This document discusses heart failure, including its definition, pathophysiology, clinical features, investigation, and management. It notes that the main causes of heart failure in Malaysian adults are ischemic heart disease, valvular/rheumatic heart disease, and non-ischemic cardiomyopathy. It classifies heart failure based on ejection fraction and presents on acute or chronic basis. The document outlines evaluation and treatment of acute heart failure as well as management of chronic heart failure with reduced or preserved ejection fraction. It also discusses device therapies and surgery for heart failure.
This document discusses heart failure, including its definition, pathophysiology, clinical features, investigation, and management. It notes that the main causes of heart failure in Malaysian adults are ischemic heart disease, valvular/rheumatic heart disease, and non-ischemic cardiomyopathy. It classifies heart failure based on ejection fraction and presents on acute or chronic basis. The document outlines evaluation and treatment of acute heart failure as well as management of chronic heart failure with reduced or preserved ejection fraction. It also discusses device therapies and surgery for heart failure.
This document discusses heart failure, including its definition, pathophysiology, clinical features, investigation, and management. It notes that the main causes of heart failure in Malaysian adults are ischemic heart disease, valvular/rheumatic heart disease, and non-ischemic cardiomyopathy. It classifies heart failure based on ejection fraction and presents on acute or chronic basis. The document outlines evaluation and treatment of acute heart failure as well as management of chronic heart failure with reduced or preserved ejection fraction. It also discusses device therapies and surgery for heart failure.
This document discusses heart failure, including its definition, pathophysiology, clinical features, investigation, and management. It notes that the main causes of heart failure in Malaysian adults are ischemic heart disease, valvular/rheumatic heart disease, and non-ischemic cardiomyopathy. It classifies heart failure based on ejection fraction and presents on acute or chronic basis. The document outlines evaluation and treatment of acute heart failure as well as management of chronic heart failure with reduced or preserved ejection fraction. It also discusses device therapies and surgery for heart failure.
• Definition, pathophysiology and Clinical features of Heart
Failure • Investigation and management of Heart failure INTRODUCTION
The main causes of HF amongst adult Malaysians were
ischaemic heart disease (68%), valvular/rheumatic heart disease (29%) and non-ischaemic cardiomyopathy (28%).Vascular risk factors such as hypertension, diabetes mellitus, and dyslipidaemia were common in Asian HF patients, particularly so in Malaysia (75%, 67%, and 52%, respectively).In-patient mortality was 6%, with a 30-day readmission rate of 30%. DEFINITION
A clinical syndrome due to any structural or
physiological abnormality of the heart resulting in its inability to meet metabolic demands of the body. CLASSIFICATION 1.Left ventricular ejection failure -Reduced EF: systolic dysfunction -Preserved EF: diastolic dysfunction
2.Clinical presentation: acute or chronic
Systolic VS Dystolic Acute VS Chronic Types Of Acute HF Congestion at Rest NO YES
Warm & Dry Warm &Wet Sign/Symptoms of
NO (PCW normal, CI normal) (PCW elevated, CI normal) Congestion: Low Perfusion at Cold & Dry Cold & Wet Orthopnea / PND Rest YES (PCW low/normal (PCW elevated JV Distension
Low serum sodium Renal / hepatic dysfunction • CAUSES OF ACUTE HF IN PREVIOUSLY WELL PT :
– INFECTIVE ENDOCARDITIS – ACUTE VALVULAR REGURGE ( Post Infarct, myxoma) – PULMONARY THROMBOEMBOLISM • CHRONIC HF PT CAN PRESENT WITH ACUTE HF SX (DECOMPENSATED HF) DUE TO THE FOLLOWING :
ACC/AHA GUIDELINES NYHA ACC/AHA ETIOLOGY Causes of Heart Failure Finding Causes Cardiac rhythm disorders CHB, SVT, SND Structural heart disease (e.g. VSD.PDA,AR,MR) Volume overload Anemia, Sepsis Structural heart disease (e.g. AS,PS,COA) Pressure overload Hypertension Myocarditis Dilated cardiomyopathy Systolic ventricular dysfunction or failure Malnutrition Ischemia Hypertrophic cardiomyopathy Diastolic ventricular dysfunction or failure Restrictive cardiomyopathy Pericardial or cardiac tamponade PATHOPHYSIOLOGY • MAIN PROBLEM : LOW CARDIAC OUTPUT • THEN COMPENSATORY MECHANISM TAKES PLACE - NEUROHORMONAL ACTIVATION - HIGHER END DIASTOLIC PRESSURE (FRANK STARLING) - MYOCARDIAL TISSUE REMODELLING -> MYOCARDIAL INJURY AND ISCHEMIA - THEN LOW CARDIAC OUTPUT AGAIN - VICIOUS CYCLE CONTINUES PATHOPHYSIOLOGY FRANK STARLING LAW CLINICAL ASSESSMENT
• THE DIAGNOSIS OF A HF IS LARGELY
DEPENDANT ON CLINICAL ASSESSMENT (BASED ON A CAREFUL HX AND PHYSICAL EXAMINATION) • ROUTINE LAB TESTS MIGHT HELP IN GETTING TO KNOW THE CAUSE OF HF RATHER THAN DIAGNOSING HF • HOWEVER, THE LEVEL OF SERUM BNP COULD HELP TO DIAGNOSE HF IN AN AMBIGOUS CASE (EG : SOB DUE TO OTHER CAUSE) FRAMINGHAM SYSTEM FOR DX HF HISTORY
• COMORBID ILLNESS OF PT • SX OF LEFT SIDED HF, EG: EXERTIONAL DYSPNEA, PND, ORTHOPNEA • SX OF RIGHT SIDED HF, EG: LL EDEMA, ASCITES • CARDIAC ASTHMA ( MIMICKING AEBA) IN ACUTE HF PHYSICAL EXAM • GENERAL – MALNOURISHED/CACHECTIC – WEAK PULSE, PULSUS ALTERNANS – SWELLING – INCREASED ADRENERGIC ACTIVITY TACHY,DIAPHORESIS, PALLOR, PERIPHERAL CYANOSIS, COLD EXTREMETIES, – JUGULAR NECK DISTENTION, MARKED HEPATOJUGULAR REFLUX – HEPATOMEGALY PHYSICAL EXAM
• HEART SIGNS – S3 GALLOP (EARLIEST SIGN IN ACUTE DECOMPENSATED CCF) – CARDIOMEGALY – PULSUS ALTERNANS – ACCENTUATION OF P2 HEART SOUND (INCREASED PULM A. PRESSURE) Investigation
Bloods FBC Anemia
RP, eGFR Baseline kidney function and concomitant CKD LFT BNP For acute decompensation Serum Screening for DM glucose Lipid profile Screening for dyslipidemia ABG Respiratory failure and acidosis. • BNP LEVEL • BNP < 100 HF unlikely • BNP >100 but < 500 use of clinical judgement • BNP > 500 HF likely Investigation
Evidence of ischemia, LV Hypertroophy and Arrthymias. CXR Cardiomegaly, pulmonary congestion and underlying lung pathology, acute decompensation. ECHO LV size, volume, systolic fx. LV wall thickness, scarring, wall motion abnormalities LV mechanical dysynchrony Dyastolic dysfx. Congenital abnormalities. Valvular structure and fx. Pulmonary hypertension CXR in Acute Decompensation/APO MANAGEMENT
• ACUTE HF / DECOMPENSATED HF/APO Unfortunately, we could not insert the clear version of the images. Some of the images might be blur, please see the cpg 2019 HF for clearer images. MX OF AHF • Assess for fluid status, vitals, perform the Ix and treat simultaneously. • Stablize haemodynamics with ABCDE. • Sit up patient. • O2 if spo2 <95%, hf nasal cannula can be used. • Diuretics, Iv furosemide 40-100 mg, target 0.5-1.0 kg of weight loss per day • Vasodilators, iv nitrates (iv nitroprusside is superior if ahf caused by hypertensive emergency) • Inotropes ( not routine but used in pt with low perfusion) • Morphine 1-3 mg bolus • Monitor for response to tx if not responding monitor in ICU setting. MANAGEMENT
• HFrEF Non-pharmacological
• Educate • Lifestyle – stop smoking, moderation in alcohol consumption, weight monitoring • Exercise – Tailored for each patient. • Diet – Low sodium diet • Restriction of fluid intake – 1.0-1.5L/day • Advice regarding sexual activity & Pregnancy Unfortunately, we could not insert the clear version of the images. Some of the images might be blur, please see the cpg 2019 HF for clearer images. Pharmacological
• Diuretics if fluid overload/congestion
• ACEI/ARB • B-blocker • MRA
• Others: Ivabradine, Nitrate, Digoxin, Anti-arthmic, ARNI DEVICE Therapy in HF • CRT (If NYHA 2-3 with OMT) – Sinus rhythm – Lvef <35% – Lbbb – QRS >130ms • IMPLANTABLE CARDIAC DEFIBRILLATORS (ICD) Primary prevention Secondary prevention As prophylactic 1. Patients resuscitated from SCD due to ventricular fibrillation or haemodynamically unstable sustained ventricular tachycardia. 2. Patients with chronic HF and LVEF ≤ 35% who experience syncope of unclear origin. 3. Prior MI and LVEF ≤ 40% with non- sustained VT AND inducible sustained VT or VF during an EP study. • In Physical exam don’t forget to look for any pacemakers at chest. SURGERY
• Revascularisation (CABG or PCI)
• Valvular repair or replacement
• Lv reduction surgery MANAGEMENT
• HFpEF HF PRESERVED EF
• Treat the underlying cause
– CAD – HTN – Volume overload – COPD – CKD References • Emedicine.medscape.com. 2020. Heart Failure: Practice Essentials, Background, Pathophysiology. [online] Available at: <https://emedicine.medscape.com/article/163062-overview> [Accessed 05 June 2020]. • Uptodate.com. 2020. Uptodate. [online] Available at: <https://www.uptodate.com/contents/overview-of- the-management-of-heart-failure-with-reduced-ejection-fraction-in- adults?search=heart%20failure&source=search_result&selectedTitle=2~150&usage_type=default&disp lay_rank=2> [Accessed 05 June 2020]. • cardioverter-defibrillator, I., 2020. Implantable Cardioverter-Defibrillator: Medlineplus Medical Encyclopedia. [online] Medlineplus.gov. Available at: <https://medlineplus.gov/ency/article/007370.htm> [Accessed 06 June 2020]. • Malaysianheart.org. 2020. Malaysian Heart. [online] Available at: <https://www.malaysianheart.org/?p=cpg> [Accessed 02 June 2020].
