1
Heart failure
2
DEFINITION
? HEART FAILURE
– the pathophysiological state in which the heart
is unable to pump blood at a rate commensurate
with the requirement of the metabolizing tissues
or can do so only from an elevated filling
pressure,
– Usually caused by a defect in myocardial
contraction (myocardial failure),
3
DEFINITION
? CONGESTIVE HEART FAILURE
– Clinical manifested as
? Pulmonary congestion
? Systemic congestion
? Inadequate tissure blood perfusion
? HEMODYNAMICALLY heart failure (cardiac
dysfunction) is diagnosed when
– LVEDP>18mmHg or
– RVEDP>10mmHg
4
UNDERLYING CAUSES
? Primary myocardial dysfunction (systolic
and/or diastolic)
– Cardiomyopathy
– Primary or secondary metabolic disturbances of
myocardium
? Overloading of heart
– Pressure overloading
– Volume overloading
– limited diastolic function
5
UNDERLYING CAUSES
Age 70.3± 10.1 yr,
Causes CHD 65.8%
Hypertension 36.0%
Dila,Cardiomy,11.9%
With 2° DM 14.9%
Shanghai OPD,Chin J Cardiol 2001;29:644
6
Precipitating factors
? infection
? arrhythmias
? Pulmonary embolism
? overfatigue
? Pregnancy and delivery
? Anemia and hemorrhage
? others
7
Pathophysiology
? Frank-Starling mechanism
? Activation of neurohormonal
pathway (SAS and RAS)
? Myocardial damage and remodeling
? Diasatolic heart failure
8
,
9
CLINICAL CLASSIFICATION
? A cute vs,chronic heart failure
? Right-sided vs,left-sided Heart failure
? Low-output vs high-output heart failure
? Systolic vs diastolic heart failure
? Asymptomatic vs congestive heart failure
10
Chronic left-sided HF, symptoms
Respiratory distress
Exertional dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
Acute pumnonary edema
Cough (nonproductive),and hemoptysis
Reduced exercise capacity
Fatigue and weakness
Urinary symptoms
11
Chron,left-sided HF, Physi,findings
General appearance
Dyspnetic
Cyanosis,icterus,malar flush,diminished
pulse pressure,reduced SBP,rapid,weak and
thready pulse in severe HF
Evidence of ↑adrenergic activity
Peripheral vasoconstriction (pallor,coldness
of extremities and cyanosis of the digits ),
Diaphoresis with sinus tachycardia
12
Chron,left-sided HF, Physi,finding
Cardiac findings
Cardiomegaly
S3 gallops
Accentuation of P2
Systolic murmur
Pulsus alternans
Pulmonary rales
Moist rales over
the lung bases
Rhonchi wheezes
↓BS
13
Chron,right-sided HF, symptoms
? Gastrointestinal symptoms
? Symtoms of urinary system
? Dull ache in right upper quadrant,
? dyspnea
14
Chron,right-sided HF, Physi,finding
? Cardiac findings
? Hepatojugular reflux
? Congetive hepatomegaly or
tenderness
? Edema
? Hydrothorax and ascites
? Others (cyanosis,and etc.)
15
Chronic HF, labolaroty findings
? Routine lab,And serum electrolytes
& liver function tests
? ECG
? Echocardiography
? Chest Roentgenogram
16
ECG
? Suggesting basic presence of basic
heart diseases
? Atrial and ventricular hypertrophy,
myocardial ischemia or infarction,
arrhythmia
? V1ptf＜－ 0.03mm／ s,indicating left
atrial overloading,
17
Echocardiogram
? M mode,2D echo and Dopler technique for
systolic and diastolic function of LV
– LVDd and LVDs（ Dd and Ds）
– LV fraction of shortening
（△ D％ ＝（ Dd - Ds ） ／ Dd × 100％）
– mVCF ＝（ Dd - Ds）／ Dd × LVET
– SV
– LVEF
18
Chest X ray
Left-sided heart failure
cardiomegaly (cardiothorax ratio＞ 50%)
dilated pulmonary vein
pulmonary infiltrates,
prominent bronchovascular markings
Interstitial edema,Kerley.s B line,alveolar edema,
pleural effusion when PCWP＞ 25～ 30mmHg,
Right-sided HF
Cardiomegaly
19
20
Invasive hemodynamic monitoring
? Using Swan-Ganz cather and
thermodilution method for
measurement of
– Intracardiac and vascular
pressure
– Cardiac output
to asses cardiac function
21
Invasive hemodynamic monitoring
? CVP（ 中心静脉压 ） 6～ 12cmH2O
? PAP（ 肺动脉压 ） 12～ 30/4～ l3mmHg
? PCWP（ 肺毛细血管楔嵌压 ） 6～ 12mmHg
? SV（ 心搏量 ） 60～ 70ml
? SI（ 心搏指数 ） 4l～ 51ml/m2
? CO（ 心排血量 ） 5～ 6L/min
? CI（ 心排指数 ） 2.6～ 4.0L/min.m2
? EF（ 射血分数 ） 0.5 ～ 0.6
22
Chronic HF, diagnosis
?causes
?anatomy
?pathology
?arrhythmia
?Functional classification
23
Functional classification（ NYHA)
? Class I-No limitation,Ordinary physical activity does not
cause undue fatigue,dyspnea,or palpitation
? Class II-slight limitation of physical activity,
Such patients are comfortable at rest,Ordinary
physical activity results in fatigue,palpitation,dyspnea,or angina,
? Class III-marked limitation of physical activity,
although patients are comfortable at rest,less than
ordinary activity will lead to symptoms,
? Class IV-inability to carry on any physical activity
without discomfort,symptoms of congestive failure
are present even at rest.With any physical activity,
increased discomfort is experience,
24
Chronic HF, diff,diagnosis
Left-sided HF
With pulmonary dyspnea,COPD,asthma
Metabolic acidosis
Cardiac neurosis
Right-sided HF
Pricarditis
Hepatic,renal edema,
25
Functional classification（ NYHA)
? Class I-No limitation,Ordinary physical activity does not cause
undue fatigue,dyspnea,or palpitation
? Class II-slight limitation of physical activity,Such patients are
comfortable at rest,Ordinary physical activity results in fatigue,
palpitation,dyspnea,or angina,
? Class III-marked limitation of physical activity,although
patients are comfortable at rest,less than ordinary activity will
lead to symptoms,
? Class IV-inability to carry on any physical activity without
discomfort,symptoms of congestive failure are present even at
rest.With any physical activity,increased discomfort is
experience,
26
Chronic HF, diff,diagnosis
Left-sided HF
With pulmonary dyspnea,COPD,asthma
Metabolic acidosis
Cardiac neurosis
Right-sided HF
Pricarditis
Hepatic,renal edema,
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
TREATMENT OBJECTIVES
28
Chronic HF,treatment
Reducing load
Rest and tranquilizer
Control salt intake
Water intake
diuretics
Vasodilators
Improve CO
digitalis
non-digitalis
positive inotropic
agents
aldost,antagonist
β-bloker
correcting PF and cause of HF
diastolic HF
dificult HF cases
29
Diuretics
Thiazides
Hydrochlorothiazide
Potassium-sparing diuretics
Spironolactone
amiloride
Loop diuretics
Frusemide
30
Vasodilators
Nitrates
Nitroglycerine
Isosorbide dinitrate
Mononitrates
Nitroprusside
ACE inhibitor
ARB (Angiotensin receptor blocker)
31
Acute heart failure
? Definition
? Etioloogy and mechanism
? Clinical picture
? Diagnosis
? treatment
谢 谢
Heart failure
2
DEFINITION
? HEART FAILURE
– the pathophysiological state in which the heart
is unable to pump blood at a rate commensurate
with the requirement of the metabolizing tissues
or can do so only from an elevated filling
pressure,
– Usually caused by a defect in myocardial
contraction (myocardial failure),
3
DEFINITION
? CONGESTIVE HEART FAILURE
– Clinical manifested as
? Pulmonary congestion
? Systemic congestion
? Inadequate tissure blood perfusion
? HEMODYNAMICALLY heart failure (cardiac
dysfunction) is diagnosed when
– LVEDP>18mmHg or
– RVEDP>10mmHg
4
UNDERLYING CAUSES
? Primary myocardial dysfunction (systolic
and/or diastolic)
– Cardiomyopathy
– Primary or secondary metabolic disturbances of
myocardium
? Overloading of heart
– Pressure overloading
– Volume overloading
– limited diastolic function
5
UNDERLYING CAUSES
Age 70.3± 10.1 yr,
Causes CHD 65.8%
Hypertension 36.0%
Dila,Cardiomy,11.9%
With 2° DM 14.9%
Shanghai OPD,Chin J Cardiol 2001;29:644
6
Precipitating factors
? infection
? arrhythmias
? Pulmonary embolism
? overfatigue
? Pregnancy and delivery
? Anemia and hemorrhage
? others
7
Pathophysiology
? Frank-Starling mechanism
? Activation of neurohormonal
pathway (SAS and RAS)
? Myocardial damage and remodeling
? Diasatolic heart failure
8
,
9
CLINICAL CLASSIFICATION
? A cute vs,chronic heart failure
? Right-sided vs,left-sided Heart failure
? Low-output vs high-output heart failure
? Systolic vs diastolic heart failure
? Asymptomatic vs congestive heart failure
10
Chronic left-sided HF, symptoms
Respiratory distress
Exertional dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
Acute pumnonary edema
Cough (nonproductive),and hemoptysis
Reduced exercise capacity
Fatigue and weakness
Urinary symptoms
11
Chron,left-sided HF, Physi,findings
General appearance
Dyspnetic
Cyanosis,icterus,malar flush,diminished
pulse pressure,reduced SBP,rapid,weak and
thready pulse in severe HF
Evidence of ↑adrenergic activity
Peripheral vasoconstriction (pallor,coldness
of extremities and cyanosis of the digits ),
Diaphoresis with sinus tachycardia
12
Chron,left-sided HF, Physi,finding
Cardiac findings
Cardiomegaly
S3 gallops
Accentuation of P2
Systolic murmur
Pulsus alternans
Pulmonary rales
Moist rales over
the lung bases
Rhonchi wheezes
↓BS
13
Chron,right-sided HF, symptoms
? Gastrointestinal symptoms
? Symtoms of urinary system
? Dull ache in right upper quadrant,
? dyspnea
14
Chron,right-sided HF, Physi,finding
? Cardiac findings
? Hepatojugular reflux
? Congetive hepatomegaly or
tenderness
? Edema
? Hydrothorax and ascites
? Others (cyanosis,and etc.)
15
Chronic HF, labolaroty findings
? Routine lab,And serum electrolytes
& liver function tests
? ECG
? Echocardiography
? Chest Roentgenogram
16
ECG
? Suggesting basic presence of basic
heart diseases
? Atrial and ventricular hypertrophy,
myocardial ischemia or infarction,
arrhythmia
? V1ptf＜－ 0.03mm／ s,indicating left
atrial overloading,
17
Echocardiogram
? M mode,2D echo and Dopler technique for
systolic and diastolic function of LV
– LVDd and LVDs（ Dd and Ds）
– LV fraction of shortening
（△ D％ ＝（ Dd - Ds ） ／ Dd × 100％）
– mVCF ＝（ Dd - Ds）／ Dd × LVET
– SV
– LVEF
18
Chest X ray
Left-sided heart failure
cardiomegaly (cardiothorax ratio＞ 50%)
dilated pulmonary vein
pulmonary infiltrates,
prominent bronchovascular markings
Interstitial edema,Kerley.s B line,alveolar edema,
pleural effusion when PCWP＞ 25～ 30mmHg,
Right-sided HF
Cardiomegaly
19
20
Invasive hemodynamic monitoring
? Using Swan-Ganz cather and
thermodilution method for
measurement of
– Intracardiac and vascular
pressure
– Cardiac output
to asses cardiac function
21
Invasive hemodynamic monitoring
? CVP（ 中心静脉压 ） 6～ 12cmH2O
? PAP（ 肺动脉压 ） 12～ 30/4～ l3mmHg
? PCWP（ 肺毛细血管楔嵌压 ） 6～ 12mmHg
? SV（ 心搏量 ） 60～ 70ml
? SI（ 心搏指数 ） 4l～ 51ml/m2
? CO（ 心排血量 ） 5～ 6L/min
? CI（ 心排指数 ） 2.6～ 4.0L/min.m2
? EF（ 射血分数 ） 0.5 ～ 0.6
22
Chronic HF, diagnosis
?causes
?anatomy
?pathology
?arrhythmia
?Functional classification
23
Functional classification（ NYHA)
? Class I-No limitation,Ordinary physical activity does not
cause undue fatigue,dyspnea,or palpitation
? Class II-slight limitation of physical activity,
Such patients are comfortable at rest,Ordinary
physical activity results in fatigue,palpitation,dyspnea,or angina,
? Class III-marked limitation of physical activity,
although patients are comfortable at rest,less than
ordinary activity will lead to symptoms,
? Class IV-inability to carry on any physical activity
without discomfort,symptoms of congestive failure
are present even at rest.With any physical activity,
increased discomfort is experience,
24
Chronic HF, diff,diagnosis
Left-sided HF
With pulmonary dyspnea,COPD,asthma
Metabolic acidosis
Cardiac neurosis
Right-sided HF
Pricarditis
Hepatic,renal edema,
25
Functional classification（ NYHA)
? Class I-No limitation,Ordinary physical activity does not cause
undue fatigue,dyspnea,or palpitation
? Class II-slight limitation of physical activity,Such patients are
comfortable at rest,Ordinary physical activity results in fatigue,
palpitation,dyspnea,or angina,
? Class III-marked limitation of physical activity,although
patients are comfortable at rest,less than ordinary activity will
lead to symptoms,
? Class IV-inability to carry on any physical activity without
discomfort,symptoms of congestive failure are present even at
rest.With any physical activity,increased discomfort is
experience,
26
Chronic HF, diff,diagnosis
Left-sided HF
With pulmonary dyspnea,COPD,asthma
Metabolic acidosis
Cardiac neurosis
Right-sided HF
Pricarditis
Hepatic,renal edema,
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
TREATMENT OBJECTIVES
28
Chronic HF,treatment
Reducing load
Rest and tranquilizer
Control salt intake
Water intake
diuretics
Vasodilators
Improve CO
digitalis
non-digitalis
positive inotropic
agents
aldost,antagonist
β-bloker
correcting PF and cause of HF
diastolic HF
dificult HF cases
29
Diuretics
Thiazides
Hydrochlorothiazide
Potassium-sparing diuretics
Spironolactone
amiloride
Loop diuretics
Frusemide
30
Vasodilators
Nitrates
Nitroglycerine
Isosorbide dinitrate
Mononitrates
Nitroprusside
ACE inhibitor
ARB (Angiotensin receptor blocker)
31
Acute heart failure
? Definition
? Etioloogy and mechanism
? Clinical picture
? Diagnosis
? treatment
谢 谢
