16. Heart failure, shock, pulmonary oedema. Left ventricular function

What is heart failure?

Heart failure is a serious medical condition where the heart can't pump sufficient blood to meet the body's metabolic demands. This is typically due to pathological changes in the myocardium, which may be functional or structural.

How many people are affected by heart failure globally?

Globally, heart failure affects about 26 million people, representing around 1-2% of adults in developed countries, with a particularly high incidence among African Americans and Hispanics. It's prevalent among the elderly and occurs as frequently as the four major types of cancer combined (breast, lung, prostate, and colon).

What are the leading causes of heart failure?

The leading causes of heart failure are coronary artery disease, hypertension, and diabetes mellitus.

What is the prognosis for heart failure?

The prognosis for heart failure is poor, with a 50% mortality rate within five years.

Types of Heart Failure:

Types of Heart Failure:

• Systolic Dysfunction:

• Diastolic Dysfunction:

• Right Heart Failure:

• Left Heart Failure:

• Biventricular Heart Failure:

• Chronic Compensated Heart Failure:

• Acute Decompensated Heart Failure:

What is Systolic Dysfunction characterized by?

Decreased cardiac contractility, reduced ejection fraction, and increased end-diastolic volume.

What is Diastolic Dysfunction characterized by?

Reduced myocardial compliance often due to hypertrophy, maintaining a preserved ejection fraction while reducing stroke volume and end-diastolic volume.

What can cause Right Heart Failure?

It typically results from left heart failure but can also originate from pulmonary conditions such as cor pulmonale.

What type of heart failure involves dysfunction of the left ventricle?

Left Heart Failure involves dysfunction of the left ventricle.

What does biventricular heart failure often extend from?

Biventricular Heart Failure often extends from left heart failure affecting both ventricles.

What do patients with chronic compensated heart failure exhibit on echocardiography?

Patients with chronic compensated heart failure exhibit heart failure signs on echocardiography but remain asymptomatic or symptomatically stable.

What characterizes acute decompensated heart failure?

Acute Decompensated Heart Failure is marked by a sudden worsening of heart failure symptoms or onset following an acute cardiac event like a myocardial infarction.

Aetiology of Heart Failure

Aetiology of Heart Failure

General Causes

1. Coronary Artery Disease and Myocardial Infarction:

2. Arterial Hypertension:

3. Valvular Heart Disease:

4. Diabetes Mellitus and Obesity:

5. Renal Disease:

6. Infiltrative Diseases:

Systolic Dysfunction

1. Dilated Cardiomyopathy:

2. Cardiac Arrhythmias:

3. Myocarditis:

Diastolic Dysfunction

1. Restrictive Cardiomyopathy:

2. Hypertrophic Cardiomyopathy:

3. Pericardial Tamponade and Constrictive Pericarditis:

General Causes

Aetiology of Heart Failure

General Causes

1. Coronary Artery Disease and Myocardial Infarction:

2. Arterial Hypertension:

3. Valvular Heart Disease:

4. Diabetes Mellitus and Obesity:

5. Renal Disease:

6. Infiltrative Diseases:

What is the most common cause of heart failure, especially in cases with reduced ejection fraction?

Coronary Artery Disease

How does chronic high blood pressure affect the heart's workload?

It increases the heart's workload, leading to left ventricular hypertrophy.

What can faulty heart valves lead to?

Heart failure by forcing the heart to work harder to pump the same amount of blood.

What are risk factors for coronary artery disease and hypertension?

Diabetes Mellitus and Obesity.

How can kidney problems impact heart function?

Kidney problems can affect heart function due to fluid overload and the accumulation of toxins.

What characterizes infiltrative diseases in relation to heart function?

Infiltrative diseases involve the accumulation of substances in the heart tissue, impairing its function.

Systolic Dysfunction

Aetiology of Heart Failure

General Causes

1. Coronary Artery Disease and Myocardial Infarction:

2. Arterial Hypertension:

3. Valvular Heart Disease:

4. Diabetes Mellitus and Obesity:

5. Renal Disease:

6. Infiltrative Diseases:

Systolic Dysfunction

1. Dilated Cardiomyopathy:

2. Cardiac Arrhythmias:

3. Myocarditis:

What is Dilated Cardiomyopathy characterized by?

Weakened and enlarged ventricles, reducing the heart's ability to pump effectively.

How can Cardiac Arrhythmias impact heart failure?

Irregular heartbeats can compromise the heart's efficiency, leading to or exacerbating heart failure.

What is Myocarditis?

Inflammation of the heart muscle, often due to infection, which impairs the heart's ability to contract normally.

Diastolic Dysfunction

Aetiology of Heart Failure

General Causes

1. Coronary Artery Disease and Myocardial Infarction:

2. Arterial Hypertension:

3. Valvular Heart Disease:

4. Diabetes Mellitus and Obesity:

5. Renal Disease:

6. Infiltrative Diseases:

Systolic Dysfunction

1. Dilated Cardiomyopathy:

2. Cardiac Arrhythmias:

3. Myocarditis:

Diastolic Dysfunction

1. Restrictive Cardiomyopathy:

2. Hypertrophic Cardiomyopathy:

3. Pericardial Tamponade and Constrictive Pericarditis:

What is Diastolic Dysfunction characterized by?

Diastolic Dysfunction is characterized by impaired relaxation or increased stiffness of the heart muscle during diastole.

What is Restrictive Cardiomyopathy?

Restrictive Cardiomyopathy is a condition that increases the rigidity of the heart walls, restricting the heart's ability to fill properly.

What is Hypertrophic Cardiomyopathy known for?

Hypertrophic Cardiomyopathy is characterized by thickened heart muscle, which can obstruct or reduce blood flow from the heart, impacting its ability to fill properly.

How do Pericardial Tamponade and Constrictive Pericarditis affect the heart?

Pericardial Tamponade and Constrictive Pericarditis compress the heart due to fluid or scarred pericardial tissue, respectively, leading to impaired heart filling and function.

Risk Factors of HF

Risk Factors

1. Obesity, Smoking, COPD:

2. Heavy Drug and Alcohol Abuse:

What are some risk factors that strain the heart and lungs, increasing the risk of heart failure?

1. Obesity, Smoking, COPD: These conditions strain the heart and lungs, increasing the risk of developing heart failure.

How can heavy drug and alcohol abuse impact the heart and lead to heart failure?

1. Heavy Drug and Alcohol Abuse: These substances can directly damage the heart muscle, leading to heart failure.

Two Types of Heart Failure

Two Types of Heart Failure

Systolic Dysfunction

1. Reduced Contractility:

2. Increased Afterload:

3. Cardiac Arrhythmias:

Diastolic Dysfunction

1. Decreased Ventricular Compliance:

2. Increased Afterload:

3. Increased Preload:

Systolic Dysfunction

Systolic Dysfunction

1. Reduced Contractility:

2. Increased Afterload:

3. Cardiac Arrhythmias:

What is systolic dysfunction?

The inability of the heart to pump blood effectively during systole.

What characterizes systolic dysfunction?

It is marked by a reduced ejection fraction.

What can result from damage to or loss of heart muscle cells, often due to myocardial infarction or chronic myocardial ischemia?

Reduced Contractility

What can increase the resistance against which the heart must pump, making it harder for the ventricles to eject blood?

Increased Afterload

How can irregular heart rhythms disrupt the coordinated contraction of the heart muscle, reducing the efficiency of blood ejection?

Cardiac Arrhythmias

Diastolic Dysfunction

Diastolic Dysfunction

1. Decreased Ventricular Compliance:

2. Increased Afterload:

3. Increased Preload:

What is diastolic dysfunction characterized by?

Diastolic dysfunction is characterized by problems with filling during diastole.

How does diastolic dysfunction differ from systolic dysfunction?

Diastolic dysfunction is characterized by a preserved ejection fraction, unlike systolic dysfunction.

What causes inadequate filling of the heart chambers in diastolic dysfunction?

In diastolic dysfunction, inadequate filling of the heart chambers is caused by increased stiffness or poor relaxation of the ventricular walls.

What is one cause of diastolic dysfunction related to ventricular walls?

Decreased Ventricular Compliance due to stiffening of the ventricular walls from conditions like long-standing hypertension.

How can conditions like pulmonary hypertension impact diastolic function?

Increased Afterload can increase the resistance the heart has to work against during systole, indirectly affecting diastolic function.

What effect can conditions causing ventricular volume overload have on diastolic dysfunction?

Increased Preload from conditions like tricuspid valve regurgitation can exacerbate filling issues during diastole.

Consequences of Diastolic Dysfunction

Consequences of Diastolic Dysfunction

• Pulmonary Congestion and Edema:

• Systemic Venous Congestion:

• Reduced Cardiac Output:

What are the consequences of diastolic dysfunction?

Pulmonary Congestion and Edema, Systemic Venous Congestion, Reduced Cardiac Output

How does pulmonary congestion and edema manifest in diastolic dysfunction?

Orthopnea (difficulty breathing while lying flat)

What is systemic venous congestion in diastolic dysfunction associated with?

Peripheral edema and congestion of internal organs like the liver

How does reduced cardiac output contribute to diastolic dysfunction?

Poor organ perfusion, overall organ dysfunction, and clinical symptoms of heart failure

Compensatory Mechanisms of Heart Failure

Compensatory Mechanisms of Heart Failure

1. Increased Adrenergic Activity

2. Increased Renin-Angiotensin-Aldosterone System (RAAS) Activity

   • Angiotensin-II:

   • Aldosterone:

3. Secretion of Brain Natriuretic Peptide (BNP)

What is the effect of increased adrenergic activity on heart rate, blood pressure, and ventricular contractility?

1. Increased Adrenergic Activity

   • The sympathetic nervous system is activated, increasing heart rate, blood pressure, and ventricular contractility. This response is designed to enhance cardiac output and maintain perfusion to vital organs.

How does increased adrenergic activity aim to enhance cardiac output and maintain perfusion to vital organs?

Increased adrenergic activity is designed to enhance cardiac output and maintain perfusion to vital organs by increasing heart rate, blood pressure, and ventricular contractility.

1. Increased Renin-Angiotensin-Aldosterone System (RAAS) Activity

1. Increased Renin-Angiotensin-Aldosterone System (RAAS) Activity

   • Angiotensin-II:

   • Aldosterone:

What does Angiotensin-II promote in the body?

1. Increased Renin-Angiotensin-Aldosterone System (RAAS) Activity

   • Angiotensin-II: Promotes peripheral vasoconstriction, which increases afterload and reduces renal blood flow. This maintains glomerular filtration rate (GFR) under stress but at the cost of increased cardiac workload.

   • Aldosterone:

How does Aldosterone affect blood volume?

• Aldosterone: Stimulates sodium and water retention, increasing blood volume (preload), which enhances cardiac output through the Frank-Starling mechanism. This increase in preload helps to initially compensate for the reduced efficiency of the heart.

What triggers the secretion of Brain Natriuretic Peptide (BNP) in the body?

Excessive stretching of ventricular tissue

How does Brain Natriuretic Peptide (BNP) affect blood pressure?

BNP causes vasodilation, which can help to reduce blood pressure

Clinical Features and Symptoms of HF

Clinical Features and Symptoms

General Symptoms of Heart Failure

• Fatigue and decreased exercise tolerance.

• Tachycardia and arrhythmias.

• Heart sounds:

• Pulsus alternans:

• Cachexia:

Left-Sided Heart Failure Symptoms (Pulmonary congestion)

Right-Sided Heart Failure Symptoms (Systemic venous congestion)

What are some general symptoms of heart failure?

General Symptoms of Heart Failure

• Fatigue and decreased exercise tolerance.

• Tachycardia and arrhythmias.

• Heart sounds: S3/S4 gallops indicate a volume overload and reduced ventricular compliance.

• Pulsus alternans: alternating strong and weak pulses, indicating severe left ventricular dysfunction.

• Cachexia: severe muscle and weight loss due to chronic illness.

How can heart sounds like S3/S4 gallops indicate in heart failure?

General Symptoms of Heart Failure

• Fatigue and decreased exercise tolerance.

• Tachycardia and arrhythmias.

• Heart sounds: S3/S4 gallops indicate a volume overload and reduced ventricular compliance.

• Pulsus alternans: alternating strong and weak pulses, indicating severe left ventricular dysfunction.

• Cachexia: severe muscle and weight loss due to chronic illness.

What does pulsus alternans indicate in heart failure?

General Symptoms of Heart Failure

• Fatigue and decreased exercise tolerance.

• Tachycardia and arrhythmias.

• Heart sounds: S3/S4 gallops indicate a volume overload and reduced ventricular compliance.

• Pulsus alternans: alternating strong and weak pulses, indicating severe left ventricular dysfunction.

• Cachexia: severe muscle and weight loss due to chronic illness.

What is cachexia in the context of heart failure?

General Symptoms of Heart Failure

• Fatigue and decreased exercise tolerance.

• Tachycardia and arrhythmias.

• Heart sounds: S3/S4 gallops indicate a volume overload and reduced ventricular compliance.

• Pulsus alternans: alternating strong and weak pulses, indicating severe left ventricular dysfunction.

• Cachexia: severe muscle and weight loss due to chronic illness.

Left-Sided Heart Failure Symptoms (Pulmonary congestion)

Left-Sided Heart Failure Symptoms (Pulmonary congestion)

• Dyspnea on exertion progressing to rest, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up at night short of breath).

• Pulmonary edema and cardiac asthma, where increased pulmonary pressure causes fluid accumulation in the lungs and airway constriction.

• Physical examination may reveal rales (crackles) in the lungs, displaced apical pulse due to enlarged heart, and cool, pale extremities indicating poor circulation.

What are the symptoms of left-sided heart failure related to pulmonary congestion?

Dyspnea on exertion progressing to rest, orthopnea, and paroxysmal nocturnal dyspnea.

What can increased pulmonary pressure in left-sided heart failure lead to?

Pulmonary edema and cardiac asthma.

What might a physical examination reveal in a patient with left-sided heart failure?

Rales (crackles) in the lungs, displaced apical pulse, and cool, pale extremities.

Right-Sided Heart Failure Symptoms (Systemic venous congestion)

Right-Sided Heart Failure Symptoms (Systemic venous congestion)

• Peripheral edema, especially noticeable in the lower extremities.

• Hepatic congestion can lead to abdominal discomfort and jaundice.

• Physical signs include jugular venous distention, Kussmaul's sign (increase in jugular venous pressure on inspiration), and hepatojugular reflux.

What are the symptoms of right-sided heart failure related to systemic venous congestion? .

Peripheral edema, hepatic congestion, jugular venous distention, Kussmaul's sign, and hepatojugular reflux

How can right-sided heart failure manifest in terms of physical signs?

Jugular venous distention, Kussmaul's sign, and hepatojugular reflux.

NYHA Functional Classification of Heart Failure

NYHA Functional Classification of Heart Failure

This system categorizes patients based on the limitation of physical activity caused by symptoms of heart failure:

• Class I:

• Class II:

• Class III:

• Class IV:

What is Class I in the classification of physical activity limitations related to heart conditions?

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or anginal pain.

What is Class II in the classification of physical activity limitations related to heart conditions?

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

What is Class III in the classification of physical activity limitations related to heart conditions?

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

What is Class IV in the classification of physical activity limitations related to heart conditions?

Unable to carry on any physical activity without discomfort. Symptoms of heart failure are present even at rest. If any physical activity is undertaken, discomfort is increased.

AHA Staging of Heart Failure

AHA Staging of Heart Failure

The AHA stages of heart failure describe the evolution of the disease and are used alongside the NYHA classification to provide a more comprehensive assessment:

• Stage A:

• Stage B:

• Stage C:

• Stage D:

What is Stage A heart failure?

• Stage A: At high risk for developing heart failure due to conditions that are strongly associated with the development of heart failure (such as hypertension, diabetes, coronary artery disease, metabolic syndrome, or use of cardiotoxins) but without structural heart disease or symptoms of heart failure.

What characterizes Stage B heart failure?

• Stage B: Structural heart disease (such as left ventricular hypertrophy, low ejection fraction, or structural valve disease) is present but without signs or symptoms of heart failure.

What defines Stage C heart failure?

• Stage C: Structural heart disease with prior or current symptoms of heart failure (similar to NYHA Class II to III).

When does Stage D heart failure occur?

• Stage D: Refractory heart failure requiring specialized interventions, representing advanced disease where conventional heart failure therapy is no longer sufficient (similar to NYHA Class IV).

Diagnostics of Heart Failure

Diagnostics of Heart Failure

1. Laboratory Tests

2. Electrocardiogram (ECG)

3. Chest X-ray

4. Transthoracic Echocardiography (TTE)

5. Cardiac Stress Test

6. Coronary Angiography

7. CT Angiography

8. Cardiac MRI

Laboratory Tests

Laboratory Tests

• BNP and NT-proBNP:

• ANP:

• Electrolytes:

• Renal Function:

• Urine Analysis:

• Blood Glucose and Lipid Profile:

What are BNP and NT-proBNP used as markers for in heart failure?

• BNP and NT-proBNP: Elevated levels of B-type Natriuretic Peptide (BNP) and its N-terminal prohormone (NT-proBNP) are markers of cardiac stretch and stress, commonly elevated in heart failure. Values above 400-500 ng/L suggest heart failure is likely.

What does an increase in ANP indicate in heart failure?

• ANP: Atrial Natriuretic Peptide, another heart failure marker, increases with atrial pressure.

How can hyponatremia be related to heart failure prognosis?

• Electrolytes: Hyponatremia (low sodium) can indicate poor heart failure prognosis due to advanced disease affecting renal function and fluid balance.

What can elevated creatinine levels indicate in relation to renal function and cardiac output?

• Renal Function: Elevated creatinine levels can indicate renal impairment secondary to reduced cardiac output.

What does a urine analysis assess in the context of heart failure?

A urine analysis assesses renal function and detects proteinuria or other abnormalities that could contribute to or result from heart failure.

Why are blood glucose and lipid profiles assessed in heart failure patients?

Blood glucose and lipid profiles are assessed to evaluate additional cardiovascular risk factors.

Electrocardiogram (ECG)

Electrocardiogram (ECG)

• Left Ventricular Hypertrophy:

• Signs of Past or Acute Myocardial Infarction:

• Arrhythmias:

• Low Voltage ECG:

What are the indicators of Left Ventricular Hypertrophy on an ECG?

Increased QRS voltage and duration.

What are common findings in Left Ventricular Hypertrophy related to the ECG?

Left bundle branch block (LBBB) and left axis deviation.

What is a sign of Past or Acute Myocardial Infarction that can be seen on an ECG?

Q waves.

Why are arrhythmias common in heart failure according to ECG findings?

Due to altered electrical pathways.

What can a low voltage ECG indicate in terms of cardiac conditions?

Pericardial effusion or tamponade.

. Chest X-ray

. Chest X-ray

• Cardiothoracic Index:

• Boot-shaped Heart:

• Pulmonary Congestion:

What does a cardiothoracic index greater than 0.5 suggest on a chest X-ray?

• Cardiothoracic Index: A ratio greater than 0.5 is indicative of cardiomegaly.

What is the significance of a boot-shaped heart on a chest X-ray?

It is often seen in right ventricular enlargement.

What do Kerley B lines, peribronchial cuffing, and pleural effusions indicate on a chest X-ray?

Pulmonary congestion.

Transthoracic Echocardiography (TTE)

Transthoracic Echocardiography (TTE)

• Assessment of Heart Chambers:

• Ejection Fraction:

• Valvular Function:

• Pulmonary Pressures: