Heart Failure

This is a presentation about heart failure from my second year of medical school. Three of the slides originally contained videos.

Transcript

1. Heart Failure Case 17
2. Congestive Heart Failure • Heart is unable to meet the metabolic needs of the body • Up to 10% of adults over age 65 • “Heart failure” = “congestive heart failure” (usually) • Three groups of causes: • Left heart failure • Right heart failure • High output heart failure
3. CHF Differential Diagnosis • Coronary artery disease is the cause of 60% of cases • Hypertension is the cause of 10% of cases • Valvular disease • Arrhythmias • Dilated cardiomyopathy Left Heart Failure
4. CHF Differential Diagnosis • Left heart failure • Pulmonary hypertension • Valvular disease • Left to right shunt • Pericardial disease • Restrictive cardiomyopathy Right Heart Failure
5. CHF Differential Diagnosis • Anemia • Thyrotoxicosis • Skeletal disorders • AV fistula • Beriberi • Cirrhosis • Acromegaly • Dermatological disorders High Output Heart Failure
6. Cardiomyopathy • Disease of the myocardium • Three categories: • Dilated cardiomyopathy • Restrictive cardiomyopathy • Hypertrophic cardiomyopathy • Hypertrophy from athletic training may be mistaken for cardiomyopathy
7. Dilated Cardiomyopathy • Normal ventricular wall thickness • Ventricular chamber enlargement • Generally systolic dysfunction • Increased preload • Ejection fraction <30% • Mitral or tricuspid regurgitation can result
9. Dilated Cardiomyopathy • Idiopathic - 50% of cases • Half of these are inherited (autosomal dominant) • Myocarditis • Ischemic • Infiltrative diseases • Hypertension • Peripartum • HIV • Connective tissue diseases • Doxorubicin and herceptin • Sleep apnea • Beriberi
10. Restrictive Cardiomyopathy • Normal or increased ventricular wall thickness • Normal or decreased ventricular chamber volume • Decreased ventricular wall compliance • Generally diastolic dysfunction • Must distinguish from restrictive pericarditis
11. Restrictive Cardiomyopathy • Amyloidosis • Sarcoidosis • Hemochromatosis • Hypereosinophilic syndromes • Endomyocardial fibrosis • Chemotherapy • Radiation therapy
12. Hypertrophic Cardiomyopathy • Genetic disease (autosomal dominant) • Left ventricular hypertrophy • Outflow obstruction • Presentation may be sudden death due to arrhythmia
14. CHF Classification • Class 1: Symptoms only at activity levels that would limit normal individuals • Class 2: Symptoms on ordinary exertion • Class 3: Symptoms on less than ordinary exertion • Class 4: Symptoms at rest New York Classification
15. CHF Classification • Stage A: High risk of heart disease without structural impairment or symptoms • Stage B: Heart disease with asymptomatic dysfunction • Stage C: Prior or current symptoms of heart failure • Stage D: Refractory end-stage heart failure AHA/ACC
16. Adaptive Mechanisms • Renin-angiotensin-aldosterone system activation • Sympathetic nervous system activation • ADH and endothelin secretion • Increased ANP and BNP Decreased Left Ventricular Output
17. Adaptive Mechanisms • Fluid retention • Increased atrial pressure • Increased pulmonary artery and capillary pressure • Pulmonary edema • Pulmonary hypertension • Catecholamine secretion • Increased afterload • Fatigue due to increased heart rate • Reduced filling time • Hypertrophy • Fetal contractile proteins Consequences
18. Systolic vs. Diastolic Dysfunction • Similar clinical symptoms • Fatigue • Dyspnea • Systolic symptoms usually more severe
19. Systolic vs. Diastolic Dysfunction • Decreased ejection fraction • Eccentric remodeling • Increased EDV • Decreased ratio of mass to cavity volume • Elongation of cardiomyocytes Systolic Dysfunction
20. Systolic vs. Diastolic Dysfunction • Normal ejection fraction • Concentric remodeling • Normal or reduced EDV • Increased ratio of mass to cavity volume • Cardiomyocytes are increased in diameter • Atrial fibrillation due to increased atrial pressure Diastolic Dysfunction
21. Left vs. Right Heart Failure • Dyspnea on exertion • Paroxysmal nocturnal dyspnea • Rales and occasional wheeze • Pleural effusion • S3 • Lateral displacement of PMI • Pulsus alternans if severe Left Heart Failure
23. Left vs. Right Heart Failure • Swelling of legs or abdomen • Raised JVP • Hepatojugular reflux • Pedal edema • Possible ascites • Parasternal heave Right Heart Failure
25. Left vs. Right Heart Failure • Left and right heart failure often overlap • Absence of dyspnea on exertion = absence of left heart failure • Waking at night with shortness of breath is more often due to asthma than heart failure
26. CHF Natural History • Untreated one-year mortality is around 30% • Death is due to arrhythmia or disease progression • Variation by etiology • Systolic has a worse prognosis • Infiltrative causes have a worse prognosis
27. CHF Treatment Guidelines • Identify and treat risk factors • Reduce heart workload • Reduce salt and water retention • Increase myocardial contraction Goals
28. CHF Treatment Guidelines • Risk factor reduction • Treatment of hypertension • Smoking cessation • Moderate exercise • Avoidance of alcohol • Treatment of metabolic syndrome • ACE inhibitor or ARB Stage A
29. CHF Treatment Guidelines • Stage A interventions • !-blockers • Implantable defibrillator Stage B
30. CHF Treatment Guidelines • Stage B interventions • Salt restriction • Diuretics • Aldosterone inhibitor • Digoxin • Hydralazine and nitrates • Biventricular pacing Stage C
31. CHF Treatment Guidelines • Stage C interventions • Heart transplant • 50% survive 13 years • Experimental drugs • End of life care Stage D
32. CHF Treatment Guidelines • Be cautious with drugs that reduce preload • Diuretics • Nitrates • Ca⁺⁺ channel blockers • ACE inhibitors • !-blockers have been shown to reduce mortality Diastolic Dysfunction
33. CHF Treatment Guidelines • Drugs to avoid: • NSAIDs • Thiazolidinediones • Metformin • 5PDE inhibitors if patient is on #-blockers or nitrates • Anti-arrhythmics other than amiodarone
34. BNP Measurement • BNP opposes the effects of RAAS, endothelin, and NE • Plasma BNP >100 pg/ml predicts heart failure • When dyspnea is present, BNP is usually >400 pg/ml
35. Evaluation of LV Function in CHF • BNP • CBC • Anemia • Polycythemia • Liver function • Hepatic congestion • Electrolytes, creatinine • Diuretic or ACE inhibitor therapy • Blood glucose
36. Evaluation of LV Function in CHF • Thyroid function • Ferritin, TBC • Viral studies • Thiamine • Genetic testing Cardiomyopathy
37. Evaluation of LV Function in CHF EKG
38. Evaluation of LV Function in CHF • Arrhythmias • Ischemia • ST depression • Left ventricular hypertrophy • V$: Deep S wave • V% or V&: Tall R wave • Left bundle branch block • Wide QRS • V% or V&: Notched R wave EKG
39. Evaluation of LV Function in CHF • Chest X-ray • Echocardiogram • Nuclear imaging • MRI • Exercise testing
40. Hyponatremia • Serum Na⁺ <135 mEq/L • Severe = <125 mEq/L • Nausea and malaise if mild • If severe, brain edema and osmotic fluid shift • Headache • Decreased level of consciousness • Seizures
41. Hyponatremia • Three categories: • Hypervolemic: Body water and Na⁺ are both increased; water is increased more • Euvolemic: Body water is increased while Na⁺ remains normal • Hypovolemic: Body water and Na⁺ are both decreased; Na⁺ is decreased more • Pseudohyponatremia: Significant hyperproteinemia or hyperlipidemia cause falsely low Na⁺ reading • Measure serum osmolality
42. Hyponatremia Differential Diagnosis • CHF • Nephrotic syndrome • Cirrhosis • Acute renal failure Hypervolemic
43. Hyponatremia Differential Diagnosis • SIADH • Glucocorticoid deficiency • Hypothyroidism • Primary polydipsia Euvolemic
44. Hyponatremia Differential Diagnosis • Salt-wasting nephropathy • Diuretics • Hypoaldosteronism • Vomiting • Diarrhea • Burns Hypovolemic
45. Clinical Evaluation of Hyponatremia • Fluid status • Plasma osmolality • Urine Na⁺ • Hypervolemic : Urine Na⁺ <20 mE/ml • Euvolemic: Urine Na⁺ >20 mE/ml • Hypovolemic: Urine Na⁺ depends on cause • >20 mE/ml if renal • Urine osmolality: >100 mOsmol/kg in hypovolemic
46. Hyponatremia Treatment • Hypovolemic • Normal saline • Euvolemic • Fluid restriction • Demeclocycline in SIADH • Hypervolemic • Fluid restriction • Hypertonic saline if neurological symptoms are present
47. Aldosterone Antagonists in CHF • RAAS activation compensates for hypoperfusion but leads to Na⁺ retention • Spironolactone and eplerenone both reduce morbidity and mortality in patients with advanced heart failure • Adverse effect: Hyperkalemia
48. Heart Failure
49. Montserrat Soufriere Hills Volcano
50. AUC: Montserrat Campus