by Salah Abusin

1. Heart Failure
Overview
Salah Abusin, MD, MRCP
Cardiology Fellow
Chicago, IL
Secretary General
Sudanese American Medical Association

2. Definition
• complex clinical syndrome characterized by
impaired myocardial performance and
progressive activation of the neuroendocrine
system leading to circulatory insufficiency and
congestion.

3. Stage A
• Stage A:
– patients at high risk for developing heart failure with
no structural heart disease
• Examples
– hypertension
– atherosclerotic disease
– Diabetes
– Obesity
– metabolic syndrome
– Patients using cardiotoxins
– with FHx CM

4. Stage B
• Patients with structural heart disease who have
not yet developed symptoms of heart failure
• Examples
– previous MI
– LV remodeling including LVH and low EF
– asymptomatic valvular disease

5. Stage C
• Patients with past or current symptoms of
heart failure associated with underlying
structural heart disease
• Examples
– known structural heart disease and shortness of
breath and fatigue, reduced exercise tolerance

6. Stage D
• Patients with end-stage heart failure who
require specialized advanced treatment
• who have marked symptoms at rest despite
maximal medical therapy (e.g., those who are
recurrently hospitalized or cannot be safely
discharged from the hospital without
specialized interventions)

7. NYHA Classification of HF

8. Causes of HF
• Valvular Heart Disease
• Ischemic Cardiomyopathy
• Non Ischemic Cardiomyopathy
– Dilated CMP
– Hypertensive CMP
– Hypertrophic CMP
• Other

9. HF Symptoms
• Classic Symptoms
• Dyspnea, usually with exertion.
• Orthopnea (i.e., dyspnea when lying down,
usually described as number of pillows used
while sleeping) is typical with more advanced
cases of LV dysfunction or in decompensated
heart failure.
• Paroxysmal nocturnal dyspnea (PND)

10. Symptoms of HF
• Fatigue and low exercise tolerance are common
complaints in patients with heart failure.
• Dizziness may occur in the setting of impaired
perfusion, but is more commonly iatrogenic
(i.e., related to the use of heart failure
medications).
• Palpitations and syncope may occur in patients
with underlying arrhythmia and require prompt
evaluation.
• Anorexia and abdominal pain are common
symptoms of
• Other cough, insomnia, and depressed mood.

11. Signs of HF
• Neck
– Elevated Jugular Venous Pressure
• Chest Examination
– Lung Crackles
– Dullness at the lung bases consistent with pleural
effusion
• Abdomen
– Ascites
– Hepatomegaly
• Tender in acute HF
• pulsatile liver in severe Tricuspid Regurgitation

12. Signs of HF
• Displaced Cardiac Apex
• Loud S2 (Pulmonary Hypertension)
• Specific murmurs in patients with valvular
heart disease
• A third heart sound (S3 gallop)

13. ECG
• Signs of prior MI
• Chamber enlargement and hypertrophy
• heart block
• Arrhythmias
• Pericardial Effusion

14. Chest Xray

15. Echocardiography
• Establishes the diagnosis most of the time
• Allows assessment of abnormalities of cardiac
structure and function
• Left Ventricular systolic and diastolic function
• Right Ventricular size and function
• Left and Right Atrial Size
• Severity of valvular lesions
• IVC size

16. Left Ventricular Function
• Ejection Fraction
• Equals Stroke Volume/End Diastolic Volume
• Expressed as a percentage
• Normal = 55 -65%
• Systolic Heart Failure if EF <50%
– Or HF with reduced EF
• Heart Failure with preserved EF if EF>50%

17. Case Examples
• Normal Echo

18. Severe LV dysfunction
EF 10-15%

19. Severe RV dysfunction

20. Hypertrophic Cardiomyopathy

21. Severe Mitral Stenosis

22. LAD MI

23. Cardiac Catheterization
• Coronary Angiography
– To diagnose ischemic cardiomyopathy
– Prior to Valve Surgery in patients > 40 or those <40
with risk factors
• Right/Left Heart Catheterization
– Assess Hemodynamics
– Measure PVR and reversibility with Vasodilators
• Endomyocardial Biopsy
– In select patients

24. Management
• Definitive Management depends on the
underlying cause
• Medical Therapy
– Acute
– Chronic
• Non Medical Therapy
– Cardiac Surgery
– Device Therapy

25. Valvular Heart Disease
• Mitral Stenosis
– Diuretics to relieve pulmonary congestion
– Beta Blockers
• for rate control in the event of atrial fibrillation
– Anticoagulation
• For all patients with atrial fibrillation
– Percutaneous Balloon Mitral Valvuloplasty for
select patients
– Mitral Valve Surgery

26. • Aortic Stenosis
– Aortic Valve Replacement
– Percutaneous Aortic Valve Replacement in non
surgical candidates
• Primary Mitral Regurgitation
– Afterload reduction with vasodilators
– Mitral Valve Surgery
• Aortic Valve Regurgitation
– Afterload reduction with vasodilators
– Mitral Valve Surgery

27. Dilated Cardiomyopathy
Systolic Heart Failure
• Acute Medical Therapy
– Oxygen
– Diuretics
– Intravenous vasodilators
• Nitroglycerin
• Nesiritide
• Nitroprusside
– Inotropic Therapy
• Milrinone
• Dobutamine

28. Chronic Medical Therapy
• ACE inhibitors
– ARB (Angiotensin Blockers) if patient cannot
tolerate ACE inhibitors
• Beta blockers
• Spironolactone
• Digoxin
• Anticoagulation

29. ACE Inhibitors
• Proven in multiple clinical trials to improve
mortality and morbidity due to Heart Failure
• Examples
– Lisinopril, Enalapril
• Side Effects
– Increase Creatinine
– Hyperkalemia
– Cough
– Hypotension
– Angioedema

30. Beta blockers
• Proven in multiple clinical trials to improve
mortality and morbidity due to Heart Failure
– Metoprolol, carvedilol, bisoprolol
• Side Effects
– bradycardia
– hypotension
– fatigue
– Hypotension
– Angioedema

31. Spironolactone
• Proven in multiple clinical trials to improve
mortality and morbidity due to Heart Failure
• Dosage: 25mg once daily (no uptitration)
• Side Effects
– hyperkalemia
– Painful gynecomastia

32. Digoxin
• Reduces rates of rehospitalization with heart
failure
• Not proven to reduce mortality from HF
• Avoid in patients with renal failure
• Dosage 0.125mg once daily
• Narrow therapeutic window
• Digoxin toxicity

33. Anticoagulation
• Indications
– LV thrombus
– Patients with Atrial Fibrillation and Mitral Stenosis
– Consider in all patients with Non valvular atrial
fibrillation and HF
• Warfarin
• Novel anticoagulants
– Rivoraxaban
– Dabigatran