CHF

Heart Failure
Heart Failure
 Results from any structural or
functional abnormality that impairs
the ability of the ventricle to eject
blood (Systolic Heart Failure) or
to fill with blood (Diastolic Heart
Failure).
Pathophysiology
Types of Heart Failure
 Low-Output Heart Failure

 Systolic Heart Failure:
 decreased cardiac output
 Decreased Left ventricular ejection fraction
 Diastolic Heart Failure:
 Elevated Left and Right ventricular end-diastolic
pressures
 May have normal LVEF
 High-Output Heart Failure
 Seen with peripheral shunting, low-systemic vascular
resistance, hyperthryoidism, beri-beri, carcinoid, anemia
 Often have normal cardiac output
 Right-Ventricular Failure
 Seen with pulmonary hypertension, large RV infarctions.
Classification of Heart Failure
 New York Heart Association (NYHA)

 Class I –No symptoms of HF only at
ordinary exertion.
 Class II – symptoms of HF with
ordinary exertion
 Class III – symptoms of HF on less
than ordinary exertion
 Class IV – symptoms of HF at rest
Causes
 Systolic Dysfunction
 Ischemia,
 Mycoarditis (viral)
 Pregnancy
 Doxorubicin
 Diastolic Dysfunction
 Hypertension
 Hypertrophic obstructive
cardiomyopathy (HCM)
 Restrictive cardiomyopathy
Clinical Presentation of Heart Failure
 Due to excess fluid accumulation:

 Dyspnea (most sensitive symptom)
 Orthopnea
 Paroxysmal Nocturnal Dyspnea (PND)
 Hepatic congestion
 Ascites
 Peripheral edema
 Due to reduction in cardiac ouput:
 Fatigue
 Weakness
 Confusion
 Oligouria
Specific Investigations
 Electrocardiogram
 X-ray Chest
 Echocardiogram
 Coronary angiogram
Pulmonary Edema due to Heart Failure
Lab Analysis in Heart Failure
 CBC
 Since anemia can exacerbate heart failure
 Serum electrolytes and creatinine
 Before starting diuretics
 Fasting Blood glucose
 To evaluate for possible diabetes mellitus
 Thyroid function tests
 Since thyrotoxicosis can precipitate HF
 Iron studies
 To screen for hereditary hemochromatosis as
cause of heart failure.
 ANA
 To evaluate for possible lupus
 Viral studies
 If viral mycocarditis suspected
Laboratory Analysis
 BNP
 With chronic heart failure, atrial mycotes
secrete increase amounts of atrial natriuretic
peptide (ANP) and brain natriuretic pepetide
(BNP) in response to high atrial and
ventricular filling pressures
 Usually is > 400 pg/mL in patients with
dyspnea due to heart failure.
Management
 Lifestyle modification
 Lower salt intake
 Medication compliance
 Daily weight
 Discontinue drugs that may
contribute to heart failure (NSAIDS,
antiarrhythmics, calcium channel
blockers)
Medical Therapy
1. ACE inhibitor (or ARB if not

tolerated)
2. Beta blockers
3. Potassium sparing diuretics
4. Loop diuretics
5. Digoxin
6. Hydralazine & Nitrate
Diuretics
 Loop diuretics
 Furosemide, buteminide
 For Fluid control, and to help relieve
symptoms
 Potassium-sparing diuretics
 Spironolactone, eplerenone
 Help enhance diuresis
 Maintain potassium
 Shown to improve survival in CHF

ACE Inhibitor
 Improve survival in patients with all
severities of heart failure.
 Begin therapy low and titrate up as
possible
 If cannot tolerate, try ARB.
Beta Blocker therapy
 Certain Beta blockers (carvedilol,
metoprolol, bisoprolol) can improve
overall and event free survival in NYHA
class II to III HF, probably in class IV.
 Contraindicated:
 Heart rate <60 bpm
 Symptomatic bradycardia
 Signs of peripheral hypoperfusion
 COPD, asthma
 PR interval > 0.24 sec, 2nd or 3rd degree block
Hydralazine plus Nitrates
 Lower rates of hospitalization, and

improvement in quality of life.
Digoxin
 Given to patients with HF and
recurrent admissions
 Shown to significantly reduce
hospitalization for heart failure, but
no benefit in terms of overall
mortality.
Implantable Cardioverter-Defibrillators
for HF
 Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
 About one-third of mortality in
HF is due to sudden cardiac
death.
 Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF ≤ 35% have a significant
survival benefit from an
implantable cardioverter-
defibrillator (ICD) for the
primary prevention of SCD.
Management of Refractory Heart
Failure
 Inotropic drugs:
 Dobutamine, dopamine, milrinone,
nitroprusside, nitroglycerin
 Mechanical circulatory support:
 Intraaortic balloon pump
 Left ventricular assist device (LVAD)
 Cardiac Transplantation

CHF

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Heart Failure

 Low-Output Heart Failure

 New York Heart Association (NYHA)

 Due to excess fluid accumulation:

1. ACE inhibitor (or ARB if not

 Shown to improve survival in CHF

 Lower rates of hospitalization, and

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