heart failure (hf) is a clinical

8/13/2019 Heart Failure (HF) is a Clinical

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Heart failure (HF) is a clinicalsyndrome in which an abnormality of

cardiac structure or function is

responsible for the inability of the heart

to eject or fill with blood at a rate

commensurate with the requirements

of the metabolizing tissues.


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HF results in a constellation of clinical

manifestations, including, in various

combinations, circulatory congestion,

dyspnea, fatigue, and weakness.


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The severity of the clinical

manifestations are commonly describedaccording to criteria developed

by the New York Heart Association.


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The New York Heart Association (NYHA) Functional Classification provides a

simple way of classifying the extent of heart failure. It places patients in one

of four categories based on how much they are limited during physical

activity; the limitations/symptoms are in regards to normal breathing and

varying degrees in shortness of breath and or angina pain:

NYHA Class Symptoms

I No symptoms and no limitation in ordinary physical activity, e.g.

shortness of breath when walking, climbing stairs etc.

II mild symptoms (mild shortness of breath and/or angina) and slight

limitation during ordinary activity.

III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m).

Comfortable only at rest.

IV Severe limitations. Experiences symptoms even while at rest. Mostly

bedbound patients.
http://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Congestive_heart_failure


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CAUSES OF HEART FAILUREUNDERLYING CAUSES

Although HF may occur as a consequence of mostforms of heart disease,

in the United States and Western Europe,ischemic heart disease is responsible

for about three-quarters of all cases.

Cardiomyopathiesare second in frequency,

while congenital, valvular,

and hypertensive heart disease are less common causes.


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PRECIPITATING CAUSES In evaluating patients with HF,

it is important

to identify not only the underlying but also theprecipitatingcause .

Frequently, clinical manifestations of HF are seen for

the first time in the course of an acute disturbance thatplaces an additional load on a myocardium that is

chronicallyexcessively burdened. Such a heart may be

adequately compensated under normal circumstances

but have little additional reserve, the additional loadimposed by a precipitating

cause results in further deterioration of cardiac

function.


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The ten mostcommon precipitating causes are described

below.1. Infection.

Patients with pulmonary vascular congestion due to

left ventricular failure are more susceptible topulmonary infection

than are normal persons; however, any infection mayprecipitate HF.

The resulting fever, tachycardia, hypoxemia, and theincreased metabolic

demands may place a further burden on an overloaded,but compensated,

myocardium of a patient with chronic heart disease.


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2.Arrhythmias. These are among the

most frequent precipitatingcauses of HF. They exert a deleterious

effect on cardiac function

through a variety of mechanisms:


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(a) Tachyarrhythmias reduce the

time available for ventricular filling, contributing

especially to diastolic

HF; they may also cause ischemic myocardial

dysfunction in

patients with ischemic heart disease.


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(b) The dissociation between

atrial and ventricular contractions characteristic

of many brady- and

tachyarrhythmias results in the loss of the atrial

booster pump mechanism,

i.e., the atrial kick, thereby raising atrial

pressures.


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(c) Cardiac performance may become further

impaired because of the loss of

normally synchronized ventricular contraction in

any arrhythmia associated

with abnormal intraventricular conduction (see

resynchroniz ation

therapy below).


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(d) Slowing of the heart rate associated with

complete atrioventricular block or other severe

bradyarrhythmias reduces

cardiac output unless stroke volume rises reciprocally;

this compensatory

response is limited in myocardial dysfunction, even in

the absence of overt HF.


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3. Physical, Dietary, Fluid, Environmental, and

Emotional Excesses.

4. Myocardial Infarction.

5. Pulmonary Embolism.

6.Anemia.7. Thyrotoxicosis and Pregnancy.

8.Aggravation of Hypertension.

9. Rheumatic, Viral, and Other Forms ofMyocarditis.

10. Infective Endocarditis.


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FORMS OF HEART FAILURE

HF may be described as

systolic or diastolic, high-output or low-output,

acute or chronic, right-sided or left-sided, andforward or backward.

SALT AND WATER RETENTION


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CLINICAL MANIFESTATIONS OF HEARTFAILURE

RESPIRATORY DISTURBANCESDyspnea, Orthopnea,

Paroxysmal(Nocturnal ) Dyspnea,

Cheyne-Stokes Respiration,


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OTHER SYMPTOMSFatigue and Weakness


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Abdominal SymptomsAnorexia and

nausea associated with abdominal

pain and fullness are frequentcomplaints and may be related to the

congested liver and portal venous

system.


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CerebralSymptomsPatients with severe HF,

particularly elderly patients

with cerebral arteriosclerosis, reduced cerebral

perfusion, andarterial hypoxemia, may develop alterations in the

mental state characterized

by confusion, difficulty in concentration, impairment of

memory, headache, insomnia, and anxiety.Nocturia is common in HF

and may contribute to insomnia.


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PHYSICAL FINDINGS

Pulmonary Rales

Cardiac EdemaHydrothorax and Ascites

Congestive Hepatomegaly

Jaundice , Cardiac Cachexia


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Other Manifestations With reduction of blood

flow, the skin, especially

in the extremities, may be cold, pale, and

diaphoretic. Urine flowis depressed, contains

albumin, has a high specific gravity, and a lowconcentration of sodium. In addition, prerenal

azotemia may be

present. In patients with long-standing severeHF, depression and sexual

dysfunction are common.


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DIFFERENTIAL DIAGNOSIS

The diagnosis


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Framingham Criteria for Diagnosis of Congestive Heart Failurea

MAJOR CRITERIA

Paroxysmal nocturnal dyspnea

Neck vein distentionRales

Cardiomegaly

Acute pulmonary edema

S3 gallop

Increased venous pressure (16 cmH2O)

Positive hepatojugular reflux

MINOR CRITERIA

Extremity edema

Night cough

Dyspnea on exertion

HepatomegalyPleural effusion

Vital capacity reduced by one-third from normal

Tachycardia (120 bpm)

MAJOR OR MINOR

Weight loss 4.5 kg over 5 days treatment


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TREATMENT

A simple rule for the treatment of all patients with HF cannot be

formulated because of its varied etiologies, hemodynamic

features, clinical manifestations, and severity. The treatment of

HF may be divided into five components:

(1) general measures; (2) correction of the underlying cause; (3)

removal of the precipitating cause; (4) prevention of

deterioration of cardiac function; and (5) control of thecongestive HF state.


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PROGNOSISThe prognosis in patients with HF

depends primarily on the nature of

the underlying heart disease and on

the presence or absence of a

precipitatingfactor that can be treated.


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216 HEART FAILURE AND COR

PULMONALEEugene Braunwald

HEART FAILURE

1367-1377

Harrisons Principle in Internal Medicine 16thEd,

heart failure (hf) is a clinical

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