Professional Documents
Culture Documents
Ali Aspar
Mappahya
Cardiology Department, Medical Faculty, Hasanuddin University
INTRODUCTION
Signs typical of HF :
(tachycardia, tachypnea, pulmonary rales, pleural effusion
raised jugular venous pressure, peripheral edema,
hepatomegaly).
Hypertension
Diabetes Mellitus Alcohol abuse
Dyslipidemia Smoking
Valvular heart disease Collagen vascular
Coronary artery disease disease
Myopathy Thyroid disorder
Rheumatic fever Pheochromocytoma
Mediastinal radiation Old age
Sleep apnea disorders Metabolic
Exposure to cardiotoxin syndrome
agents
PRECIPITATING FACTORS OF
HEART FAILURE
1. Infections
2. Brady-or tachyarrhythmia
3. Myocardial ischemia or infarction (MI)
4. Physical or emotional stress
5. Pulmonary embolism
6. High-output states such anemia,
thyrotoxicosis, Pagets disease, pregnancy,
beriberi and A-V fistula
7. Cardiac infection and inflammation
(myocarditis, infective endocarditis)
8. Comorbidities (renal, liver, thyroid, respiratory
insufficiency)
9. Cardiac toxin (chemotherapy, cocain, alcohol
Pathophysiology
of Heart Failure
Relationship between end-diastolic
volume and stroke volume in normal and
failing myocardium
Pathophysiology of
Chronic Heart Failure
Vasodilating and
growth inhibiting
Vasoconstricting and Natriuretic peptides
growth promoting Bradykinin
Norepinephrine Nitric oxide/EDHF
Angiotensin II Prostaglandins
Endothelins
Arginine vasopressin Improve hemodynamics,
prevent remodeling
Worsen hemodynamics,
progressive remodeling
500 250
12
6 6
400 200
9
Levels
300 4 150 4
6
200 100
2 2
100 3 50
0 0 0 0 0
NL HF NL HF NL HF NL HF NL HF
Cohn 1997.
Obesity
Diabetes
LVH
Diastolic
Dysfunction
Hypertension
CHF Death
Systolic
MI Dysfunction
Smoking
Dyslipidemia
Diabetes
Normal LV LV Subclinical
Overt HF
structure and function remodelling LV dysfunction
forward effects
backward effects
symptoms
signs
NYHA Functional Classification of HF
Severity based on symptoms and physical activity
A
High Risk For Hypertension, Diabetes Mellitus, CAD,
Developing Heart Family History of Cardiomyopathy
Failure
Hypotension
BACKWAR
D EFFECTS
1.DEMOGRAPHICS: 2. CLINICAL:
- Advanced aged* - Hypotension*
- Ischemic etiology* - NYHA class III_IV*
- Resuscitated- - Recent HF-
sudden death* hospitalization*
- Poor compliance - Tachycardia
- Renal dysfunction - Pulmonary rales
- Diabetes - Aortic stenosis
- Anemia - Low BMI
- COPD - Sleep related
- Depression breathing disorders
* = powerful predictors
CONDITIONS ASSOCIATED
3. ELECTROPHYSIOLOGICAL:
- Tachycardia 4. FUNCTIONAL/
- Q-waves EXERTIONAL:
- Wide QRS* - Reduced work
- LVH - Low peak VO2*
- Complex ventricular- - Poor 6 minutes-
arrhythmias* walk distance
- Low HR variability - High VE/VCO2-
- T-wave alternans slope
- Atrial fibrillation (AF) - Periodic breathing
* = powerful predictors
CONDITIONS ASSOCIATED
5. LABORATORY: 6. IMAGING:
- Marked elevation of BNP/ - Low LVEF*
NT-pro BNP* - Increased LV vol.
- Hyponatremia* - Low cardiac index
- Elevated troponin* - High LV filling-
- Elevated biomarkers, pressure
neurohumoral activation* - Restrictive mitral-
- Elevated creatinine/ filling pattern
BUN - Pulmonary htn.
- Elevated bilirubin - Impaired RV -
- Anemia function
- Elevated uric acid
* = powerful predictors
EVOLUTION OF
CLINICAL STAGES
NORMAL
NORMAL
No
Asymptomati
Asymptomati
No symptoms
symptoms
Normal exercise c
Normal exercise c LV
LV
Normal
Normal LV
LV fxn
fxn Dysfunction
Dysfunction
No symptoms
No symptoms
Normal
Compensate
Compensate
Normal
exercise
exercise d
d CHF
CHF
Abnormal
AbnormalLV
fxn
LVNo Decompensat
Decompensat
symptoms
No symptoms
fxn Exercise
Exercise
ed
ed CHF
Abnormal
Abnormal LVLV CHF
fxn
fxn Refracto
Refracto
Symptoms
Symptoms
Exercise
Exercise
ry
ry CHF
CHF
Abnormal
Abnormal LV
LV
fxn
fxn Symptoms
Symptoms notnot
controlled
controlled with
with
treatment
treatment
MANAGEMENTOFCARDIACFAILURE
Rhythm control :
Electrical cardioversion is recommended when the rapid ventricular
response does not respond promptly to appropriate pharmacological
measures, especially in patients with AF causing myocardial ishemia,
symptomatic hypotension or symptom of pulmonary congestion.
VENTRICULAR ARRHYTHMIAS (VA)
It is essential to detect, and if possible, correct all potential factors
precipitating ventricular arrhythmias. Neurohumoral blockade with
optimal doses of BB, ACEI, ARB and/or aldosterone blockers is
recommended.
There are significant overlap in the signs and symptoms with a relatively
lower sensitivity of diagnostic tests such as Chest X-ray, ECG,
echocardiography and spirometry.
It is essential to detect and treat pulmonary congestion.
Agents with documented effect on morbidity and mortality sych as ACEI,
BB and ARBs are recommended in patients with co-existing pulmonary
disease.