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Heart Failure Heart Failure Sandra Keavey, DHSc, PAC, DFAAPA Defined Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders Epidemiology-Magnitude Heart failure disproportionately affects the older population. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older. In the older population, heart failure accounts for more hospital admissions than any other single condition. Following hospitalization for heart failure, nearly half are readmitted within 6 months. Epidemiology-Prevalence Prevalence. About 5.1 million people in the United States have heart failure. One in 9 deaths in 2009 included heart failure as contributing cause. About half of people who develop heart failure die within 5 years of diagnosis. 25% of all heart failure patients are re-admitted to the hospital within 30 days. 50% of all heart failure patients are re-admitted to the hospital within 6 months. Systolic vs Diastolic There are two common types of heart failure Systolic HF Systolic HF is the most common type of HF Now referred to as HFrEF Heart Failure reduced Ejection Fraction The heart is weak and enlarged. The muscle of the left ventricle loses some of its ability to contract or shorten. Diastolic HF Diastolic HF is not an isolated disorder of diastole; there are widespread abnormalities of both systolic and diastolic function that become more apparent with exercise. Heart Failure Preserved Ejection Fraction-HFpEF also seen in the literature is HFNEF, where N is normal. It is characterized by a stiff left ventricle with decreased relaxation, decreased compliance, increased filling pressure in the setting of normal LV dimensions. There is raised LV end-diastolic pressure, end-systolic pressure, diastolic dysfunction, pulmonary capillary wedge pressure and pulmonary artery systolic pressure. Types of Heart Failure High output heart Bounding pulses, wide pulse pressure, accentuated heart failure sounds, peripheral vasodilatation, increased cardiac output and ejection fraction, moderate four-chamber enlargement Low cardiac Fatigue, loss of lean body mass, prerenal azotemia, peripheral output syndrome vasoconstriction, reduced left or right contractility Right heart failure Dependent edema, jugular venous distention, right atrial and ventricular dilatation, reduced right-sided contractility Left heart failure Dyspnea, pulmonary vascular congestion, reduced left-sided contractility Biventricular Dyspnea, dependent edema, jugular venous distention, failure pulmonary vascular congestion, bilateral reduced contractility Diastolic Normal myocardial contractility, left ventricular volume, and dysfunction ejection fraction; impaired myocardial relaxation; diminished early diastolic filling Types of Heart Failure High output heart High output heart failure occurs when the demand for blood failure exceeds the capacity of an otherwise normal heart to meet the demand. This type of heart failure may occur in patients with severe anemia, AV malformations with shunting of blood, or hyperthyroidism. Low cardiac Patients have fatigue and loss of lean muscle mass as their output syndrome most prominent symptoms, but they also may have dyspnea, impaired renal function, or altered mental status. Right heart failure Characterized by peripheral edema’ Left heart failure Characterized by pulmonary congestion. Biventricular Both systemic and pulmonary congestion are present in patients failure with biventricular heart failure. Diastolic The treatment of diastolic heart failure is less well defined than dysfunction the treatment of systolic heart failure. None of the treatment recommendations have been validated by randomized controlled trials. Conditions That Contribute to HF Coronary heart disease –the most common cause of HF due to systolic dysfunction in Western countries. Cigarette smoking – Increases BP, decreases exercise tolerance and increases the tendency for blood to clot. Obesity-approximately 11 percent of cases of HF in men and 14 percent in women are attributable to obesity alone. Diabetes –from microvascular dysfunction and increased fatty acid utilization and decreased NO bioavailability. Valvular heart disease- an increasingly common cause of HF at older ages, with calcific aortic stenosis being the most common disorder requiring surgery. Impact of Stress IMPAIRED RESPONSE TO STRESS — Patients with heart failure have particular difficulty in tolerating certain types of hemodynamic stresses: Atrial fibrillation poorly tolerated Sinus tachycardia also not well tolerated. Elevations in systemic blood pressure that worsen myocardial relaxation Ischemia resulting in worsening of diastolic function Hypertension Hypertension increases the risk of HF at all ages. Data from the Framingham Heart Study found that, after age 40, the lifetime risk of developing HF was twice as high in subjects with a blood pressure ≥160/100 mmHg compared to <140/90 mmHg The risk of developing HF increases with the degree of blood pressure elevation. Even moderate elevations contribute to risk in the long term. The average blood pressure of hypertensive candidates for HF in the Framingham Study was 150/90 Chronic hypertension is the most common cause of diastolic dysfunction and failure. It leads to left ventricular hypertrophy and increased connective tissue content, both of which decrease cardiac compliance. Conditions That HF Contributes to Atrial Fibrillation (Afib) -As the ventricle stiffens and develops higher end-diastolic pressures, the atria are distended and stressed; often resulting in Afib. Atrial fibrillation with uncontrolled rate worsens HF symptoms Loss of atrial contraction worsens symptoms of HF, because patients with diastolic dysfunction often are dependent on the atrial kick of the left ventricle LV hypertrophy is a prominent feature of evolving HF. Each method of demonstrating LV hypertrophy (ECG, chest film, or echocardiogram) independently predicts HF. As a result, persons having any combination of them have a greater risk than those with any one alone. QUIZ Of the HF cases that occur in the United States what percentage occurs in those 65 years and older? A. 20% B. 50% C. 60% D. 80% Of the HF cases that occur in the United States what percentage occurs in those 65 years and older? A. 20% B. 50% C. 60% D. 80% In Western countries the most common cause of HF due to systolic dysfunction is caused by _______. A. Cigarette smoking B. Coronary artery disease C. Obesity D. Valvular heart disease In Western countries the most common cause of HF due to systolic dysfunction is caused by _______. A. Cigarette smoking B. Coronary artery disease C. Obesity D. Valvular heart disease Which of the following conditions is made worse by heart failure? A. Chronic hypertension B. Diabetes C. Atrial fibrillation D. Valvular heart disease Which of the following conditions is made worse by heart failure? A. Chronic hypertension B. Diabetes C. Atrial fibrillation D. Valvular heart disease Diagnosis HF is a clinical syndrome with multiple causes. The likelihood of HF is increased in those patients with older age, history of coronary artery disease or myocardial infarction, and using a loop diuretic. The approach to the patient with suspected HF includes the history and physical examination, and diagnostic tests to help establish the diagnosis. These will also indicate acuity and severity. Signs and Symptoms Excess fluid causes A reduction in cardiac dyspnea, orthopnea, edema, output causes fatigue pain from hepatic and weakness that is congestion, and abdominal most pronounced with distention from ascites. exertion. A fall in cardiac output, leading to alterations in renal function, due in part to activation of the sodium-retaining renin-angiotensin-aldosterone and sympathetic nervous systems. Symptoms-Acute HF Acute and subacute presentations (days to weeks) are characterized primarily by shortness of breath, at rest and/or with exertion. Also common are orthopnea, paroxysmal nocturnal dyspnea, and, with right HF, right upper quadrant discomfort due to acute hepatic congestion. Patients with atrial and/or ventricular tachyarrhythmias may complain of palpitations. This may be accompanied by lightheadedness. Symptoms-Chronic HF When HF develops over months patients differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors including poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion. Over time, pulmonary venous capacitance accommodates to the chronic state of volume overload, leading to less or no fluid accumulation in the alveoli, despite the increase in total lung water. All HF Patients may report…. Fatigue and/or weakness Dyspnea, orthopnea. Dry, hacking cough or cough productive of frothy or blood-tinged sputum Restlessness, change in mental status Decreased urine output during day, nocturia Dizziness, syncope Think HF if… Dyspnea-Nearly all patients with heart failure present with dyspnea. The absence of dyspnea makes heart failure highly unlikely (sensitivity: greater than 95 percent) Heart failure is present in only about 30 percent of patients who present with
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