopnea Dyspnea on ordinary exertion Hepatomegaly Elevated jugular venous Pleural effusion pressure Tachycardia (heart rate 120 Pulmonary rales beats/min) Third heart sound Weight loss 4.5 kg in five days Cardiomegaly on chest xray Pulmonary edema on chest x-ray Weight loss 4.5 kg in five days in response to Diagnosis: treatment of presumed 2 major or 1 major and 2 minor criteria cannot be attributed to another medical condition. heart failure

New York Heart Association (NYHA)

Class I symptoms of HF only at levels that would limit normal individuals. Class II symptoms of HF with ordinary exertion Class III symptoms of HF on less than ordinary exertion Class IV symptoms of HF at rest

ACC/AHA Guidelines
Stage A High risk of HF, without structural heart disease or symptoms Stage B Heart disease with asymptomatic left ventricular dysfunction Stage C Prior or current symptoms of HF Stage D Advanced heart disease and severely symptomatic or refractory HF

Correction of systemic factors

Thyroid dysfunction Infections Uncontrolled diabetes Hypertension

Lifestyle modification
Lower salt intake Alcohol cessation Medication compliance

Maximize medications

Discontinue drugs that may contribute to heart failure (NSAIDS, antiarrhythmics, calcium channel blockers)

1. 2. 3. 4. 5. 6.

Loop diuretics ACE inhibitor (or ARB if not tolerated) Beta blockers Digoxin Hydralazine, Nitrate Potassium sparing diuretcs

Loop diuretics
Furosemide, buteminide For Fluid control, and to help relieve symptoms

Potassium-sparing diuretics
Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF

Improve survival in patients with all severities of heart failure. Begin therapy low and titrate up as possible:
Enalapril 2.5 mg po BID Captopril 6.25 mg po TID Lisinopril 5 mg po QDaily

If cannot tolerate, may try ARB

Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV. Contraindicated:
Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma PR interval > 0.24 sec, 2nd or 3rd degree block

Dosing:

Hydralazine
Started at 25 mg po TID, titrated up to 100 mg po TID

Isosorbide dinitrate
Started at 40 mg po TID/QID

Decreased mortality, lower rates of hospitalization, and improvement in quality of life.

Given to patients with HF to control symptoms such as fatigue, dyspnea, exercise intolerance Shown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality.

Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease. Some studies have shown a possible benefit specifically in HF with statin therapy
Improved LVEF Reversal of ventricular remodeling Reduction in inflammatory markers (CRP, IL-6,

TNF-alphaII)

NSAIDS
Can cause worsening of preexisting HF

Thiazolidinediones
Include rosiglitazone (Avandia), and pioglitazone (Actos) Cause fluid retention that can exacerbate HF

Metformin
People with HF who take it are at increased risk of potentially lethic lactic acidosis

Sustained ventricular tachycardia is associated with sudden cardiac death in HF. About one-third of mortality in HF is due to sudden cardiac death. Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.

Inotropic drugs:

Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin

Mechanical circulatory support:

Intraaortic balloon pump Left ventricular assist device (LVAD)

Cardiac Transplantation

A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.

Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress. Characterized by the transudation of excess fluid into the lungs secondary to an increase in left atrial and subsequently pulmonary venous and pulmonary capillary pressures.

Causes:
Acute MI Rupture of chordae tendinae/acute mitral valve insufficiency Volume Overload Transfusions, IV fluids Non-compliance with diuretics, diet (high salt intake) Worsening valvular defect Aortic stenosis

Symptoms
Severe dyspnea Cough

Clinical Findings

Tachypnea Tachycardia Hypertension/Hypotension Crackles on lung exam Increased JVD S3, S4 or new murmur

Chemistry, CBC EKG Chest X-ray May consider cardiac enzymes 2D-Echo

Treatment
Strict Is and Os, daily weights Oxygen, mechanical ventilation if needed Loop diuretics Morphine Vasodilator therapy (nitroglycerin) (BNP) can help in acute setting, for short term therapy