Heart Failure

What is Heart Failure?

The heart is not pumping as well as it
should
Usually, the heart has been weakened
by an underlying condition

Blocked arteries
MI
High blood pressure
Infections
Heart valve abnormalities

What is Heart Failure?

Heart failure can involve the left or right
side of the heart or both
Usually the left side is affected first
Heart failure occurs when either side of
the heart cannot keep up with the flow
of blood

Heart Failure
What is Heart Failure?

What is Left Heart Failure?

Involves the left ventricle (lower
chamber) of the heart
Systolic failure
The heart looses its ability to contract or
pump blood into the circulation

Diastolic failure
The heart looses its ability to relax because
it becomes stiff
Heart cannot fill properly between each beat

What is Left Heart Failure?

Systolic and diastolic heart failure are
treated with different types of
medications
In both types, blood may back up in
the lungs causing fluid to leak into the
lungs (pulmonary edema)
Fluid may also build up in tissues
throughout the body (edema)

What is Right Heart Failure?

Usually occurs as a result of left heart
failure
The right ventricle pumps blood to the
lungs for oxygen
Occasionally isolated right heart failure
can occur due to lung disease or blood
clots to the lung (pulmonary embolism)

How fast does heart failure

develop?
Usually a chronic disease
The heart tries to compensate for the
loss in pumping function by:
Developing more muscle mass
Enlarging
Pumping faster

Worsening
the HF

What Causes Heart Failure?

Health conditions that either damage
the heart or make it work too hard

Coronary artery disease

Heart attack
High blood pressure
Abnormal heart valves
Heart muscle diseases (cardiomyopathy)
Heart inflammation (myocarditis)

What Causes Heart Failure?

Congenital heart defects

Severe lung disease
Diabetes
Severe anemia
Overactive thyroid gland (hyperthyroidism)
Abnormal heart rhythms

What Causes Heart Failure?

Coronary artery disease
Cholesterol and fatty deposits build up in
the hearts arteries
Less blood and oxygen reach the heart
muscle
This causes the heart to work harder and
occasionally damages the heart muscle

What Causes Heart Failure?

Heart attack
An artery supplying blood to the heart
becomes blocked
Loss of oxygen and nutrients damages
heart muscle tissue causing it to die
Remaining healthy heart muscle must pump
harder to keep up

What Causes Heart Failure?

High blood pressure
Uncontrolled high blood pressure doubles a
persons risk of developing heart failure
Heart must pump harder to keep blood
circulating
Over time, chamber first thickens, then gets
larger and weaker

What Causes Heart Failure?

Abnormal heart valves
Heart muscle disease
Damage to heart muscle due to drugs,
alcohol or infections

Congenital heart disease

Severe lung disease

What Causes Heart Failure?

Diabetes
Tend to have other conditions that make the
heart work harder
Obesity
Hypertension
High cholesterol

What Causes Heart Failure?

Severe anemia
Not enough red blood cells to carry oxygen
Heart beats faster and can become overtaxed with
the effort

Hyperthyroidism
Body metabolism is increased and overworks the
heart

Abnormal Heart Rhythm

If the heart beats too fast, too slow or irregular it may
not be able to pump enough blood to the body

Signs and symptoms of HF

Signs and Symptoms of Heart

Failure
Shortness of Breath (dyspnea)
WHY?
Blood backs up in the pulmonary veins
because the heart cant keep up with the supply
an fluid leaks into the lungs

SYMPTOMS
Dyspnea on exertion or at rest
Difficulty breathing when lying flat
Waking up short of breath

Signs and Symptoms of Heart

Failure
Persistent Cough or Wheezing
WHY?
Fluid backs up in the lungs

SYMPTOMS
Coughing that produces white or pink bloodtinged sputum

Signs and Symptoms of Heart

Failure
Edema
WHY?
Decreased blood flow out of the weak heart
Blood returning to the heart from the veins
backs up causing fluid to build up in tissues

SYMPTOMS
Swelling in feet, ankles, legs or abdomen
Weight gain

Signs and Symptoms of Heart

Failure
Tiredness, fatigue
WHY?
Heart cant pump enough blood to meet needs of
bodies tissues
Body diverts blood away from less vital organs
(muscles in limbs) and sends it to the heart and
brain

SYMPTOMS
Constant tired feeling
Difficulty with everyday activities

Signs and Symptoms of Heart

Failure
Lack of appetite/ Nausea
WHY?
The digestive system receives less blood
causing problems with digestion

SYMPTOMS
Feeling of being full or sick to your stomach

Signs and Symptoms of Heart

Failure
Confusion/ Impaired thinking
WHY?
Changing levels of substances in the blood (
sodium) can cause confusion

SYMPTOMS
Memory loss or feeling of disorientation
Relative or caregiver may notice this first

Signs and Symptoms of Heart

Failure
Increased heart rate
WHY?
The heart beats faster to make up for the loss
in pumping function

SYMPTOMS
Heart palpitations
May feel like the heart is racing or throbbing

New York Heart Association

(NYHA)
Functional
Classification
Class

% of
Symptoms
patients

35%

No symptoms or limitations in ordinary physical

activity

II

35%

Mild symptoms and slight limitation during

ordinary activity

III

25%

Marked limitation in activity even during minimal

activity. Comfortable only at rest

IV

5%

Severe limitation. Experiences symptoms even at

rest

Pathophysiology

Treatment Options
The more common forms of heart failure
cannot be cured, but can be treated
Lifestyle changes
Medications
Surgery

Lifestyle changes
Stop smoking
Loose weight
Avoid alcohol
Avoid or limit caffeine
Eat a low-fat, low-sodium diet
Exercise

Lifestyle changes
Reduce stress
Keep track of symptoms and weight and
report any changes or concern to the
doctor
Limit fluid intake
See the doctor more frequently

Cardiac glycoside

Positive inotropic
drugs

Diuretics

Drugs used in HF

ACE I,AT1
blockers

Vasodilators

Beat blockers

Phosphodiesterase
inhibitors

Beta 1 agonist

Positive inotropic agents

1. Cardiac glycosides:

Digitalis derivatives :

Digoxin
Digitoxin

Nondigitalis derivatives:

Ouabain

Physiology of myocyte contraction

Digoxin mechanism of action

Therapeutic Uses of Digitalis

Congestive Heart Failure
Atrial fibrillation
Atrial flutter

Overall Benefit of Digitalis to

Myocardial Function

cardiac output
cardiac efficiency
heart rate
cardiac size

NO survival benefit

Other Beneficial Effects

Restoration of baroreceptor sensitivity
Reduction in sympathetic activity
increased renal perfusion, with edema
formation
Increase parasympathetic outflow

Administration
Digoxin has a long enough half life (24-36 hr.) and
high enough bioavailability to allow once daily
dosing
Digoxin has a large volume of distribution and
dose must be based on lean body mass
Increased cardiac performance can increase renal
function and clearance of digoxin
Eubacterium lentum

Adverse Effects
Cardiac

AV block
Bradycardia
Ventricular extrasystole
Arrhythmias

CNS toxicity
Delirium
Confusion and somnolence

GI
Anorexia ,nausea and vomitting

Blurred vision
Tendency to yellow-green vision
Photophobia

Therapeutic index is ~ 2!

Serum Electrolytes Affect Toxicity

K+
Digitalis competes for K binding at Na/K ATPase
Hypokalemia: increase toxicity
Hyperkalemia: decrease toxicity

Mg2+
Hypomagnesemia: increases toxicity

Ca2+
Hypercalcemia: increases toxicity

Treatment of Digitalis Toxicity

Bile resins or activated charcoal

Atropine: advanced heart block
KCl: increased automaticity
Antiarrythmics: ventricular arrhythmias
Fab antibodies: toxic serum concentration; acute
toxicity

Van Gogh

b-Adrenoceptor and Dopamine

Receptor Agonists
Dobutamine
Dopamine

Dobutamine

Beta 1 agonist
Administered as IV infusion
Used in acute HF
Can induce arrhythmias

Mechanism of Action: Dobutamine

Stimulation of cardiac b1-adrenoceptors:
inotropy > chronotropy
peripheral vasodilatation

myocardial oxygen demand

Mechanism of Action: Dopamine

Stimulation of peripheral postjunctional
D1 and prejunctional D2 receptors
Splanchnic and renal vasodilatation

Therapeutic Use
Dobutamine: management of acute failure
only
Dopamine: restore renal blood in acute failure

Adverse Effects
Dobutamine
Tolerance
Tachycardia

Dopamine
tachycardia
arrhythmias
peripheral vasoconstriction if given at high doses

Phosphodiesterase inhibitors
Amrinone
Milrinone
PDE 3 inhibitor

Role of phosphodiesterase

Mechanism of action
inhibition of type III phosphodiesterase
increase intracellular cAMP
activation of protein kinase A
o Ca2+ entry through L type Ca channels
o inhibition of Ca2+ sequestration by SR
increase cardiac output
decrease peripheral vascular resistance

Phosphodiesterase Inhibitors:
Therapeutic Use
short term support in advanced cardiac failure
long term use not possible why?

Adverse Effects of
Phosphodiesterase Inhibitors
Cardiac arrhythmias
GI: Nausea and vomiting
Sudden death

ACE-I
First line treatment
Lower the morbidity and mortality rate among
HF pts

Mechanism of Action
Afterload reduction
Preload reduction
Reduction of facilitation of sympathetic
nervous system
Reduction of cardiac hypertrophy

Diuretics
Thiazide
For mild fluid retention

Furoseamide
More effective than thiazide
Rapid onset and short duration

Potassium sparing diuretics

Use to along with the above diuretics to prevent
electrolyte imbalance
Spironolactone have beneficial effect on heart
remodeling

Diuretics: Mechanism of
Action in Heart Failure
Preload reduction: reduction of excess
plasma volume and edema fluid
Afterload reduction: lowered blood
pressure

Spironolactone
Aldosterone antagonist, K-sparing diuretic
Prevention of aldosterone effects on:
Kidney
Heart

Aldosterone inappropriately elevated in CHF

Mobilizes edema fluid in heart failure
Prevention of hypokalemia induced by loop diuretics
(protection against digitalis toxicity?)
Prolongs life in CHF patients

Vasodilators
Sodium nitroprusside
Hydralazine
Nitrates
Alpha1 blocker
Ca2+ channel blockers

must be avoided

Vasodilators
Mechanism of action: reduce preload and
afterload

Beta blockers
Metoprolol
Carvidilol
Bisoprolol

b-Blockers in Heart Failure:

Mechanism of Action
Standard b-blockers:
Reduction in damaging sympathetic influences in
the heart (tachycardia, arrhythmias, remodeling)
inhibition of renin release

Carvedilol:
Beta blockade effects
peripheral vasodilatation via a1-adrenoceptor
blockade (carvedilol)

Anti coagulant therapy

Not followed as standard regimen only in pts
with prior embolic events

Surgery and other Medical

Procedures
Treatment options
Not often used in heart failure unless there
is a correctable problem
Coronary artery bypass
Angioplasty
Valve replacement
Defibrillator implantation
Heart transplantation
Left ventricular assist device (LVAD)

Management of heart failure

Treat the cause
Combination of diuretic therapy and ACE-I
If ACE-I is contraindicated use vasodilators

Add beta blocker if the patient was stabilized

Start with low dose

Spironolactone has shown 30%reduction in mortality when

administered with the conventional therapy
If the above drugs dont releive the symptoms use digoxin
Positive inotropic agents must be used for short time

If the patient condition become worse make surgery

intervention