Heart failure: Basic Cocepts

The basic concepts of heart failure for paramedical staffs.

1. Heart Failure Dr Arindam Pande , MBBS ( Hons ), MD, DM, FESC, FACC (USA) Consultant Cardiologist , Academic Coordinator: DNB Cardiology and PGDCC Training Apollo Gleneagles Hospital, Kolkata

2. www.healthprice.in Heart Heart has four chambers - Two Atrium(upper) Two Ventricles(lower)

3. www.healthprice.in Atria – It collects blood from the body. Ventricle - It supplies blood to the body Right Ventricle supplies blood to lungs Left Ventricle supplies blood into the system for circulation

4. www.healthprice.in

5. In medical terms heart failure is defined as the condition when heart is unable to pump enough blood required for normal body functions . Human body needs sufficient amount of oxygen which is supplied by heart through blood. Heart failure is a serious condition and needs immediate medical care. What is Heart Failure?

6. Congestive Heart Failure Congestion of pulmonary or systemic circulation (backward failure) Reduced output to body tissues (forward failure)

7. Cardiac structural abnormalities occur as a result of injury and remodeling MI=myocardial infarction Konstam et al. J Am Coll Cardiol 2011;4:98–108 Cardiac injury (e.g. MI) Infarct zone thinning and elongation Spherical ventricular dilation Fibrous scar Myocyte hypertrophy Increased Interstitial collagen Ventricle

8. LV=left ventricular McMurray. N Engl J Med 2010;362:228–38; Francis et al. Ann Intern Med 1984;101:370–7; Krum, Abraham. Lancet 2009;373:941–55 The pathophysiology of chronic HF HF symptoms dyspnea, edema, fatigue Progressive remodelling and worsening of LV function Morbidity and mortality arrhythmias, pump failure Hemodynamic alterations, salt and water retention These changes lead to systemic neurohormonal imbalance Damage to cardiac myocytes and extracellular matrix leads to changes in the size, shape and function of the heart (remodeling) and cardiac wall stress This may lead to fibrosis, apoptosis, hypertension, hypertrophy, cellular and molecular alterations, myotoxicity

9. Congestive Heart Failure Left sided Right sided Biventricular

10. Left-Sided Heart Failure Left ventricle fails as effective pump Left ventricle cannot eject blood delivered from right heart through pulmonary circulation Blood backs up into pulmonary circulation

11. Left-Sided Heart Failure Increase pressure in pulmonary capillaries forces blood serum out of capillaries into interstitial spaces and alveoli Increase respiratory work and decrease gas exchange occur

12. Left-Sided Heart Failure Common causes ACUTE MI especially if involves left ventricle Chronic hypertension Dysrhythmias especially tachydysrhythmias

13. Left-Sided Heart Failure Pulmonary Signs/Symptoms

14. Left Heart Failure Symptoms Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Fatigue, generalized weakness

15. Left Heart Failure Signs Anxiety, confusion, restlessness Persistent cough Pink, frothy sputum Tachycardia Tachypnea Noisy, labored breathing Rales, wheezing (“cardiac asthma”) Cyanosis (late) Third heart sound (S 3 )

16. Right-sided Heart Failure Right ventricle fails as effective pump Right ventricle cannot eject blood returning through vena cavae Blood backs up into systemic circulation

17. Right Heart Failure Increased pressure in systemic capillaries forces fluid out of capillaries into interstitial spaces Tissue edema occurs

18. Right Heart Failure Causes Most Common Cause: Left sided Heart Failure

19. Right Heart Failure Causes Others Chronic pulmonary hypertension (Idiopathic) COPD ( cor pulmonale ) Congenital Heart Disease Pulmonary embolism Right ventricular infarction

20. Right-Sided Heart Failure Systemic Signs/Symptoms

21. Right Heart Failure Signs/Symptoms Tachycardia Jugular vein distension Pedal, pre-tibial, sacral edema Hepatomegaly Splenomegaly Classic Triad of Right Ventricular Failure: JVD, Hypotension, Clear Lungs

22. Right Heart Failure Signs/Symptoms Anasarca (generalized edema) Fluid accumulation in body cavities Ascites Pleural effusion Pericardial effusion

23. Management of Heart Failure

24. Goals of Management Improve oxygenation, ventilation Decrease venous return to heart Decrease cardiac work, O 2 demand Improve cardiac output by Reducing afterload Increasing myocardial contractility

25. Management Sit patient up, dangle feet Do not lay flat Oxygen by non-rebreather mask Consider positive pressure ventilation

26. Management Consider intubation if: O 2 saturation cannot be kept >90% on 100% O 2 PaO 2 cannot be kept >60 torr on 100 % O 2 Patient displays signs of worsening cerebral hypoxia PaCO 2 progressively increases Patient becoming exhausted

27. Management Monitor ECG Hypoxia, increased heart wall tension leads to dysrhythmias IV NS TKO via microdrip or lock Limit Fluids If RVF only, fluid challenges to  preload

28. Drug management in acute setings Nitroglycerin Furosemide ( Lasix ®) - Morphine Sulfate Dobutamine , Noradrenaline Bronchodilators (beta agonists) Digitalis

29. Long Term CHF Management Fluid minimization Diuretics (+ Potassium if non-potassium sparing) Diet restrictions Increase contractility Digitalis Blood pressure control ACE Inhibitors Betablockers ARNI Ivabradin Coronary artery perfusion Nitroglycerin

30. If medication or other means fail to improve the condition, left ventricular assist devices and / or heart transplantation is opted. For patients in cardiogenic shock, ECMO (extracorporeal membrane oxygenator) therapy is given to stabilize the condition temporarily.

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