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Chronic Heart Failure A Clinical Perspective1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. Management1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementThe Function of the HeartThe Function of the Heart Sinoatrial node Bundle of His Atrioventricular node Purkinje fibresThe Function of the HeartThe Function of the HeartThe Function of the HeartThe Function of the Heart Cardiac Output = Stroke Volume x Heart RateThe Function of the Heart Cardiac Output = Stroke Volume x Heart RateThe Function of the Heart Cardiac Output = Stroke Volume x Heart Rate Stroke Volume = End Diastolic Volum End Systolic VolumeThe Function of the Heart Cardiac Output = Stroke Volume x Heart Rate • Preload • Contractility • Afterload1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. Management1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementPathophysiology What is the heart failing to do? ‘a clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body’ passmedicine.comPathophysiology What is the heart failing to do? ‘a clinical syndrome where the art is unable to pump enough blood to meet the metabolic needs of the body’ Pumping function of the heart Metabolic needs of the body normal increased impaired normalPathophysiology What is the heart failing to do? ‘a clinical syndrome where the art is unable to pump enough blood to meet the metabolic needs of the body’ Pumping function of the heart Metabolic needs of the body normal increased impaired normalPathophysiology High Output Heart Failure metabolic demandPathophysiology High Output Heart Failure Causes • Pregnancy • Hyperthyroidism • AnaemiaPathophysiology What is the heart failing to do? ‘a clinical syndrome where the art is unable to pump enough blood to meet the metabolic needs of the body’ Pumping function of the heart Metabolic needs of the body normal increased impaired normalPathophysiology What is the heart failing to do? ‘a clinical syndrome where the art is unable to pump enough blood to meet the metabolic needs of the body’ Pumping function of the heart Metabolic needs of the body normal increased impaired normalPathophysiology What is the heart failing to do?Pathophysiology What is the heart failing to do?Pathophysiology What is the heart failing to do? Diastolic Failure - Thick walls - Stiff Walls - External compressionPathophysiology What is the heart failing to do? Diastolic Failure - Thick walls: ventricular hypertrophy - Stiff Walls: restrictive cardiomyopathy - External compression: cardiac tamponade constrictive pericarditisPathophysiology What is the heart failing to do?Pathophysiology What is the heart failing to do?Pathophysiology What is the heart failing to do? Systolic Failure - Thin, stretched walls - Poor blood supply - Faulty electrical conductionPathophysiology What is the heart failing to do? Systolic Failure - Thin, stretched walls: dilated cardiomyopathy - Poor blood supply:ischaemic heart disease - Faulty electrical conductioarrhythmiaPathophysiology What is the heart failing to do? Pathophysiology What is the heart failing to do? Diastolic Failure Systolic Failure - Thick walls: ventricular hypertrophy - Thin, stretched walls: dilated cardiomyopathy - Stiff Walls: restrictive cardiomyopathy - Poor blood supply ischaemic heart disease - External compression: cardiac tamponade - Faulty electrical conduction arrhythmia constrictive pericarditisPathophysiology What is the heart failing to do? ‘a clinical syndrome where the art is unable to pump enough blood to meet the metabolic needs of the body’ Pumping function of the heart Metabolic needs of the body normal increased impaired normal1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementSigns and Symptoms Right Heart Left Heart Failure FailureSigns and Symptoms Right Heart Left Heart Failure FailureWhat symptoms are caused by: - poor blood flow into the systemic circulation? - a backlog of blood in the pulmonary circulation?Signs and Symptoms Left heart failure Symptoms § Syncope § Weakness § Racing heart § Shortness of breath § Orthopnoea § Paroxysmal nocturnal dyspnoea § Nocturnal cough Signs and Symptoms Left heart failure: New York Association Classification Severity of chronic heart Breathless when…. failure least severe Class I N/A Class II Doing ordinary physical activity Class III Doing less than ordinary physical activity most severe Class IV At restSigns and Symptoms Left heart failure Signs § Cardiomegaly § Displaced apex beat § S3 gallop § Pulmonary oedema § Pleural effusion § Crepitations § Decreased vital capacitySigns and Symptoms Left heart failureSigns and Symptoms Left heart failure Signs § Cardiomegaly § Displaced apex beat § S3 gallop § Pulmonary oedema § Pleural effusion § Crepitations § Decreased vital capacitySigns and Symptoms S 3 Middle of diastoleSigns and Symptoms Left heart failure Signs § Cardiomegaly § Displaced apex beat § S3 gallop § Pulmonary oedema § Pleural effusion § Crepitations § Decreased vital capacitySigns and Symptoms Left heart failureSigns and Symptoms Left heart failure Signs § Cardiomegaly § Displaced apex beat § S3 gallop § Pulmonary oedema § Pleural effusion § Crepitations § Decreased vital capacitySigns and Symptoms Right Heart Left Heart Failure FailureSigns and Symptoms Right Heart Left Heart Failure FailureWhat symptoms are caused by: - backlog of blood in the systemic circulation?Symptoms Right heart failure Symptoms § Bilateral ankle oedema § Sacral oedema § Ascites § Weight gainSymptomsSymptoms Right heart failure Signs § Parasternal heave § Neck vein distension § Hepatojugular reflux § Hepatomegaly § Weight loss with treatmentSymptoms external jugular vein internal jugular vein Symptoms RquadranterSymptoms quadrantwerSymptoms Right heart failure Signs § Parasternal heave § Neck vein distension § Hepatojugular reflux § Hepatomegaly § Weight loss with treatmentSigns and Symptoms Right Heart Left Heart Failure Failure1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementWhat are the important investigations?Investigations • Blood tests • ECG • Echocardiogram • (CXR)Investigations • Blood tests • ECG • Echocardiogram • (CXR)Investigations (N-terminus) NT pro BNP stretch! pro BNP (brain natriuretic peptide) BNP myocyte) (circulation) Investigations NT pro BNP Normal <400ng/litre Moderately raised 400-2000ng/litre High >2000ng/litre Investigations NT pro BNP consider other Normal <400ng/litre diagnoses Moderately raised 400-2000ng/litre Echo within 6 weeks High >2000ng/litre Echo within 2 weeksInvestigations NT pro BNP • Age (over 70) • Ischaemia • Afro-Caribbean • Hypoxaemia • Obesity • Sepsis • COPD, CKD, diabetes • Heart failure drugs (!!!)Investigations • Blood tests • ECG • Echocardiogram • (CXR)Investigations ECG: Recap of the basicsInvestigations ECG: Atrial Fibrillation atrial fibrillation healthyInvestigations ECG: Atrial Fibrillation atrial fibrillation healthyInvestigations ECG: Previous myocardial ischaemia or infarction Healthy T wave inversion Pathological Q waveInvestigations ECG: (Right) Ventricular hypertrophy healthy right axis deviationInvestigations ECG: (Left) Ventricular hypertrophy ealthy left axis deviation Litfl.comInvestigations • Blood tests • ECG • Echocardiogram • (CXR)Investigations Echo(cardiogram) Investigations Echo(cardiogram) Blue= blood Red= blood moving moving away towards the from the transducer transducerInvestigations Echo(cardiogram)Investigations • Blood tests • ECG • Echocardiogram • (CXR)InvestigationsInvestigations Heart failure HealthyInvestigations Heart failureInvestigations Heart failure HealthyInvestigations Heart failureInvestigations Heart failureInvestigations Heart failure HealthyInvestigations Heart failure HealthyInvestigations Heart failure HealthyInvestigations Heart failure HealthyInvestigations A= alveolar shadowing B= Kerley B lines C= cardiomegaly D= dilated upper lobe vessels E= pleural effusion F= fluid in the fissures Heart failureInvestigations • Blood tests • ECG • Echocardiogram • (CXR)1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementDiagnosisDiagnosis Framingham CriteriaDiagnosis1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementManagementManagement symptom reliefManagementManagement e.g. furosemideManagement e.g. furosemide WARNING: acute kidney injury, hypokalaemiaManagementManagement (Stroke volume) Ejection Fraction = End Diastolic Volume – End Systolic Volume End Diastolic VolumeManagement Ejection Fraction = End Diastolic Volume – End Systolic Volume End Diastolic Volume Management Ejection Fraction = End Diastolic Volume – End Systolic Volume End Diastolic Volume Preserved ejection fraction (Diastolic Failure) Management Ejection Fraction = End Diastolic Volume – End Systolic Volume End Diastolic Volume Reduced ejection fraction (Systolic Failure)ManagementManagement Co-morbidity Management Hypertension Lifestyle advice ACE inhibitor Vasodilators (Ca2+ channel blockers) Diuretics (thiazides) Atrial fibrillation Rate control Rhythm control Anti-coagulation Ischaemic heart Lifestyle advice disease Anti-platelets Vasodilators (Ca2+ channel blockers, nitrates) Management Drug type Name Effect ACE inhibitors ‘pril’ Vasodilation ARBs ‘sartan’ Offload fluid Vasodilators Hydralazine Vasodilation and nitrates B blockers ‘olol’ Inhibit chronic sympathetic reduce mortality stimnulation MRA spironolactone Offload fluidManagement Angiotensinogen vasoconstrictionAngiotensin renin receptor Angiotensin I Angiotensin II Aldosterone Angiotensin converting enzyme (ACE) water reabsorption at kidney Management Drug type Name Effect ACE inhibitors ‘pril’ Vasodilation ARBs ‘sartan’ Offload fluid Vasodilators Hydralazine Vasodilation and nitrates B blockers ‘olol’ Inhibit chronic sympathetic reduce mortality stimnulation MRA spironolactone Offload fluidManagement Angiotensinogen Angiotensin renin receptor Angiotensin I Angiotensin II Aldosterone Angiotensin converting enzyme (ACE) water reabsorption at kidneyManagementManagement1. Function of the heart 2. Pathophysiology 3. Signs and Symptoms 4. Investigation 5. Diagnosis 6. ManagementThank Y ou for Listening ! Email: ag2048@cam.ac.uk