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Heart Failure Abdullah Saadah K.J.B

28 / 10 / 2009

Heart Failure
To define the heart failure we have to concepts: Low output heart failure High output heart failur The low output heart failure is the most commonly seen; so when we define heart failure we mean the low output heart failure in that the myocardium fails to eject adequate blood for the bodys requirements or to meet the oxygen requirement of the bodys tissues. The high output HF is rare in that the blood output is enough and normal to meet the bodys demands but the tissues and the organs need for more blood than the normal or usual oxygen. The high output heart failure occurs in some diseases such as thyrotoxycosis, Paget disease of bone (in that the bones become weaker and there are multiple fractures; with healing lead to formation of new blood vessels, and with the connection of these vessels multiple AV fistulas are formed that leads to high output heart failure to meet these fistulas), large fistula created for dialysis, very rarely vasodilator drugs in large doses and beriberi disease (vitamin B1 deficiency) in alcoholic pt. they will have sever anemia (any anemia when it is sever can cause high output HF).

There is another HF that classifieds neither high nor low output HF in that the cells fail to utilize the oxygen from the blood. In case of gram negative septicemia.

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Types of Heart Failure:

Left heart failure: Right heart failure: rarely occurs alone; however, the most common cause of right HF is left HF in that long standing left HF causes pulmonary hypertension that leads to right HF. other causes are: congenital anomalies of the heart like tricuspid atresia and sever pulmonary stenosis, in adult it may be caused by cor pulmonale* and recurrent pulmonary embolism. Congestive heart failure: left HF and right HF together. Less commonly ( Forward or Backward heart failure) Acute heart failure: when there is acute overload to the left ventricle and the left ventricle does not have a time to accommodate for this overload. The overload can be systolic or diastolic: Systolic: like in hypertension and aortic stenosis. Diastolic: like in aortic and mitral regurgitation and PDA The response of the myocardium to the systolic overload is by hypertrophy, but for the diastolic is by the dilatation or hyperplasia increase the number of the myocyte the systolic overload with time will become like diastolic overload increase the myocytes number.
LEFT VENTRICLE CARRIED 90% OF THE HEART FUNCTION ; WHILE RV CARRIED LESS THAN 10%.

Cor pulmonale:
Right HF caused by chronic pulmonary hypertension Causes include: chronic lung diseases like asthma and COPD, pulmonary vascular diseases and neuromuscular and skeletal diseases

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Examples of acute heart failure is when suddenly the infected endocarditis damage the aortic or mitral valve that will lead to aortic or mitral valve regurgitation; and that will lead to diastolic overload, so the pressure of this sudden overload will conducted back to the left atrium and back to the pulmonary veins and to pulmonary capillaries, and when this pressure reach more than 25-30mmHg leads to transudation from the capillaries to the alveoli acute pulmonary edema. Other example: stunning trauma, car accidents and acute MI; but the last one cause acute HF in the 3 or 4th day of the MI Chronic heart failure
ed

Causes of left heart Failure:

Ischemic heart disease most common(coronary artery diseases) Hypertensive heart disease Cardiomyopathy Valvular heart disease Rheumatic heart disease Congenital heart disease ( i.e HOCM and VSD ) All of these causes by time can cause right HF

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Causes of Right Heart Failure:

Mitral Stenosis With pulmonary Hypertenion Primary pulmonary hypertension: in certain entity occur in young female Secondary pulmonary hypertension: occur in chronic pulmonary diseases like COPD, asthma, lung fibrosis and bronchiectasis Pulmonary embolism Certain congenital heart disease affecting the right side (i.e pulmonary stenosis,ASD with reversed shunt, Tricuspid atresia, Ebstein anomaly,RV dysplasia) most of congenital heart diseases cause Right HF Corpulmonale

Causes of Congestive Heart Failure

All causes of LV failure When They develop Pulmonary Hypertension (as we said before); so that the beginning of HF is left HF, with time it develops pulmonary HT that leads to Right HF (LHF + RHF congestive HF), with time more than 8 years it will become RHF only haa eza al 3aiesh

Precipitating causes of Heart Failure:

These are not causes of heart failure, the causes we discussed them previously, and these are the precipitating factors; so we should ask: why the pt. come with HF??, what is the underlying causes of his

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HF??; and we should eliminate these causes.. give medication is not enough to treat the HF;;; Cardiac Arrhythmias Pulmonary Embolism Hypertensive Crises Chest Infection Drugs like -blocker Excessive Salt Fluid Overload Pregnancy Thyrotoxicosis Anaemia if we give the anaemic pt. with HF all the medication of the HF; we cant treat him unless we correct the Hb level.

Symptoms of Left Heart Failure:

Dyspnoe ( Exertional , PND , Orthopnoe ) Fatigue Nocturia PND is related to the posture of the pt, when the pt is laying down, the return blood to the heart increase, and this pressure transmitted to the lungs, and that will lead to transudation of the fluid to the alveoli; the pt. will weak up and run to the window or sleep at the edge of the bed to relieve the pressure. But if this pressure is

We should diff. between nocturia, polyuria and frequency Nocturia: look at the text. Polyuria: large amount of urine, or large passage of urine. Frequency: increase num. of urination, may be due to inflammation the bladder wall

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sever and prolong for long time the pt. will go to the hospital, at this moment we call it pulmonary oedema; so the pulmonary oedema is (sever sudden onset of left ventricular HF) Fatigue is not clear manifestation of LV HF, but it is clear for RV HF. because the RV HF occur in end stage HF as we said when the ejection fraction is less than 22%(so that the O2 to the tissues is very little fatigue), but in LV HF it around 55-75%. As we now urination is more in day light than night (3:1), but when occur the opposite (urination more in night 1:3); so this is called nocturia; and we should consider the drinking habits and the season in which we are. This noctutia that occur with LF HF is an isolated nocturia and not related to polyuria that caused by hypercalcimia or DM or uremia Note: isolated nocturia occur only in three cases early stage of LV HF, acute renal failure and component of enuresis incontinency at night .

Signs of Left Heart Failure

Dyspnoe Signs Of Cardiac Dilatation OR Hypertrophy ( Hyperdynemic or Sustained Apex beat ) Third Heart Sound S3 ,Pulsus Alternans Sinus Tachycardia Lung Crepitations Or Pleural Effusions: depend on the severity of the HF Signs Of The Underlying Cause: murmur of the mitral or aortic regurgitation, or additional sounds.

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Symptoms of RT Heart Failure: (pure RT HF)

Fatigue Dependent Oedema Enlarged Congested Liver Anorexia And Abdominal Distension Simply, the Rt HF causes systemic symptoms but Lt HF causes pulmonary symptoms. In congestive HF the pt. complains of the both symptoms and signs of Lf & Rt HF

Signs OF RT Heart Failure

High JVP With Positive Hepato Jugular Reflux Dependent Oedema Ascites Pleural Effusions Tricuspid Regurgitation Murmurs Signs Of The Underlying Cause

Diagnosis Of Heart Failure:

History Signs Chest X-RAY
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In our book, they wrote that the echocardiography as diagnostic technique for HF. but the doctor said that is wrong . And he said that the echocardiography is so important in assessment of pt. with HF, in that it give us a lot of information like: the dimension of the heart chambers, functional reserved of Rt ventricle, aortic or mitral regurgitation and wall abnormalities So that the echocardiography has a lot of uses but has no diagnostic function of HF at all. So in diagnosis of HF we only depend on the history, sign and chest X-ray

Investigations
Chest X-RAY ECG Echocardiography CBC (looking for anaemia, polycythemia ),Renal Profile(nephropathy, proteinuria , DM), FBS(fasting blood sugar), Lipids, ABGs (not for every pt. but who has cyanosis or pulmonary edema or who is not be fine after the medication of HF we do to him arterial blood gases test; for investigate the underlying cause)

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Treatment Of Heart Failure:

Bed Rest (Acute Stage) ,Later On Decreased Physical Activity Oxygen Therapy for 2 days, but if not cure we do ABGs for investigate of other causes like COPD Low Salt Diet Treatment Of The Precipitating Cause Treatment Of The Underlying Cause Diuretics Spironolactone ACE Inhibitors Beta blockers (Under Certain Conditions ) selective 1 blokers, and they are used after the control of the acute HF Digitalis in end stage of the HF Anticoagulation prevent the formation of clot Implantable ICD Cardiac Transplantation

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