Heart Failure


Definition

Heart failure is a state in which the ventricle at normal filling pressures can’t maintain an adequate cardiac output to meet the metabolic needs of peripheral tissues or can do so only with an elevated filling pressure.

PATHOPHYSIOLOGY

– It is characterized by decrease in cardiac output. In heart failure, preload is increase, afterload is increase and myocardial contractibility is decrease.

TYPES OF HEART FAILURE(HF)

–  Acute and chronic heart failure.
–  High output and low output heart failure.
–  Left, right sided and biventricular heart failure.
–  Forward and backward heart failure.
–  Systolic and diastolic heart failure.

CAUSES

1 PRESSURE OVERLOAD OF VENTRICLE
– Systemic HTN
– Pulmonary HTN
– Aortic stenosis
– Pulmonary stenosis

2 VOLUME OVERLOAD OF VENTRICLE
– Mitral regurgitation
– Aortic regurgitation
– VSD
– ASD

3 INFLOW OBSTRUCTION OF VENTRICLE
– Mitral stenosis
– Tricuspid stenosis
– Endomyocardial fibrosis.

4 IMPAIRED VENTRICLE FUNCTION
– Myocarditis
– Cardiomyopathy
– MI.

CLINICAL FEATURES

  • Dyspnea– Initially on exertional. But on progress even at rest.
  • Orthopnea.
  • PND ( Paroxysmal nocturnal dyspnea).
  • Cardiac asthma- Characterized by wheezing secondary to bronchospasm prominent at night. Acute pulmonary edema. Severe form elevate pulmonary pressure leading to alveolar edema. Characterized by severe breathlessness, cough with copious, pinkish, frothy expectoration.
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  • Cheyne strokes respiration- Periodic breathing with alternate periods of apnea and hyperventilation seen in advanced heart failure.
  • Nocturia – It is feature of early heart failure.
  • Cerebral symptoms– Confusion, difficulty in concentration. Memory impairment:) headache, insomnia and anxiety.
  • Non specific symptoms– Fatigue and weakness, Low grade fever, Anorexia, nausea, abdominal pain.
  • Cardiac edema– Due to gravity, cardiac edema accumulates over dependent parts. In advanced stages, there is anasarca.
  • Cyanosis – Mainly affects lip and nail beds.
  • Pulse – Sinus tachycardia. Pulsus alterance is the sign of severe heart failure.
  • BP – Decrease due to reduced stroke volume. Hypotension is prominent in acute heart failure.
  • JVP – Raised.
  • Heart sounds– 3rd heart sounds in an adult is suggestive of heart failure.
  • Respiratory System – Dull percussion note over the lung bases. Inspiratory crepitation over lung base.
  • Liver – Right upper quadrant pain from stretching of the capsule of the liver. Liver is enlarge and tender. Jaundice is late feature.
  • Kidney – Oliguria, Prerenal azotemia.
  • Cardiac cachexia.

INVESTIGATION

1 CHEST x ray – may shows cardiomegaly.
– Prominence of upper lobe veins.
– Kerley A and B lines.
– Other feature of pulmonary edema.
2 ECG.
3 ECHOCARDIOGRAPHY
4 EXERCISE STRESS TESTING

MANAGEMENT OF HEART FAILURE

1 Physical and emotional rest.
2 Correction of obesity
3 ACE inhibitors in all patients – Captopril 6.25 mg tid
 – Enalapril 2.5 mg/day
 – Lisinopril 2.5 mg/day
4 Beta blocker in all patients- Carvedilol 3.125 mg/day
 – Bisoprolol 1.25 mg /day
5 Diuretics use if patient has volume overload
 – Furosemide 20-60 mg PO, IV, IM
 – Spironolactone 50-200 mg PO
6 Digoxin – Loading dose 0.25-0.5 mg orally or IV followed by 0.25 mg 6 hrly to dose of 1- 1.5 mg
– Maintenance dose 0.125-0.375 orally.
7 Aldosterone receptor blockage with spironolactone is recommended for patients who remain severely symptomatic despite appropriate doses of ACE inhibitors and diuretics.
8 Vasodilators
9 Restriction of sodium intake.
10 Mechanism of removal of fluid by thoracentesis, paracentesis and dialysis use in severe case.