Transcript when your heart is weak

Heart Failure
Definition
Heart failure (HF) can be defined as a clinical
syndrome that is based on abnormal structure or
function of the heart and clinical symptoms and
signs of heart failure such as dyspnea, fatigue and
fluid retention. Chronic heart failure (CHF) is a
common condition that is responsible for a large
number of death and considerable morbidity and
cost.
Description

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HF can occur in people of any age, even in young children
(especially those born with a heart defect).
But, it is much more common among older people, because
older people are more likely to have disorders that damage
the heart muscle and because age-related changes in the
heart tend to make the heart pump less efficiently.
HF develops in about 1 of 100 people. The disorder is likely
to become more common because people are living longer
and because, in some countries, certain risk factors for heart
disease (such as smoking, high blood pressure, and a highfat diet) are affecting more people.Abdominal obesity
Description

HF does not mean that the heart has stopped, as
some people mistakenly believe; it means that the
heart cannot keep up with the work required of it
(its workload).
 But this definition is remarkably simplified. Heart
failure is extremely complex, and no simple
definition can encompass its many causes, aspects,
forms, and consequences.
Description
The function of the heart is to pump blood.
Pumping has two aspects:
-to move a fluid into something (the heart pumps blood
into the arteries)
-to move a fluid out of something (the heart moves blood
out of the veins, as a sump pump moves water out of a
basement).
 HF develops when the pumping action of the heart is
inadequate. As a result, blood flow to body tissues is
reduced and blood returning to the heart accumulates,
causing congestion in the veins.
 That is why HF is also known as congestive heart
failure.
Description
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Accumulation of blood coming into the left side of the
heart (from the lungs causes congestion in the lungs,
impairing lung function and making breathing
difficult.
Accumulation of blood coming into the right side of
the heart (from the rest of the body) causes congestion
in other parts of the body, including fluid
accumulation (edema) in the legs and enlargement of
organs such as the liver.
HF usually affects both the right and left sides of the
heart to some degree. But, one side may be affected
more than the other. In such cases, HF may be
described as right-sided heart failure or left-sided
heart failure.
HF: Pumping and Filling
Problems
Normally, the heart stretches as it fills with blood (during
diastole), then contracts to pump out the blood (during
systole).
HF: Pumping and Filling
Problems
HF due to systolic dysfunction usually develops
because the heart cannot contract normally. It may fill
with blood, but it cannot pump out as much of the
blood it contains because the muscle is weaker. As a
result, the amount of blood pumped to the body and to
the lungs is reduced, and the heart, particularly the left
ventricle, usually enlarges.
HF: Pumping and Filling
Problems
HF: Pumping and Filling
Problems
HF due to diastolic dysfunction develops because the
heart's walls stiffen and may thicken so that the heart
cannot fill normally with blood. Consequently, blood
backs up in the left atrium and lung (pulmonary)
blood vessels and causes congestion. Nonetheless, the
heart may be able to pump out a normal percentage of
the blood it receives.
HF: Pumping and Filling
Problems
Pathogeny
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In HF, the heart cannot pump enough blood to meet the body's
need for oxygen and nutrients, which are supplied by the blood.
As a result, arm and leg muscles may tire more quickly, and the
kidneys may not function normally. Blood pressure in the
arteries normally enables the kidneys to filter fluid and waste
products from the blood into the urine.
When the heart cannot pump adequately, blood pressure falls and
the kidneys malfunction: The kidneys cannot remove excess
fluid from the blood.
As a result, the amount of fluid in the bloodstream increases, and
the workload of the failing heart increases, creating a vicious
circle. Thus, HF becomes even worse.
Pathogeny
HF has two main forms:


Systolic dysfunction (which is more common)
In systolic dysfunction, the heart contracts less forcefully and
cannot pump out as much of the blood that is returned to it as it
normally does. As a result, more blood remains in the lower
chambers of the heart (ventricles). Blood then accumulates in the
veins.
Diastolic dysfunction
In diastolic dysfunction, the heart is stiff and does not relax
normally after contracting. Even though it may be able to pump a
normal amount of blood out of the ventricles, the stiff heart does
not allow as much blood to enter its chambers from the veins. As
in systolic dysfunction, the blood returning to the heart then
accumulates in the veins.
Often, both forms of heart failure occur together.
Causes
Any disorder that directly affects the heart can lead to
HF, as can some disorders that indirectly affect the
heart.
 Some disorders cause HF quickly; others do so only
after many years.
 Some disorders cause systolic dysfunction, impairing
the heart's ability to pump out blood, and others cause
diastolic dysfunction, impairing the heart's ability to
fill with blood.
 Some disorders, such as high blood pressure and
heart valve disorders, can cause both types of
dysfunction.

COMMON CAUSES OF HEART
FAILURE
Coronary artery disease
 Hypertensive cardiovascular disease
 Diabetes mellitus plus hypertension
 Valvular heart disease
 Dilated cardiomyopathy
 Infiltrative cardiomyopathy
 Myocardial hypertrophy

Systolic Dysfunction
Disorders that cause systolic dysfunction may
impair the entire heart or one area of the heart. As
a result, the heart does not contract normally.
 Coronary artery disease is a common cause of
systolic dysfunction. It can impair large areas of
heart muscle because it reduces the flow of
oxygen-rich blood to the heart muscle, which
needs oxygen for normal contraction. Blockage of
a coronary artery can cause a heart attack, which
destroys an area of heart muscle. As a result, that
area can no longer contract normally.

Systolic Dysfunction
Heart valve disorders - narrowing (stenosis) of a
valve, which hinders blood flow through the heart, or
leakage of blood backward (regurgitation) through a
valve—can cause heart failure.
 Both stenosis and regurgitation of a valve can
severely stress the heart, so that over time, the heart
enlarges and cannot pump adequately.
 An abnormal connection (septal defects between
the heart chambers can allow blood to recirculate
within the heart, increasing the workload of the
heart, and thus can cause heart failure.

Systolic Dysfunction
 Myocarditis
(inflammation of heart muscle)
caused by a bacterial, viral, or other infection
can damage all or part of the heart muscle,
impairing its pumping ability.
 Disorders that affect the heart's electrical
conduction system, producing changes in
heart rhythms, (especially if heartbeats are
fast or irregular), can cause HF. When the heart
beats abnormally, it cannot pump blood
adequately.
Systolic Dysfunction
Some lung disorders, such as pulmonary
hypertension, may alter or damage blood vessels
in the lungs.
 As a result, the heart has to work harder to pump
blood into the arteries that supply the lungs
(pulmonary arteries).
 Pulmonary hypertension may lead to cor
pulmonale. In this disorder, the right ventricle,
which pumps blood to the lungs, becomes
enlarged, eventually resulting in right-sided heart
failure.

Systolic Dysfunction
Sudden, usually complete blockage of a pulmonary
artery by several small blood clots or one very large
clot (pulmonary embolism) also makes pumping
blood into the pulmonary arteries difficult.
 A very large clot can be immediately life threatening.
 The increased effort required to pump blood into the
blocked pulmonary arteries can cause the right side of
the heart to enlarge and may cause the walls of the
right ventricle to thicken, resulting in right-sided heart
failure.

Systolic Dysfunction
Disorders that indirectly affect the heart's pumping
ability include a deficiency of red blood cells or
hemoglobin (anemia), an overactive thyroid gland
(hyperthyroidism), an under active thyroid gland
(hypothyroidism), and kidney failure.
 Red blood cells contain hemoglobin, which enables
them to carry oxygen from the lungs and deliver it to
body tissues. Anemia reduces the amount of oxygen
the blood carries, so that the heart must work harder
to provide the same amount of oxygen to tissues.
(Anemia has many causes, including chronic
bleeding due to a stomach ulcer).

Systolic Dysfunction
An overactive thyroid gland over stimulates the
heart, so that it pumps too rapidly and does not
empty normally during each heartbeat. When the
thyroid gland is under active, levels of thyroid
hormones are low. As a result, all muscles, including
the heart, become weak because muscles depend on
thyroid hormones to function normally.
 Kidney failure strains the heart because the kidneys
cannot remove excess fluid from the bloodstream, so
the heart has to pump more blood. Eventually, the
heart cannot keep up, and heart failure develops.

Diastolic Dysfunction
Inadequately treated high blood pressure is the most
common cause of diastolic dysfunction.
 High blood pressure stresses the heart because the
heart must pump blood more forcefully than normal to
force blood into the arteries against the higher
pressure.
 Eventually, the heart's walls thicken (hypertrophy),
then stiffen. The stiff heart does not fill quickly or
adequately, so that with each contraction, the heart
pumps less blood than it normally does.

Diastolic Dysfunction
 As
people age, the heart's walls also tend to
stiffen.
 The combination of high blood pressure, which
is common among older people and age-related
stiffening, makes HFparticularly common
among older people.
 In constrictive pericarditis, the sac that
envelops the heart (pericardium) stiffens,
preventing even a healthy heart from pumping
and filling normally.
Diastolic Dysfunction
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HF may result from disorders that cause the heart's walls to
stiffen, such as infiltrations and infections.
In amyloidosis, amyloid, an unusual protein not normally
present in the body, infiltrates many tissues in the body. If
amyloid infiltrates the heart's walls, they stiffen, and HF
results.
In tropical countries, infiltration by certain parasites into
heart muscle can cause HF, even in young people.
Some heart valve disorders, such as aortic valve stenosis,
hinder blood flow out of the heart. As a result, the heart
muscle has to work harder and thickens, and diastolic
dysfunction develops initially. Eventually, systolic
dysfunction also develops.
Compensatory Mechanisms
The body has several mechanisms to compensate for
HF.
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The body's first response to stress, including that due to HF, is to
release the fight-or-flight hormones, epinephrine (adrenaline)
and norepinephrine (noradrenaline).
These hormones may be released immediately after a heart
attack damages the heart. Epinephrine and norepinephrine cause
the heart to pump faster and more forcefully.
They help the heart increase the amount of blood pumped out
(cardiac output), sometimes to a normal amount, and thus help
compensate partially and temporarily for the heart's impaired
pumping ability.
Compensatory Mechanisms
People who do not have heart disease usually benefit
from release of these hormones when more work is
temporarily required of the heart.
 But for people who have chronic HF, this response
results in increased demands on an already damaged
heart. Over time, the increased demands lead to
further deterioration of heart function.

Compensatory Mechanisms
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Another of the body's main compensatory mechanisms for HF is
to decrease the amount of salt and water excreted by the
kidneys. Retaining salt and water instead of excreting it into
urine increases the volume of blood in the bloodstream and
helps maintain blood pressure.
The larger volume of blood also stretches the heart muscle,
enlarging the heart chambers, particularly the ventricles, which
pump blood out of the heart.
The more the heart muscle is stretched, the more forcefully it
contracts.
At first, this mechanism improves heart function, but after a
point, stretching no longer helps but instead weakens the heart's
contractions (as when a rubber band is overstretched).
Consequently, HF worsens.
Compensatory Mechanisms
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Another important compensatory mechanism is enlargement
of the muscular walls of the ventricles (ventricular
hypertrophy).
When the heart must work harder, the heart's walls enlarge
and thicken, as biceps muscles enlarge after months of weight
training.
At first, the thickened heart walls can contract more
forcefully. But the thickened heart walls eventually become
stiff, worsening diastolic dysfunction. Eventually, the
contractions become weaker, causing systolic dysfunction.
Symptoms
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Symptoms of HF may begin suddenly, especially if the
cause is a heart attack. But, in most people, symptoms
develop over days to months. The disorder may stabilize
for periods of time but often progresses slowly and
insidiously.
People with HF feel:
tired and weak when performing physical activities,
because their muscles are not receiving enough blood. In
older people, HF sometimes causes vague symptoms such
as sleepiness, confusion, and disorientation, as well as
weakness and fatigue.
Right-sided heart failure
Symptoms
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The main symptoms of right-sided heart failure are fluid
accumulation and swelling (edema) in the feet, ankles, legs,
liver, and abdomen.
Where the fluid accumulates depends on the amount of excess
fluid and the effects of gravity.
If a person is standing, fluid accumulates in the legs and feet.
If a person is lying down, fluid usually accumulates in the lower
back.
If the amount of fluid is large, fluid also accumulates in the
abdomen.
Fluid accumulation in the liver or stomach can cause nausea and
loss of appetite.
Eventually, food is not absorbed well, resulting in loss of weight
and muscle.This condition is called cardiac cachexia.
Left-sided heart failure
Symptoms
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Left-sided HF leads to fluid accumulation in the lungs,
which causes shortness of breath. At first, shortness of
breath occurs only during exertion, but as HF progresses, it
occurs with less and less exertion and eventually occurs
even at rest.
People with severe left-sided HF may be short of breath
when lying down (a condition called orthopnea, because
gravity causes more fluid to move into the lungs.
Such people often wake up, gasping for breath or wheezing
(a condition called paroxysmal nocturnal dyspnea).
Sitting up causes some of the fluid to drain to the bottom
of the lungs, making breathing easier. Eventually, leftsided HF causes right-sided HF.
Left-sided heart failure
Symptoms
 A sudden
accumulation of a large amount of
fluid in the lungs (acute pulmonary edema)
causes extreme difficulty breathing, rapid
breathing, bluish skin, and feelings of
restlessness, anxiety, and suffocation. Some
people have severe spasms of the airways
(bronchospasms) and wheezing; this condition
is called cardiac asthma, which resembles
asthma but has a different cause. Acute
pulmonary edema is a life-threatening
emergency.
SIGNS OF HF
ON PHYSICAL EXAMINATION
Left HF and pulmonary venous congestion:
Pulmonary rales
 Decreased breath sounds
 Dullness to percussion
 Third heart sound
 Displaced apical impulse

SIGNS OF HF
ON PHYSICAL EXAMINATION
Right HF and systemic venous congestion:
 Peripheral edema
 Elevated jugular venous pressure, prominent v
wave and steep y descent
 Hepatojugular reflux Hepatomegaly
 Ascites
 Right-sided third heart sound
 Left parasternal heave
SIGNS OF HF
ON PHYSICAL EXAMINATION
Low cardiac output
Tachycardia
 Pulsus alternans
 Decreased pulse pressure
 Hypotension

Diagnosis
Doctors usually suspect HF on the basis of symptoms alone.
 The diagnosis is supported by the results of a physical
examination, including
- a weak,
- often rapid pulse,
- reduced blood pressure,
- abnormal heart sounds
- fluid accumulation in the lungs (both heard through a
stethoscope),
- an enlarged heart,
- swollen neck veins,
- an enlarged liver,
- swelling in the abdomen or legs.
Diagnosis
Electrocardiogram:
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Q waves
ST-T wave abnormalities
Left ventricular hypertrophy
Right ventricular hypertrophy
Low voltage (infiltrative cardiomyopathy, pericardial effusion,
hypothyroidism)
Intraventricular conduction disturbances
Tachyarrhythmias
Diagnosis
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A chest x-ray can show an enlarged heart and fluid
accumulation in the lungs.
Diagnosis
 Echocardiography,
which uses sound waves to
produce an image of the heart, is one of the best
procedures for evaluating heart function,
including the pumping ability of the heart and
the functioning of heart valves.
 It can show whether the heart walls are
thickened,
 whether the valves are functioning normally,
 whether contractions are normal,
 whether any area of the heart is contracting
abnormally.
Diagnosis

Echocardiography may help determine
whether heart failure is due to systolic or diastolic
dysfunction by enabling doctors to estimate the thickness
of the heart walls
- the ejection fraction.
The ejection fraction, an important measure of heart function,
is the percentage of blood pumped out by the heart with
each beat.
A normal left ventricle ejects about 60% of the blood in it.
If the ejection fraction is low, systolic dysfunction is likely.
If it is normal or high, diastolic dysfunction is likely.
-
Diagnosis
Other procedures, such as radionuclide imaging and
cardiac catheterization with angiography, may be
performed to identify the cause of heart failure.
 Rarely, a biopsy is needed, usually when doctors suspect
infiltration of the heart (as occurs in amyloidosis) or
myocarditis due to a bacterial, viral, or other infection.
 BNP blood test. This new test checks the level of a
hormone called BNP (B-type natriuretic peptide) that
rises in HF.

Classification of HF (NYHA)
Class 1: No limits-ordinary physical activity does not
cause undue tiredness or shortness of breath.
 Class 2: Slight or mild limits-comfortable at rest, but
ordinary physical activity results in tiredness or
shortness of breath.
 Class 3: Marked or noticeable limits-comfortable at
rest, but less than ordinary physical activity causes
tiredness or shortness of breath.
 Class 4: Severe limits-unable to carry on any physical
activity without discomfort. Symptoms are also present
at rest. If any physical activity is undertaken,
discomfort increases.

The treatment for HF
The goals of treatment are to:
 Treat the underlying cause of HF
 Improve symptoms and quality of life
 Stop HF from getting worse.
 Prolong life span
The treatment for HF
The treatment for HF includes:
 Lifestyle
changes
 Medications
 Specialized care for those in the most
advanced stage.
The treatment for HF
Lifestyle Changes
Follow a diet low in salt. Salt can cause extra fluid to
build up in your body making your heart failure worse.
 Limit the amount of fluids that you drink.
 Weigh yourself every day and let your doctor know
right away if you have a sudden weight gain. This
could mean you have extra fluid building up in your
body.
 Exercise as directed to help build up your fitness level
and ability to be more active. Lose weight if you are
overweight
 Quit smoking if you smoke
 Limit the amount of alcohol that you drink.

The treatment for HF
Medications
The main medicines are:
Diuretics (water or fluid pills) to help reduce fluid
buildup in your lungs and swelling in your feet and
ankles.
 ACE inhibitors to lower blood pressure and reduce
the strain on your heart. These medications also may
reduce the risk of a future heart attack.
 Beta blockers to slow your heart rate and lower your
blood pressure to decrease the workload on your
heart.
 Digoxin to make the heart beat stronger and pump
more blood.

Some Drugs Used to Treat HF
Type Drug
Angiotensin-converting enzyme
(ACE) inhibitors
Captopril
Enalapril
Fosinopril
Lisinopril
Moexipril
Perindopril
Quinapril
Ramipril
Comments
ACE inhibitors cause blood
vessels to widen (dilate),
thus decreasing the amount
of work the heart has to do;
they may also have direct
beneficial effects on the
heart. These drugs are the
mainstay of heart failure
treatment. They reduce
symptoms and the need for
hospitalization, and they
prolong life.
Some Drugs Used to Treat HF
Type Drug
Angiotensin II receptor
blocers
Candesartan
Eprosartan
Irbesartan
Losartan
Telmisartan
Valsartan
Comments
Angiotensin II receptor blocers have
effects similar to those ACE.
Inhibitors may be tolerated better.
But, their effects are still being
evaluated in people with HF.
They may be used with ACE
inhibitors or used alone in people
who cannot take an ACE inhibitors.
Some Drugs Used to Treat HF
Type Drug
Beta-blockers
Bisoprolol
Carvedilol
Metoprolo
Comments
Beta-blockers drugs slow the heart
rate and block excessive stimulation
of the heart. They are appropriate for
some people with heart failure. These
drugs are usually used with ACE
inhibitors and provide an added
benefit. They may temporarily worsen
symptoms but result in long-term
improvement in heart function
Some Drugs Used to Treat HF
Type Drug
Other vasodilators
Hydralazine
Isosorbide dinitrate
Nitroglycerin
Comments
Vasodilators cause blood vessels to
dilate. These vasodilators are
usually given to people who cannot
take an ACE inhibitor or
angiotensin II receptor blocker.
NitroglycerinSOME TRADE
NAMES
NITRO-BID
NITROL
is particularly useful in people who
have heart failure and angina.
Some Drugs Used to Treat HF
Type Drug
Cardiac glycosides
Digitoxin
Digoxin
Comments
Cardiac glycosides increase the force
of each heartbeat and slow a heart
rate that is too fast.
Some Drugs Used to Treat HF
Type Drug
Comments
Loop diuretics
Bumetanide
Ethacrynic acid
Furosemide
These diuretics help the kidneys eliminate salt
and water, thus decreasing the volume of fluid
in the bloodstream.
Potassium-sparing
diuretics
Amiloride
Spironolactone
Triamterene
Because these diuretics prevent potassium loss,
they may be given in addition to thiazide or
loop diuretics, which cause potassium to be
lost.
Spironolactone (ALDACTONE)
is particularly useful in the treatment of severe
heart failure.
Some Drugs Used to Treat HF
Type Drug
Thiazide and thiazidelike diuretics
Chlorthalidone
Hydrochlorothiazide
Indapamide
Metolazone
Comments
The effects of these diuretics are
similar to but milder than those of
loop diuretics. The two types of
diuretics are particularly effective
when used together.
Some Drugs Used to Treat HF
Type Drug
Comments
Anticoagulants Anticoagulants may be given to prevent clots
from forming in the heart chambers.
Heparin
Warfarin
Opioids
Morphine
Morphine (MS CONTIN,ORAMORPH)
is given to relieve the anxiety that usually
accompanies acute pulmonary edema, which is
a medical emergency.
Some Drugs Used to Treat HF
Positive
inotropic drugs
(drugs that make
muscle contract
more forcefully)
Dobutamine
Dopamine
Milrinone
For people who have severe
symptoms, these drugs may be
given intravenously to stimulate
heart contractions and help keep
blood circulating.
Treatment of Acute HF
HF that develops or worsens quickly requires emergency treatment in a
hospital.

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If acute pulmonary edema develops:
oxygen is given through a face mask.
diuretics given intravenously
nitroglycerin given intravenously or under the tongue can
produce rapid, dramatic improvement.
Morphine relieves the anxiety that usually accompanies acute
pulmonary edema. It also decreases the rate of breathing,
slows the heart rate, dilates blood vessels, and thereby reduces
the amount of work the heart has to do. If these measures do
not adequately improve breathing, a tube may be inserted into
the person's airway so that a mechanical ventilator can assist
breathing.