Congestive Heart Failure

Michele Ritter, M.D.

Argy February, 2007

Heart Failure

Results from any structural or

functional abnormality that impairs
the ability of the ventricle to eject
blood (Systolic Heart Failure) or
to fill with blood (Diastolic Heart
Failure).

The Vicious Cycle of Congestive Heart

Failure

LV Dysfunction causes
Decreased cardiac output

Decreased Blood Pressure and

Decreased Renal perfusion

Stimulates the Release

of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure

Types of Heart Failure

Low-Output Heart Failure

Systolic Heart Failure:

Diastolic Heart Failure:

Elevated Left and Right ventricular end-diastolic

pressures
May have normal LVEF

High-Output Heart Failure

decreased cardiac output

Decreased Left ventricular ejection fraction

Seen with peripheral shunting, low-systemic vascular

resistance, hyperthryoidism, beri-beri, carcinoid, anemia
Often have normal cardiac output

Right-Ventricular Failure

Seen with pulmonary hypertension, large RV infarctions.

Causes of Low-Output Heart Failure

Systolic Dysfunction

Coronary Artery Disease

Idiopathic dilated cardiomyopathy (DCM)

50% idiopathic (at least 25% familial)

9 % mycoarditis (viral)
Ischemic heart disease, perpartum, hypertension,
HIV, connective tissue disease, substance abuse,
doxorubicin

Hypertension
Valvular Heart Disease

Diastolic Dysfunction

Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy

Clinical Presentation of Heart Failure

Due to excess fluid accumulation:

Dyspnea (most sensitive symptom)

Edema
Hepatic congestion
Ascites
Orthopnea, Paroxysmal Nocturnal Dyspnea
(PND)

Due to reduction in cardiac ouput:

Fatigue (especially with exertion(

Weakness

Physical Examination in Heart Failure

S3 gallop

Cool, pale, cyanotic extremities

Low sensitivity, but highly specific

Have sinus tachycardia, diaphoresis and peripheral
vasoconstriction

Crackles or decreased breath sounds at bases

(effusions) on lung exam
Elevated jugular venous pressure
Lower extremity edema
Ascites
Hepatomegaly
Splenomegaly
Displaced PMI

Apical impulse that is laterally displaced past the midclavicular

line is usually indicative of left ventricular enlargement>

Measuring Jugular Venous Pressure

Lab Analysis in Heart Failure

CBC

Serum electrolytes and creatinine

To evaluate for possible diabetes mellitus

Thyroid function tests

before starting high dose diuretics

Fasting Blood glucose

Since anemia can exacerbate heart failure

Since thyrotoxicosis can result in A. Fib,

and hypothyroidism can results in HF.

Iron studies

To screen for hereditary hemochromatosis as cause of heart

failure.

To evaluate for possible lupus

ANA

Viral studies

If viral mycocarditis suspected

Laboratory Analysis (cont.)

BNP
With chronic heart failure, atrial mycotes
secrete increase amounts of atrial natriuretic
peptide (ANP) and brain natriuretic pepetide
(BNP) in response to high atrial and
ventricular filling pressures
Usually is > 400 pg/mL in patients with
dyspnea due to heart failure.

Chest X-ray in Heart Failure

Cardiomegaly
Cephalization of the pulmonary
vessels
Kerley B-lines
Pleural effusions

Cardiomegaly

Pulmonary vessel congestion

Pulmonary Edema due to Heart Failure

Kerley B lines

Cardiac Testing in Heart Failure

Electrocardiogram:
May

show specific cause of heart failure:

Ischemic heart disease

Dilated cardiomyopathy: first degree AV
block, LBBB, Left anterior fascicular block
Amyloidosis: pseudo-infarction pattern
Idiopathic dilated cardiomyopathy: LVH

Echocardiogram:
Left

ventricular ejection fraction

Structural/valvular abnormalities

Further Cardiac Testing in Heart Failure

Exercise Testing

Should be part of initial evaluation of all patients

with CHF.

Coronary arteriography

Should be performed in patients presenting with

heart failure who have angina or significant
ischemia
Reasonable in patients who have chest pain that
may or may not be cardiac in origin, in whom
cardiac anatomy is not known, and in patients with
known or suspected coronary artery disease who do
not have angina.
Measure cardiac output, degree of left ventricular
dysfunction, and left ventricular end-diastolic
pressure.

Further testing in Heart Failure

Endomyocardial biopsy
Not frequently used
Really only useful in cases such as viralinduced cardiomyopathy

Classification of Heart Failure

New York Heart Association (NYHA)

Class

I symptoms of HF only at
levels that would limit normal
individuals.
Class II symptoms of HF with
ordinary exertion
Class III symptoms of HF on less
than ordinary exertion
Class IV symptoms of HF at rest

Classification of Heart Failure (cont.)

ACC/AHA Guidelines
Stage

A High risk of HF, without

structural heart disease or symptoms
Stage B Heart disease with
asymptomatic left ventricular
dysfunction
Stage C Prior or current symptoms
of HF
Stage D Advanced heart disease and
severely symptomatic or refractory HF

Chronic Treatment of Systolic Heart

Failure

Correction of systemic factors

Lifestyle modification

Thyroid dysfunction
Infections
Uncontrolled diabetes
Hypertension
Lower salt intake
Alcohol cessation
Medication compliance

Maximize medications

Discontinue drugs that may contribute to heart

failure (NSAIDS, antiarrhythmics, calcium channel
blockers)

Order of Therapy
1.
2.

3.
4.
5.
6.

Loop diuretics
ACE inhibitor (or ARB if not
tolerated)
Beta blockers
Digoxin
Hydralazine, Nitrate
Potassium sparing diuretcs

Diuretics

Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve
symptoms

Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Shown to improve survival in CHF

ACE Inhibitor

Improve survival in patients with all

severities of heart failure.
Begin therapy low and titrate up as
possible:
Enalapril 2.5 mg po BID
Captopril 6.25 mg po TID
Lisinopril 5 mg po QDaily

If cannot tolerate, may try ARB

Beta Blocker therapy

Certain Beta blockers (carvedilol,

metoprolol, bisoprolol) can improve
overall and event free survival in NYHA
class II to III HF, probably in class IV.
Contraindicated:

Heart rate <60 bpm

Symptomatic bradycardia
Signs of peripheral hypoperfusion
COPD, asthma
PR interval > 0.24 sec, 2nd or 3rd degree block

Hydralazine plus Nitrates

Dosing:
Hydralazine

Started at 25 mg po TID, titrated up to 100

mg po TID

Isosorbide

dinitrate

Started at 40 mg po TID/QID

Decreased mortality, lower rates of

hospitalization, and improvement in
quality of life.

Digoxin

Given to patients with HF to control

symptoms such as fatigue, dyspnea,
exercise intolerance
Shown to significantly reduce
hospitalization for heart failure, but
no benefit in terms of overall
mortality.

Other important medication in Heart

Failure -- Statins

Statin therapy is recommended in

CHF for the secondary prevention of
cardiovascular disease.
Some studies have shown a
possible benefit specifically in HF
with statin therapy
Improved LVEF
Reversal of ventricular remodeling
Reduction in inflammatory markers (CRP,
IL-6, TNF-alphaII)

Meds to AVOID in heart failure

NSAIDS

Can cause worsening of preexisting HF

Thiazolidinediones
Include rosiglitazone (Avandia), and
pioglitazone (Actos)
Cause fluid retention that can exacerbate HF

Metformin

People with HF who take it are at increased

risk of potentially lethic lactic acidosis

Implantable Cardioverter-Defibrillators
for HF

Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
About one-third of mortality in
HF is due to sudden cardiac
death.
Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF 35% have a significant
survival benefit from an
implantable cardioverterdefibrillator (ICD) for the
primary prevention of SCD.

Management of Refractory Heart

Failure

Inotropic drugs:

Mechanical circulatory support:

Dobutamine, dopamine, milrinone,

nitroprusside, nitroglycerin
Intraaortic balloon pump
Left ventricular assist device (LVAD)

Cardiac Transplantation

A history of multiple hospitalizations for HF

Escalation in the intensity of medical therapy
A reproducable peak oxygen consumption with
maximal exercise (VO2max) of < 14 mL/kg
per min. (normal is 20 mL/kg per min. or more)
is relative indication, while a VO2max < 10
mL/kg per min is a stronger indication.

Acute Decompensated Heart Failure

Cardiogenic pulmonary edema is a

common and sometimes fatal cause
of acute respiratory distress.
Characterized by the transudation of
excess fluid into the lungs
secondary to an increase in left
atrial and subsequently pulmonary
venous and pulmonary capillary
pressures.

Acute Decompensaated Heart Failure

(cont.)

Causes:

Acute MI

Volume Overload

Rupture of chordae tendinae/acute mitral

valve insufficiency
Transfusions, IV fluids
Non-compliance with diuretics, diet (high
salt intake)

Worsening valvular defect

Aortic stenosis

Decompensated Heart Failure

Symptoms

Severe dyspnea
Cough

Clinical Findings

Tachypnea
Tachycardia
Hypertension/Hypotension
Crackles on lung exam
Increased JVD
S3, S4 or new murmur

Labs/Studies in Acute Decompensated

Heart Failure

Chemistry, CBC
EKG
Chest X-ray
May consider cardiac enzymes
2D-Echo

Decompensated Heart Failure

Treatment
Strict

Is and Os, daily weights

Oxygen, mechanical ventilation if
needed
Loop diuretics (Lasix!)
Morphine
Vasodilator therapy (nitroglycerin)
Nesiritide (BNP) can help in acute
setting, for short term therapy

Case # 1

A 65-year old male with a history of

hypertension, DM, CAD s/p MI and threevessel CABG in 2002, presents with
worsening dyspnea on exertion. He
states that he occassionally has a dry
cough, but denies any recent chest pain,
fevers, N/V. Patient states that he usually
can get up a flight of stairs if he stops
half-way, but over the last several days,
has not been able to climb them at all.

Case # 1 (cont.)

PMH:
CAD MI and CABG in 2002
Hypertension
Diabetes Mellitus
Hypothyroidism

Allergies:

NKDA

Outpatient Meds:
Synthroid
Metformin
Norvasc

Case # 1 (cont.)

Physical Exam:
97.6,

168/72, 99, 28, 93% on RA

Gen: Alert and oriented x 3, breathing
rapidly
CV: RRR, no murmurs; mod. JVD
Resp: Crackles throughout lungs
Abd.: soft, nontender, NABS
Ext: 2 + pitting edema bilaterally

Case # 1 (cont.)

Labs:

Hgb: 13.5
WBC: 8
Platelets: 240
Sodium: 139
Potassium: 3.8
BUN: 18
Cr: 0.8

Trop. I 0.01
CPK: 120

Case # 1

Case # 1

What studies would you like to

check in this patient?
What medications would you like to
start/change?
What vital signs do you want to
monitor?

Case # 2

A 45-year old obese woman with diabetes

mellitus is evaluated for a 1-month
history of progressive shortness of breath.
Two months ago, she had a flu-like
illness with nausea, vomiting, and
sweating. She has not followed up with a
physician regularly. One of her siblings
has heart problems and her mother died
suddenly and unexpectedly at age 55
years.

Case # 2

On examination her heart rate is 75/min and her

blood pressure is 185/93 mm Hg. BMI is 32.9.
Jugular venous pressure is mildly elevated. Lung
examination reveals a few bibasilar crackles.
Cardiac examination reveals regular rhythm,
normal S1 and S2 and the presence of an S3.
There is mild peripheral edema. An
echocardiogram is significant for left ventricular
hypertrophy and severely decreased systolic
function (left ventricular ejection fraction, 20%)
An electrocardiogram shows a previous
anteroseptal MI.

Case # 2

(A)
(B)
(C)
(D)
(E)

Which of the following is the most

appropriate next diagnostic test?
Measurement of plasma BNP
Serum Protein Electrophoresis
Cardiac Stress Test
Cardiac catheterization
Endomyocardial biopsy