Heart Failure

Dr. Hamad Albalawi R2

Supervised by: Dr. Huda
Case Scenario

Mrs. Nourah is 68 years old. She has come in today at the insistence •
of her daughter, Asma, who is worried about her breathlessness. She
has shortness of breath in exertion, it’s not affect her sleeping , and her
daughter mentioned that she was using 2 pillows before , now she is
.using 3 pillows
Q1. WHAT ARE THE KEY POINTS?
Q2. WHAT THE MOST LIKELY
DIAGNOSIS?
?Q3.ANY EXTRA QS FOR THE PT
 Heart failure is a condition in which the heart is •
unable to generate a cardiac output sufficient to meet
the demands of the body. It can result from any
What is heart cardiac disease that compromises ventricular systolic
?failure or diastolic function or both heart failure (HF)

A complex clinical syndrome that can result from any •

structural or functional cardiac disorder that impairs •
.the ability of the ventricle to fill with or eject blood
 History:(Symptoms, Risk factors , underlying
:causes )
.Dyspnea on exertion •
.Edema •
.Fatigue •
.Orthopnea •
.Paroxysmal nocturnal dyspnea •
.Recent weight gain •
.Abdominal swelling •
Orthopnea •
is the sensation of breathlessness in the recumbent position, relieved •
.by sitting or standing

Paroxysmal nocturnal dyspnea (PND) •

is a sensation of shortness of breath that awakens the patient, often •
after 1 or 2 hours of sleep, and is usually relieved in the upright
.position
Signs and Symptoms of HF
 HF Symptoms Associated with Specific
Diseases
Chest pain (coronary artery disease) •
Claudication (atherosclerotic disease) •
Cough (pulmonary disease) •
Diarrhea or skin lesions (amyloidosis) •
Dyspnea on exertion (pulmonary disease, valvular disease) •
Edema (liver or kidney failure) •
Palpitations (tachyarrhythmia) •
Fever (endocarditis, myocarditis, infection) •
Syncope (bradycardia, heart block) •
Etiology
.Coronary artery diseases 
:Inflammatory 
.Hypertension  .Myocarditis 
.Valvular Heart disease  .AIDS 
.Idiopathic cardiomyopathy 
:Rheumatological/Connective Tissue Disorders 
:Endocrine & metabolic causes  .SLE ( Pericarditis) 
.DM  .Scleroderma 
.Obesity  .Rheumatoid arthritis 
.Thyroid diseases 
.Peripartum Cardiomyopathy 
.Arrythmias 
: Toxic cardiomyopathy  .Hemochromatosis 
.Alcohol 
.Cocaine  .Amyloidosis 

.Cardiac Sarcoidosis 
 Causes of Heart Failure

Common
Coronary artery disease
Hypertension
Idiopathic cardiomyopathy
Valvular heart disease
 Nourah 68 years old
• PMHX
• T2 DM
• Ischemic Heart ds
• Medications :
• Aspirin 75 mg od
• Atorvastatin 40 od
• Metformin 500 tid
• F.HX
• Father with IHD
? What you will do next
On Examination

HR= 92 bpm regular •

BP= 138/82 mmHg •
RR= 16 breaths per mins •
Temp= 37.2 C •
BMI = 27 kg\m2 •

.General appearance: looks well , no cyanosis or pallor

Chest: bilateral air entry with no added sounds, no chest
. pain
CVS: normal s1+s2+0
. Abdomen: soft lax no tenderness
. JVP: mildly elevated
.LL edema : she has pitting edema around her ankles
General look:
Signs of volume overload in patients with HF:
?What the next step after ex
 Heart Faliure

Investigations

pro-BNP ECHO CXR

 Full blood count
Electrolyets
Renal profile
Liver profile
What you will Thyroid function test

?order for her ECG

Lipid profile
HbA1c
Calcium and magnesium
 :pro-BNP
A low plasma pro-BNP level (<100 nanograms/L or <100 picograms/mL) •
can rapidly rule out decompensated heart failure and point to a
.pulmonary cause
A high plasma pro-BNP level (>400 nanograms/L or >400 picograms/mL) •
strongly supports the diagnosis of abnormal ventricular function (i.e.,
.heart failure)
:High in •
Heart failure, Acute coronary syndrome, Cardiac surgery, Myocarditis , •
.Severe burns, Bacterial sepsis
.Affected by: Age, Weight, Gender, Renal Failure •
 CXR
Help in identifying •
other causes of
:dyspnea
e.g., pneumonia,( •
pneumothorax,
.)mass
Labs:
• Lipids profile : • OTHERS :
• Total cholesterol 178 mg/dl • PRO NBP 470 PG/ML
• HGA1C 8.2
• LDL 90 MG/DL
• UREA 7 MG/DL
• HDL 42 • CR 1.1
• TAG 242 • NA 138
• K4
• CXR NORMAL
• ECG: ECG is suggestive of
ischemia
WHAT YOU WILL
? DO NEXT
Refer for Echocardiogram
RT HG VS. LT HF- •

HF r EF. VS. HF p EF •

Sytolic HF VS. DIASTOLIC HF •

Functional Classification. AHA VS . NYHA •

Signs and Symptoms of HF
Approach to diagnosis
Echocardiography
 NOURAH case

EF = 38%

The results of
mrs.Nourah
echocardiogram Structural abnormalities : mild
regional wall motion
abnormalities noted with no
valvular abnormalities
Given the Heart failure with preserved ejection fraction .A
(HFpEF)
results of
mrs.Noura Heart failure with mid-range ejection fraction .B
echocardiogram (HFmrEF)
, which of the
Heart failure with reduced ejection fraction .C
following does (HFrEF)
?she have
 Given the Heart failure with preserved ejection fraction .A
(HFpEF)
results of
mrs.Noura Heart failure with mid-range ejection fraction .B
echocardiogram (HFmrEF)
, which of the
Heart failure with reduced ejection fraction .C
following does (HFrEF)
?she have
 Which of the
following is Valvular heart disease .A
the most
likely cause of Ischaemic heart disease (IHD) .B

mrs.Noura Aortic stenosis .C

?heart failure
 Which of the
following is Valvular heart disease .A
the most
likely cause of Ischaemic heart disease (IHD) .B

mrs.Noura Aortic stenosis .C

?heart failure
According to
mrs.Noura case,
she is in
which of the Stage A .A
following Stage B .B
Stage C .C
AHA/ACC Stage D .D
stages of heart
?failure
 Which
AHA/ACC Stage A .A
stage of heart Stage B .B

failure she is Stage C

Stage D
.C
.D
?in
? What you will do next

.You refer mrs.Noura to cardiology for further investigation

The cardiologist will decide if she needs an angiogram to see if she has
significant coronary artery disease and if further interventions are
.required
Noura returns from the cardiologist. She • Follow up
had a percutaneous coronary intervention
to her left circumflex artery to open a
.blockage in it
She was started on an ACE inhibitor, •
ramipril 5 mg OD, and on frusemide 40
mg OD. The cardiologist’s letter asks you
.to continue to manage her condition

Next, you will work through a •

simulated consultation to continue
.managing Noura s treatment
Follow up
appointment

She came with additional •

medications prescribed by the
:cardiologist

Ramipril 5 mg OD •
frusemide 40 mg OD •
 Follow up
You assess her symptoms severity by New York Heart Association •
(NYHA) Functional Classification of Heart Failure
 She is in which
of the following
Class I .A
NYHA class of Class II .B
heart failure , if Class III .C
she has dyspnea Class IV .D
after a significant
?exertion

NYHA: New York Heart Association

 She is in which
of the following
Class I .A
NYHA class of Class II .B
heart failure , if Class III .C
she has dyspnea Class IV .D
after a significant
?exertion

NYHA: New York Heart Association

What you will
add next for ARBs .A

her Beta blockers .B

Calcium channel blocker .C
medications to Digoxin .D
improve her
heart function
?further
What you will
add next for ARBs .A

her Beta blockers .B

Calcium channel blocker .C
medications to Digoxin .D
improve her
heart function
?further
 Management
.Diuretics: Used acutely to relieve symptoms of pulmonary edema •
.Confers no mortality benefit

ACEIs: Mortality benefit in all classes of CHF. If not tolerated, an •

.ARB may be substituted

β-blockers: Mortality benefits in classes II, III, and IV have been •

shown with carvedilol, metoprolol, and bisoprolol. Avoid starting in decompensated
.heart failure, but acceptable to continue during an exacerbation unless it is severe
 Management
Digoxin: May provide symptomatic relief, but confers no mortality benefit.
.Helpful for rate control in patients with concurrent AF

Hydralazine with nitrates: Can be used as an alternative to other treatments if

contraindicated or as an addition for patients with moderate-severe symptoms on
.optimal therapy with ACEI, β-blocker, and diuretics

Spironolactone: Confers a mortality benefit in class III–IV heart failure.

.Creatinine should be < 2.5 in men or < 2.0 in women
 Recommendations
:Always start with lifestyle modifications
Sodium restriction (2 g to 3 g daily) and fluid restriction when necessary • •
Tobacco and alcohol discontinuation • •
Aggressive control of hypertension and diabetes (e.g., provide patients with blood pressure • •
and
)HbA1c goal •
Lipid management (e.g., provide leaflets and show website links for diet, exercise, and healthy • •
Daily home weight monitoring • •
Follow up •
)lifestyle •
Regular, symptom-limited exercise • •
.Routine health-care maintenance • •
 Take home messages
Heart failure is a complex clinical syndrome that results from structural or functional impairments of the •
.heart

..Patient should screened for any of the risk factors of the CHF e.g HTN, DM, dyslipidemia •

It is important to diagnose heart failure early so that treatment can begin as soon as possible in order to help •
.slow progression of the disease

:Heart failure is most commonly categorized based on the left ventricular ejection fraction (LVEF) •
HFrEF – LVEF < 40%
HFmrEF – LVEF 40-49%
HFpEF – LVEF >= 50%
Heart failure can be left-sided, right-sided, or both. Right-sided heart failure is •
.most commonly caused by left-sided heart failure

Echocardiography is a very useful way to see changes in the heart. It employs •

.different modalities—2D, Doppler and Color Doppler

Life style modifications along with the medications is an important part in •

.preventing the mortality of HF
It is recommended that all patients with heart failure should be seen by a •
specialist to confirm the diagnosis of heart failure and to identify the cause of
.the heart failure
You are seeing a patient who was discharged from the hospital. She initially presented
to the ED with dyspnea and was found to be in heart failure with reduced ejection
fraction (HFrEF). Her ejection fraction (EF) was found to be 30%. She was admitted
for diuresis and initiation of appropriate first-line therapy.
According to the American College of Cardiology/American Heart Association/Heart
Failure Society of America (ACC/AHA/HFSA) heart failure guidelines, once this patient’s
symptoms have been controlled with diuresis,
what is the most appropriate first-line therapy for her HFrEF?
A. ACE-inhibitors
B. B-Blockers
C. Calcium channel blockers
D. Nitrates
E. Hydralazine
 .The answer is A •
The ACC/AHA/HFSA guidelines recommend therapy based on their four categories of heart •
failure. Stage A includes patients at risk for heart failure but without structural heart disease
.or symptoms
Stage B includes patients with structural heart disease •
without signs or symptoms of heart failure. Patients in stage )atherosclerosis, valvular disease( •
C heart failure have current or prior symptoms of heart failure and structural heart disease,
.while stage D patients have refractory heart failure

In contrast, the New York Heart Association (NYHA) functional classification categorizes •
patients based on the degree of symptoms they currently have. All NYHA classes fall into the
.ACC/AHA/HFSA stages C or D
Class I patients have no limitation of activity. Class II patients have slight limitations, are •
comfortable at rest, but have fatigue, palpitations, dyspnea, or angina with ordinary activity
This same patient returns to your office for a follow-up visit 3 •
months later. She is following her low-sodium diet and taking her
medications daily without side effects. Sheappears euvolemic and
vitals today are: heart rate 88 beats/ min, blood pressure 130/83
mmHg, respiratory rate 14 breaths/min, and SpO2 92%. However,
she continues to have considerable dyspnea on exertion and her
.repeat echocardiogram shows an unchanged EF
?What is the next best course of action
-A-Admit her to the hospital for acute diuresis and oxygen
B-Increase the diuretic
C-Add an angiotensin II-receptor blocker (ARB)
D-Add a ß-blocker
E-Add metolazone
The answer is D
This patient is euvolemic and has normal oxygen saturation and does not have any
indication for acute, inpatient treatment.
In patients who continue to be symptomatic with an EF less than 35% and are already
euvolemic and on an ACE or ARB, the next step is the addition of a B-blocker.
Studies have shown that three B-blockers
(bisoprolol, metoprolol, and carvedilol) can reduce symptoms, improve quality of
life, and reduce mortality.
The concomitant use of ACEs and ARBs is not recommended due to the increased risk
of hyperkalemia. Metolazone is useful in patients with refractory edema, but this is
not the case with this patient
References