heart failure
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CARDIAC FAILURE
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Group members:
Karjome Lama Alok Chandra Thakur
Namita GyawaliNanayakkara Sattambi R.D.Thanuga
Dilhani
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NORMAL HEART HEART FAILURE
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INTRODUCTION One of the most common ailments treated by
the physicians. In simple words, “cardiac failure” means failure
of the heart to pump the blood to satisfy the bodily needs but it doesn’t mean that the heart has completely stopped like in cardiac arrest.
It is not considered as a disease. Rather, it is the result from any heart condition that reduces the ability of the heart to pump the blood due to decreased contractility of myocardium.
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Heart failure may occur suddenly, or it may develop gradually. When heart function deteriorates over years, one or more conditions may exist. The strength of muscle contractions may be reduced, and the ability of the heart chambers to fill with blood may be limited by mechanical problems, resulting in less blood to pump out to tissues in the body. Conversely, the pumping chambers may enlarge and fill with too much blood when the heart muscle is not strong enough to pump out all the blood it receives.
In addition, as the architecture of the heart changes as it enlarges, regurgitation of the mitral valve may develop, making the heart failure even worse.
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Cardiac Physiology(remember this?)
CO = SV x HR
HR: parasympathetic and sympathetic tone
SV: preload, afterload, contractility
Preload Contractility Afterload
Stroke Volume Heart Rate
Cardiac Output
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PreloadDef: Passive stretch of muscle prior
to contractionMeasurement: Swan-Ganz
LVEDP(Left Ventricular End-Diastolic Volume)
Really a function of LVEDVAffected by compliance
Low compliance = higher LVEDP @ lower LVEDV
False high estimate of preload04/10/23 7
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AfterloadDef: Force opposing/stretching
muscle after contraction beginsMeasurement: SVR(Systemic
Vascular Resistance)Really a function of:
SVR Chamber radius (dilated
cardiomyopathies) Wall thickness (hypertrophy)
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ContractilityDef: Normal ability of the muscle to
contract at a given force for a given stretch, independent of preload or afterload forces
In other words: How healthy is your heart muscle?
Ischemia, Hypertrophy, Muscle loss 04/10/23 9
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What Causes Heart Failure?
Health conditions that either damage the heart or make it work too hard Coronary artery disease Heart attack High blood pressure & Hypertension Abnormal heart valves Heart muscle diseases (cardiomyopathy) Heart inflammation (myocarditis &
pericarditis)
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ENDOCARDITIS PERICARDITIS
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NORMAL HEARTHYPERTROPHIED
HEART
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What Causes Heart Failure?
Congenital heart defectsSevere lung diseaseDiabetesSevere anemiaOveractive thyroid gland (hyperthyroidism)
Abnormal heart rhythms(Arrhythmias)
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What Causes Heart Failure?
Coronary artery diseaseCholesterol and fatty deposits
build up in the heart’s arteriesLess blood and oxygen reach
the heart muscleThis causes the heart to work
harder and occasionally damages the heart muscle
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What Causes Heart Failure?
Heart attackAn artery supplying blood to
the heart becomes blockedLoss of oxygen and nutrients
damages heart muscle tissue causing it to die
Remaining healthy heart muscle must pump harder to keep up
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What Causes Heart Failure?
High blood pressure & Hypertension
Uncontrolled high blood pressure and hypertension doubles a persons risk of developing heart failure
Heart must pump harder to keep blood circulating
Over time, chamber first thickens, then gets larger and weaker
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What Causes Heart Failure? Abnormal heart valves Heart muscle disease
Damage to heart muscle due to drugs, alcohol or infections
Congenital heart disease Severe lung disease
Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.04/10/23 17
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What Causes Heart Failure?
DiabetesTend to have other conditions that make the heart work harder
ObesityHypertensionHigh cholesterol
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What Causes Heart Failure?
Severe anemiaNot enough red blood cells to carry
oxygenHeart beats faster and can become
overtaxed with the effort
HyperthyroidismBody metabolism is increased and
overworks the heart
Abnormal Heart Rhythm If the heart beats too fast, too slow or
irregular it may not be able to pump enough blood to the body
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TYPES OF HEART FAILURE Anatomically
Left versus Right
Physiologically Systolic versus Diastolic
Functionally How symptomatic is your
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Left versus Right Failure
Left Heart Failure Dyspnea Decrease exercise
tolerance Cough
OrthopneaPink, frothy
sputum
Right Heart Failure
Decrease exercise tolerance
Edema Hepatomegaly Ascites
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Bilateral pulmonary effusion in right heart failure
Pitting edema of the ankle.
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The renin–angiotensin–aldosterone system
1.Reduction of renal blood flow and glomerular filtration rate.
2.The renin–angiotensin–aldosterone system is activated.
3.Increase in peripheral vascular resistance.
4.Increase in sodium and water retention.
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THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM
ACE
ACE INHIBITORS
JGA
RENIN
ADRENAL
ALDOSTERONE
ANGIOTENSINOGEN ANGIOTENSIN 1
ANGIOTENSIN 2
VASOCONSTRICTS
Na RETENTION
INCREASED BP
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Systolic versus Diastolic
Systolic– “can’t pump” Aortic Stenosis HTN Aortic Insufficiency Mitral
Regurgitation Muscle Loss
IschemiaFibrosisInfiltration
Diastolic- “can’t fill” Mitral Stenosis Tamponade Hypertrophy Infiltration Fibrosis
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DIASTOLIC HEART FAILURE
SYSTOLIC HEART FAILURE
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ACUTE MITRAL REGURGITATION
CHRONIC MITRAL REGURGITATION
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Acute versus Chronic
Acute heart failure develops rapidly can be immediately life
threatening due to lack of time to undergo compensatory adaptations.
may result from cardiopulmonary by-pass surgery, acute infection (sepsis), acute myocardial infarction, valve dysfunction, severe arrhythmias, etc.
can often be managed successfully by pharmacological or surgical interventions.
Chronic heart failure a long-term condition
(months/years) that is associated with the heart undergoing adaptive responses (e.g., dilation, hypertrophy) to a precipitating cause.
These adaptive responses, however, can be deleterious in the long-term and lead to a worsening condition.
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Class
% of patient
s
Symptoms
I 35% No symptoms or limitations in ordinary physical activity
II 35% Mild symptoms and slight limitation during ordinary activity
III 25% Marked limitation in activity even during minimal activity. Comfortable only at rest
IV 5% Severe limitation. Experiences symptoms even at rest
Functional classification of Heart Failure by New York Heart Association
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Pathophysiology of the Heart Failure
1.Decreased stroke volume2.Raised end-diastolic volume and
pressure 3.Ventricular dilation will occur. 4.Chronic elevation of diastolic pressures.5.Increased capillary pressure.6.Increased peripheral vascular
resistance.7.Transudation of fluid with resulting
pulmonary or systemic edema.
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8. Activation of neural and humoral systems.
9. Frank –starling mechanism10.Increased LV afterload, so that
excessive sympathetic activity may further depress cardiac function.
11.Increased activity of the sympathetic nervous system(mainly adrenergic activity) but reduced vagal activity to heart.
12.Increased myocardial contractility, heart rate, and venous tone.
Pathophysiology of the Heart Failure
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Frank-starling Mechanism
The Frank-Starling law of the heart states that as the ventricular volume increases and stretches the myocardial muscle fibers, the stroke volume increases, up to its maximum capacity. After that point, increasing volume increases pulmonary capillary pressure (and pulmonary congestion), without increasing the stroke volume or cardiac output. The mechanism is the length-force relationships of muscle contraction.
Str
oke
volu
me
End-Diastolic volume
Maximum capacity to produce stroke volume
Normal range: stroke volume increases with end-diastolic volume
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An overall view of Heart Failure
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Shortness of Breath (Dyspnea)WHY?
• Blood “backs up” in the pulmonary veins because the heart can’t keep up with the supply an fluid leaks into the lungs
SYMPTOMS• Dyspnea on exertion or at rest• Difficulty breathing when lying flat
(Orthopnea)• Waking up short of breath
Signs and Symptoms of Heart Failure
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Persistent Cough or WheezingWHY?
•Fluid “backs up” in the lungs
SYMPTOMS•Coughing that produces white or pink blood-tinged sputum
Signs and Symptoms of Heart Failure
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EdemaWHY?
•Decreased blood flow out of the weak heart
•Blood returning to the heart from the veins “backs up” causing fluid to build up in tissues
SYMPTOMS•Swelling in feet, ankles, legs or abdomen•Weight gain
Signs and Symptoms of Heart Failure
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Tiredness, fatigueWHY?
•Heart can’t pump enough blood to meet needs of bodies tissues
•Body diverts blood away from less vital organs (muscles in limbs) and sends it to the heart and brain
SYMPTOMS•Constant tired feeling•Difficulty with everyday activities
Signs and Symptoms of Heart Failure
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Lack of appetite/ NauseaWHY?
•The digestive system receives less blood causing problems with digestion
SYMPTOMS•Feeling of being full or sick to your stomach
Signs and Symptoms of Heart Failure
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Confusion/ Impaired thinkingWHY?
•Changing levels of substances in the blood ( sodium) can cause confusion
SYMPTOMS•Memory loss or feeling of
disorientation•Relative or caregiver may notice this
first
Signs and Symptoms of Heart Failure
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Increased heart rateWHY?
•The heart beats faster to “make up for” the loss in pumping function
SYMPTOMS•Heart palpitations•May feel like the heart is racing or
throbbing
Signs and Symptoms of Heart Failure
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Clinical Data
CXR(Chest X-Ray) Kerley’s lines : A and B Pulmonary Edema Cephalization Pleural Effusions (bilateral)
EKG(Electrocardiogram) Left atrial enlargement Arrhythmias Hypertrophy (left or right)
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Cardiomyopathy Pulmonary Edema
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Clinical Data
HEART SOUNDS!!!Systolic Murmurs
Mitral Regurgitation Aortic Stenosis
Diastolic Murmurs Mitral Stenosis Aortic Insufficiency
S3: Rapid filling of a diseased ventricle
Mitral Stenosis
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Clinical DataLaboratory Data
Chemistry Renal Function: Be Wary
BNP(Brain Natriuretic Peptide) Test Used in ER departments the world over Good negative correlation Need baseline for positivity Pulmonary versus cardiac dyspnea
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Modified Framingham Criteria Diagnosis for Heart Failure
Major criteriaNeck vein distensionOrthopneaCardiomegaly on CXRCVP > 12 mm HgLeft Ventricular
dysfunction on EKGWeight lossAcute pulmonary
edema
Minor criteriaBilateral ankle
edemaNight coughDyspnea on exertionHepatomegalyPleural effusionTachycardia (> 120
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The more common forms of heart failure cannot be cured, but can be treatedLifestyle changesMedicationsSurgery
Treatment Options
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Stop smoking Avoid alcohol Avoid or limit caffeine Eat a low-fat, low-sodium diet
Exercise Reduce stress
Lifestyle Changes
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Lose weight Keep track of symptoms and weight and report any changes or concern to the doctor
Limit fluid intake See the doctor more frequently
Lifestyle Changes
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ACE InhibitorsCornerstone of heart failure therapy
Proven to slow the progression of heart failure
Vasodilator – cause blood vessels to expand lowering blood pressure and the hearts work load
Medications used to treat Heart Failure
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Diuretics (water pills) Prescribed for fluid build up, swelling or
edema Cause kidneys to remove more sodium
and water from the bloodstream Decreases workload of the heart and
edema Fine balance – removing too much fluid
can strain kidneys or cause low blood pressure
Medications used to treat Heart Failure
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PotassiumMost diuretics remove potassium from the body
Potassium pills compensate for the amount lost in the urine
Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles
Medications used to treat Heart Failure
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VasodilatorsCause blood vessel walls to relax
Occasionally used if patient cannot tolerate ACE
Decrease workload of the heart
Medications used to treat Heart Failure
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Digitalis preparationsIncreases the force of the hearts contractions
Relieves symptomsSlows heart rate and certain irregular heart beats
Medications used to treat Heart Failure
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Beta-blockersLower the heart rate and blood pressure
Decrease the workload of the heart Blood-thinners (coumadin)
Used in patients at risk for developing blood clots in the blood vessels, legs, lung and heart
Used in irregular heart rhythms due to risk of stroke
Medications used to treat Heart Failure
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Surgery and other Medical ProceduresNot often used in heart failure unless there is a correctable problemCoronary artery bypassAngioplastyValve replacementDefibrillator implantationHeart transplantationLeft ventricular assist device(LVAD)
Treatment Options
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Incidence of Heart Failure and its Prognosis
Heart failure is the leading cause of hospitalization of patients over 65 years in age.
> 15million new cases of Heart failure estimated each year worldwide.
Rapidly increasing number because of the aging population.
Despite many new advances in drug therapy and cardiac assist devices, the prognosis for chronic heart failure remains very poor.
One year mortality figures are 50-60% for patients diagnosed with severe failure, 15-30% in mild to moderate failure, and about 10% in mild or asymptomatic failure.04/10/23 57
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Thank you for listening!!!
Questions?????
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