CONGESTIVE HEART FAILURE Sagar Naik, PT 1 CONGESTIVE HEART FAILURE Sagar Naik, PT Heart failure is a pathophysiologic state in which

an abnormality of cardiac function is responsible for the failure of the heart to pump blood at rate commensurate with the requirements of the metabolizing tissues or can do so only from an abnormally elevated filling pressure. It can be thought of as a clinical syndrome comprising a constellation of symptoms and signs attributable to cardiac dysfunction. Etiology: Heart failure is frequently, but not always, caused by a defect in myocardial contraction. It may result from Primary abnormality in the heart muscle Cardiomyopathies Extramyocardial abnormalities Coronary atherosclerosis Abnormalities of the heart valves Mitral stenosis A similar clinical syndrome may be present without any detectable abnormality of myocardial function. Acute hypertensive crisis Rupture of aortic valve cusp Massive pulmonary embolism

In addition, conditions associated with impairment of filling of the ventricles like tricuspid or mitral stenosis, constrictive pericarditis and endocardial fibrosis can lead to heart failure in presence of normal myocardial function. physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 2 Precipitating Causes: Infection Anemia Thyrotoxicosis, Pregnancy & Obesity Arrhythmias Rheumatic, viral, & other forms of myocarditis Infective endocarditis Physical, dietary, fluid, environmental, & emotional excesses Systemic hypertension Myocardial infarction Pulmonary embolism Drugs induced Classification of Heart Failure: Heart failure can be classified or described in several ways, which are as follows: High Output VS Low Output Heart Failure: The low output heart failure i.e., heart failure with low cardiac output is seen in patients with heart failure secondary to Ischaemic heart disease Dilated Cardiomyopathy Valvular & Pericardial diseases

 Hypertension The high output heart failure i.e., heart failure with high cardiac output is seen in patients with Hyperthyroidism Anemia Pregnancy Arteriovenous fistulas Beriberi physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 3 Pagets disease In clinical practice, however, low-output and high-output HF cannot always be readily distinguished. The normal range of cardiac output is wide [2.2 to 3.5 (L/min)/m2]; in many patients with so-called low-output heart failure, the cardiac output may actually be just within the normal range at rest (although lower than it had been previously), but it fails to rise normally during exertion. On the other hand, in patients with so-called high-output heart failure, the output may not exceed the upper limits of normal (although it would have been elevated had it been measured before heart failure supervened); rather, it may have fallen to within normal limits. Acute VS Chronic Heart Failure: The acute heart failure is the sudden development of a large myocardial infarction or rupture of a cardiac valve in a patient who previously was entirely well.

 Chronic heart failure is typically observed in patients with dilated cardiomyopathy or multivalvular heart disease that develops or progresses slowly. Acute heart failure is usually predominantly systolic, and the sudden reduction in cardiac output often results in systemic hypotension without peripheral oedema. In contrast, in chronic heart failure, arterial pressure is ordinarily well maintained until very late in the course, but there is often accumulation of oedema. Right-Sided VS Left-Sided Heart Failure: Many of the clinical manifestations of heart failure result from the accumulation of excess fluid behind either one or both ventricles. This fluid usually localizes upstream to (behind) the ventricle that is initially affected. Patients in whom the left ventricle is hemodynamically overloaded (e.g., aortic stenosis) or weakened (e.g., postmyocardial infarction) develop dyspnoea and orthopnoea as a result of pulmonary congestion, a condition referred to as left-sided heart failure. physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 4 In contrast, when the underlying abnormality affects the right ventricle primarily (e.g., congenital valvular pulmonic stenosis or pulmonary hypertension secondary to pulmonary thromboembolism), symptoms resulting from pulmonary congestion are uncommon, and edema, congestive hepatomegaly, and

systemic venous distention, i.e., clinical manifestations of right-sided heart failure, are more prominent. When heart failure has existed for months or years, such localization of excess fluid behind the failing ventricle may no longer exist. E.g. Patients with long-standing aortic valve disease or systemic hypertension may develop ankle edema, congestive hepatomegaly, and systemic venous distention late in the course of their disease, even though the abnormal hemodynamic burden initially was placed on the left ventricle. Backward VS Forward Heart Failure: The concept of backward heart failure contends that in heart failure, one or the other ventricle fails to discharge its contents or fails to fill normally. As a consequence, the pressures in the atrium and venous system behind the failing ventricle rise, and retention of sodium and water occur as a consequence of the elevation of systemic venous and capillary pressures and the resultant transudation of fluid into the interstitial space. In contrast, the proponents of the forward heart failure hypothesis maintain that the clinical manifestations of heart failure result directly from an inadequate discharge of blood into the arterial system. According to this concept, salt and water retention is a consequence of diminished renal perfusion and excessive proximal tubular sodium reabsorption and of excessive distal tubular reabsorption through activation of the renin-angiotensinaldosterone (RAA) system. Systolic VS Diastolic Heart Failure: The distinction between these two forms of heart failure, relates to whether the principal abnormality is the inability of the ventricle to contract normally and expel sufficient blood (systolic failure) or to relax and/or fill normally (diastolic failure).

physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 5 The major clinical manifestations of systolic failure relate to an inadequate cardiac output with weakness, fatigue, reduced exercise tolerance, and other symptoms of hypoperfusion, while in diastolic failure the manifestations relate principally to the elevation of filling pressures. Clinical Features: Symptoms: Dyspnoea on exertion Orthopnoea Paroxysmal nocturnal dyspnoea Cheyne-Stokes respiration (Periodic or cyclic respiration) Fatigue & weakness Anorexia & Nausea associated with abdominal pain Weight loss Cerebral Symptoms Confusion Difficulty in concentration Impairment of memory Headache Insomnia Anxiety Nocturia Physical Signs: Pulse

 Pulse pressure may be diminished (Severe) Sinus tachycardia Pulsus alternans Raised Jugular Venous Pressure 3rd & 4th heart sounds are often audible but are not specific for heart failure Pulmonary Rales physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 6 Cardiac oedema Pleural effusion & ascites Congestive hepatomegaly & enlargement of spleen may occur Cardiac Cachexia Laterally displaced apical impulse Investigations: Chest radiograph Pulmonary venous hypertension (left ventricular failure) seen as dilatation and engorgement the upper lobe pulmonary veins Pleural effusion & interlobal thickening Cardiomegaly ECG Echocardiogram Cardiac catheterization Exercise testing with respiratory gas analysis Differential Diagnosis: Non-cardiogenic pulmonary oedema Renal insufficiency with fluid overload

 Hepatic insufficiency Anemia Thyrotoxicosis Treatment: Medical Management: The treatment of heart failure may be divided into four components: Removal of the precipitating cause Correction of the underlying cause Prevention of deterioration of cardiac function physio4all... CONGESTIVE HEART FAILURE Sagar Naik, PT 7 Control of the congestive HF state General therapeutic measures to be taken by the patient of heart failure are as follows: Restrict salt intake Recommend regular, moderate exercise Avoid antiarrhythmic agents for asymptomatic arrhythmias Avoid non-steroidal anti-inflammatory agents (NSAIDs) Provide influenzal and pneumococcal immunization Diuretics are generally prescribed for all patients with symptoms of heart failure who have fluid retention.

All patients with heart failure due to left ventricular systolic dysfunction should receive an ACE inhibitor, unless they have been shown to be unable to tolerate these drugs. All patients with heart failure due to left ventricular systolic dysfunction should receive -adrenergic receptor blockers, unless they are unable to tolerate treatment with these drugs or have a contraindication to their use. Digoxin is recommended to improve the clinical status of patients with heart failure and should be used in conjunction with diuretics, ACE inhibitors or blockers. Other drugs, which can be used, are as follows: Hydralazine & Isosorbide Dinitrate Angiotensin Receptor Blockers Aldosterone Antagonists Calcium Antagonists Antiarrhythmic & Device Therapy Anticoagulant Therapy Positive Inotropic Therapy Surgical Management: Pacemaker Heart transplant physio4all...