HEART FAILURE

Dr. S. C JHA
Associate professor
Department of Medicine
DMCH, Laheriasarai
 Heart Failure
The clinical syndrome that can result
from any structural or functional cardiac
disorder that impairs the ability of the
heart to function as a pump to support a
physiological circulation.

This is the leading cause of medical

hospital admission admission in over 65 yr
old and accounts for 5% of admission in
medical ward.
 Inclinical practice, heart failure may be diagnosed
when a patient with signifificant heart disease
develops the signs or symptoms of a low cardiac
output, pulmonary congestion or systemic venous
congestion at rest or on exercise.
 Three types of heart failure are recognised.
Left heart failure
 Thisis characterised by a reduction in left ventricular
output and an increase in left atrial and pulmonary
venous pressure.
Right heart failure
 This is characterised by a reduction in right
ventricular output and an increase in right atrial and
systemic venous pressure.
 The most common causes are chronic lung disease,
pulmonary embolism and pulmonary valvular stenosis.
 The term ‘cor pulmonale’ is used to describe right
heart failure that is secondary to chronic lung disease.
Biventricular heart failure
 In biventricular failure, both sides of the heart are
affected.
 PATHOPHYSIOLOGY


Heart failure occurs when cardiac output fails to
meet the demands of the circulation.
Cardiac output is determined by preload ,afterload,
myocardial contractility.
The physiological changes in response to the
hemodynamic changes associated with heart failure
are compensatory and maintain cardiac output and
peripheral perfusion .
However, as heart failure progresses , these
mechanism are overwhelmed and become
pathological.
 Pathophysiological changes in

HEART FAILURE
Ventricular dilation
Myocyte hypertrophy
Increased collagen synthesis
Altered myosin gene expression
Altered sarcoplasmic ca2+ ATP density
Increased ANP Secretion
Salt and water retention
Sympathetic stimulation
Peripheral vasoconstriction
CLINICAL SYNDROME IN
HEART FAILURE

1. HEART FAILURE WITH REDUCED EJECTION

FRACTION(HRrEF<40%)
2. HEART FAILURE WITH PRESERVED EJECTION
FRACTION(HRpEF>50)
3. HEART FAILURE WITH MID-RANGE EJECTION
FRACTION(HFmEF)
4. RIGHT VENTRICULAR SYSTOLIC DYSFUNCTION(RVSD)
CLINICAL FEATURES OF
HEART FAILURE
SYMPTOMS Signs
Exertional
Tachycardia
Elevated jvp
dyspnea Cardiomegaly third
Orthopnea
and fourth heart sound
Paroxysmal Bi-basal crackles
nocturnal Pleural effusion
dyspnea Peripheral ankle
Fatigue edema
Ascites
Tender hepatomegaly
 Management of heart failure
 General lifestyle advice
1. Education
2. Dietary modification
3. Smoking cessation
4. Physical activity,exercise training and rehabilitation
5. Vaccination-pneumococcal and influenza

Monitoring
1. Functional capacity
2. Fluid status
3. Cardiac rhythm
Multidisciplinary approach
 Drug management
 1) Diuretics –acts by promoting the renal excretion of salt and water by blocking
tubular reabsorption of sodium and chloride.
 E.g.-loop diuretics(furosemide &bumetanide )and thiazide diuretic
( hydrochlorthiazide).
 Serum electrolytes & renal function must be monitored regularly.

 2) Ace inhibitor – improve survival in patients in all functional classes and

recommended in all patient at risk of developing heart failure.
E.g.-ramipril ,enalapril ,captopril
Adverse effects-cough ,hypotension ,hyperkalemia and renal
dysfunction.
Contraindication-renal artery stenosis ,pregnancy and previous angio-
oedema.

 3)Angiotensin receptor blocker- second line therapy in pt intolerant of ace

inhibitor.
 Eg-candesartan ,losartan , valsartan
Beta blockers -improve functional status and reduce
cardiovascular morbidity and mortality. eg – bisoprolol ,carvedilol,
metoprolol succinate ,nevibolol.

Aldosterone antagonist- spironolactone & eplerenone

 Angiotensin receptor Neprilysin inhibitor –produce dual
inhibition of the angiotensin and the natriuretic system.
E.g- sacubitril+ valsartan- superiority over ace inhibitor in lowering
morbidity& mortality.

 Cardiac glycosides-digoxin – indicated in patients in

atrial fibrillation with heart failure.
 Vasodilators and nitrates –combination of hydralazine
and nitrates (isolazine) reduces preload and afterload
and is used in patient with intolerant of acei/arb.
 Other medications

 Anticoagulation – in hospital ,all patients require prophylactic

anticoagulation.
 Oral anticoagulants are recommended in patients with atrial
fibrillation ,and in those with sinus rhythm and a history of
thromboembolism ,left ventricle aneurysm or thrombus.
 Inpeople with known ishaemic heart disease ,antiplatelet
therapy(aspirin ,clopidogrel) and statin therapy should be
continued.
 Ivabradine –used in patients in sinus rhythm with an elevated
heart rate despite beta blocker treatment or those who are
unable to tolerate beta blocker.
Non- pharmacological treatment

1. Revascularization
2. Cardiac resynchronization
therapy or ICD
3. Cardiac transplantation
Thank you !!