Medical Archive

Heart failure

Definition

Epidemiology

Etiology

Depressed Ejection Fraction (<40%)
# Coronary artery disease
(Myocardial infarction, Myocardial ischemia)
# Chronic pressure overload
(Hypertension, Obstructive valvular disease)
# Chronic volume overload
(Regurgitant valvular disease, Intracardiac (lex-to-right) shunting, Extracardiac shunting)
# Chronic lung disease
(Cor pulmonale, Pulmonary vascular disorders)
# Nonischemic dilated cardiomyopathy
(Familial/genetic disorders, Infiltrative disordersa)
# Toxic/drug-induced damage
(Metabolic disorder, Viral)
# Chagas’ disease
# Disorders of rate and rhythm
(Chronic bradyarrhythmias, Chronic tachyarrhythmia

Preserved Ejection Fraction (>40–50%)
# Pathologic hypertrophy
(Primary (hypertrophic cardiomyopathies), Secondary (hypertension))
# Aging
# Endomyocardial disorders

High-Output States
# Metabolic disorders
(Thyrotoxicosis)
# Nutritional disorders (beriberi)
# Excessive blood flow requirements
(Systemic arteriovenous shunting, Chronic anemia)

Global considerations

Prognosis

• Functional status (NYHA)? ?? ??.
  • Poor prognosis factor
    • Very low LV EF
    • Low K
    • Low Na – caused by ?renin, norepinephrine, ADH.
    • High BNP
  • ???? BNP? ??

Pathogenesis

Pathology
Acute: engorged capillaries and alveoli filled with acellular pink material
Chronic: numerous hemosiderin-laden macrophages in the alveoli

• 

• 

• 

Preload: ? ???, ????, Atrial kick
Afterload: ??? ??

???? RAAS ??? ?? ???? ?? remodeling? vicious cycle? ??? ?.
Endothelin-TNFa ? ??? ????, blocking? ??? ?? ???
ANP, BNP ?? – poor prognosis ???.

??? description?? CCS classification? ????

Hyperdynamic circulation in high-output HF
Widened pulse pressure(>60mmHg difference)
Brisk carotid upstroke
Increased pulse to aid C.O.

Clinical manifestations

• Left
  • Pul.congestion, dyspnea (exertional -> orthopnea)
  • Small, congested capillaries may burst, leading to intraalveolar hemorrhage; marked by hemosiderin-laden macrophages (‘heart-failure’ cells)
  • Cheyne-Stokes, Pulsus alternans
• Right
  • Systemic edema, Painful hepato-splenomegaly with characteristic ‘nutmeg’ liver
  • S3/S4
    • S4: https://www.youtube.com/watch?v=KcMF8rJDTIk
  • JVD, Hepatojugular reflux
    • Hepatojugular reflux: https://www.youtube.com/watch?v=JxyECMTEmmc
    • JVP normal value: 6 to 8 cmH2O
  • Forward: hypovolemic shock -> N/S infusion ??

Physical examination

https://www.youtube.com/watch?v=r1FeJ5pb3TM

Diagnosis

?? ???? Sx?? ???? ????? ???? ?? ?? BNP ??? ??.
????? LV ?? ??? ??!

Differential diagnosis

Cor pulmonale

Definition

• ??/?? ?? ??? ??? RV failure
• ?? HF??? ?? ???? ?? ??? ??? (or kyphoscoliosis)
• Dyspnea, Tachypnea, ?JVP, hepatomegaly
• ?? ? ?? ??? ?? ??!

Etiology and epidemiology

COPD (~25%)
ILD
Pulmonary vascular diseases (eg, thromboembolism)
Obstructive sleep apnea

Pathophysiology and basic mechanisms

Clinical manifestations

Symptoms

Dyspnea on exertion, fatigue, lethargy
Exertional syncope (d/t ?cardiac output)
Exertional angina (d/t ?myocardial demand)

Signs

Lower-extremity edema, ascites, and/or pleural effusions
?JVP with prominent a wave
Loud P2
RV 3rd heart sound
Right-sided heave
Hepatomegaly and pulsatile liver from congestion
Tricuspid regurgitation murmur

Diagnosis

ECG	Right axis deviation, RBBB, RVH, RAE
?ECHO	RV failure? m/c cause ? LV failure? ?? ??. Estimates pulmonary artery pressure and assess RV function.
?Right heart catheterization	Mean pulmonary artery pressure >25mmHg – definitive (compared to the normal: 8-20mmHg) LVF ???? PCWP ??? ?. + intracardiac shunt ??
CXR	1° Pulmonary lesion: Main pulmonary artery, hilar vessel ?? ?? – enlarged central pulmonary arteries with rapid tapering of the distal vessels (pruning)
Spiral CT	embolism ???
HRCT	ILD ???

#Treatment

Acute	IV saline?? C.O.?? (RV preload ??) 100% O2 ? vasoconstriction, afterload ?? ?? Anticoagulation (?? embolism? ?????) Unstable: thrombolytics or thromboembolectomy
Chronic	Recurrent embolism, pul. HTN? ??

Pul. Parenchymal disease
COPD, chronic bronchitis – hypoxemic vasoconstriction
ILD, lung resection, TB sequelae(fibrosis)
Long term O2, bronchodilator, anti, diuretics(RV failure? ??)