CARDIOVASCULAR DISEASES

CARDIAC (HEART) FAILURE

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Heart Failure Incidence and Prevalence
Prevalence
Worldwide 22 million
United States 5 million
Incidence
Worldwide 2 million new cases / year
United States 500,000 new cases / year
Afflicts 10 out of every 1,000 people over age 65 in the
United States - (Statistics from American Heart association - 2002)

In India
20% of hospital admissions among persons older than 65
45% annual mortality in severe symptomatic heart failure
 What Is HF ?
The heart does not pump efficiently, not able
to move as much blood as it should pump
with each beat

Not maintain adequate cardiac output

Organs in the body do not get enough oxygen

rich blood that they need to work well
 Causes of Cardiac (Heart) Failure
Elevated filling pressure
(Metabolic demand like exercise / stress)

Clinical syndrome
(All forms of heart disease can lead to failure)

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The most common clinical causes of HF

HF is a syndrome, so always possible for one or more

underlying cause!

Ischemic heart disease ~ 40 percent

Dilated cardiomyopathy ~ 30 percent
Primary valvular heart disease ~ 15 percent
Hypertensive heart disease ~ 10 percent
Other ~ 5 percent
Specific Causes & Mechanisms
Ventricular outflow obstruction (Pressure overload)

Ventricular inflow obstruction

Ventricular volume overload

Impaired Ventricular function

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Cardiac Output
Preload
- Volume and pressure of blood entering in ventricle at
end of diastole
After load
- At end of systole
(Arterial resistance)
Myocardial contractility

Cardiac Failure
- Increases 3

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Symptoms

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Affects Peripheral Circulation
Impaired renal perfusion
- Salt / water retention
- Oedema
- Aldosteronism

Neuro-hormonal activation
- Activation of sympathetic nervous system
- Activation of renin-angiotensin system
- Peripheral vascular resistance

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ACE Angiotensin Converting Enzyme, ADH Anti Diuretic Hormone, Aldosterone Steroid
hormone that balances the Na, K, Ca levels, Sympathetic Stimulating Nerves 10
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Types of Heart Failure
Acute / Chronic heart failure

Left / Right / Biventricular heart failure

Forward & Backward heart failure

Diastolic & Systolic dysfunction

High Output failure

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Acute / Chronic heart failure
Acute Myocardial infarction

Chronic Progressive valvular heart disease

Compensatory changes in heart includes hypertrophy,

chamber enlargement, increased heart rate

Common in persons with pulmonary embolism, increased

metabolic demand, pregnancy, thyrotoxicosis, anaemia

FACTORS AGGRAVATING:
- Reduction on therapy
- Fluid retaining drugs (Corticosteroids)
- Stress
- Arrhythmia
- Infection & illness 13
 Left / Right / Biventricular heart failure

Due to cardiac myopathy ischaemic heart diseases

Left Heart: Right Heart:

LA, LV, Mitral valve, Aortic
valve
Decrease output & increase
pressure
Leads to pulmonary
congestion, Pulmonary
oedema, pulmonary
hypertension
RA, RV, Tricuspid valve,
Pulmonary valve
Decrease output & increase
pressure
Due to multiple pulmonary
emboli, pulmonary valvular
stenonis

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 Signs & Symptoms
Left-Sided Heart Failure Right-Sided Heart Failure
Dyspnea
Unexplained cough Lower extremity edema
Pulmonary crackles Liver enlargement
Low oxygen saturation Anorexia
Third heart sound Abdominal pain
Reduced urine output Nausea
Altered digestion Weight gain
Dizziness and light- Weakness
headedness
Confusion
Restlessness and anxiety
Fatigue and weakness
Forward & Backward heart failure
Forward Inadequate cardiac output

Backward Normal output, but more salt and water retention

leading to pulmonary and systemic venous congestion

High output failure

Large Atrio Ventricular (AV) shunt, severe anaemia, thyrotoxicosis

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Diastolic & Systolic heart failure
Diastolic Poor ventricular filling, High filling pressure,
Abnormal ventricular relaxation
Systolic Impaired myocardial contraction

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 Diagnostic Tests
Echocardiography to assess
ejection fraction (EF)
Chest X-ray
ECG
Cardiac stress test
Cardiac catheterization
Cardiac computed
tomography (CCT) scan or
magnetic resonance
imaging (MRI)
Radionuclide ventriculo-
graphy
Ambulatory ECG
monitoring (Halter
monitor)
Pulmonary function tests
Heart biopsy
Exercise testing
(6-minute walk)
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 Other Diagnostic Tests
Medical history and physical exam

Brain natriuretic peptide (Na+, proteins) measurement

Lab tests: complete blood cell count, metabolic panel,

liver function studies and urine analysis

Other tests: Thyroid function tests and fasting lipid

profile
 Non-pharmacologic treatment
Exercise training for stable HF patients, increased exercise
capacity -> decreased hospitalization rate, increased quality of
life, decreased symptoms.
Weight loss in obese patients
Dietary Na restriction ( 2 g/day)
Fluid and free water restriction ( 1.5 L/day)
Minimize medications known to have deleterious effects on
heart failure (negative ionotrops, NSAIDs, over-the-counter
stimulants)
Adequate Oxygen
Fluid removal (dialysis, thoracentesis, paracentesis)
 Pharmacologic treatment
IV Vasodilators
- Nitroglycerine
- Nitroprusside

IV Inotropic agents
- Dopamine
- Dobutamine
- ACE inhibitors

IV Diuretics
- Furosemide
- Bumetanide
 Surgical treatment

Coronary artery bypass grafting

(revascularization)
Percutaneous coronary intervention (Angioplasty)
Valve replacement surgery
Biventricular pacemaker
Heart transplantation
Left ventricular assist device (LVAD)
 Drugs to avoid in HF patients

NSAIDs - Induce systemic vasoconstriction, counteract ACE

inhibitors, blunt the effects of diuretics.

Thiazolidinediones - Contribute to fluid retention. Should be

avoided in severe failure.

Metformin - Increased risk of lactic acidosis.

Cilostazole - (Phosphodiesterase (PDE) inhibitor) Increases

mortality.

Calcium channel blockers - (avoid Verapamil and Diltiazem)

Trials with amlodipine and felodipine showed a neutral effect
on mortality.
 What should be done to prevent
Progression of the Disease?
Become Conscious of Lifestyle Choices!
Make Better Choices
Quit Smoking
Reduce Weight
Avoid Excess Alcohol and Drugs
Exercise
Take Medication
Immunization
Communicate with health care specialists and get
knowledge about your health
Treat high cholesterol, diabetes and irregular heart beat
Attention on salt intake, swelling and stress
 Early Symptoms of Heart Failure
Can be Treated and Cured

A weight gain - Loss of 2 or more pounds

in 1 day, or 4 pounds in 1 week
Confusion, restlessness or lightheaded
A feeling of fullness or bloating in your
stomach
Cough, shortness of breath, swelling
Fatigue, lose of appetite, or nausea