3. Introduction
■ A complex clinical syndrome that results from any structural or functional impairment of
ventricular filling or ejection of blood
■ Heart fails to act as a pump
■ Manifested by cardinal symptoms
– Dyspnoea & fatigue exercise intolerance
– Fluid retention pulmonary oedema, splanchnic oedema, peripheral oedema
11. Classification
■ Acute vs Chronic
■ Systolic vs Diastolic dysfunction
■ Right sided vs Left sided
■ High output vs Low output
12. Systolic vs diastolic
Systolic Diastolic
Age All ages Frequently elderly
Sex Often male Frequently female
LV EF Decrease ( <50 ) Normal ( Preserved )
LV cavity size Dilate ( increase intracardiac
volume )
Normal ( often with LVH )
13. Current categorization
■ Heart failure with a reduced ejection fraction (HFrEF) [SYSTOLIC]
■ Heart failure with preserved ejection fraction (HFpEF) [DIASTOLIC]
22. General Physical Examination
■ Mild to moderate HF : No distress except when lying flat for more than a
few minutes
■ Severe HF: Must sit upright, labored breathing, unable to finish a
sentence
– Cardiac cachexia
– Cyanosis
– Edema
– Jaundice
29. Chest x-ray (upright)
– Pulmonary venous congestion
– Cardiomegaly (80%) or normal (20%)
– Interstitial edema
■ Most specific for a final diagnosis of acute heart failure but the absence
of these does not rule it out
30. ■ CardiomegalyCTR = 18/30 (>50%)
■ Upper zone vessel enlargement (1) – a sign of
pulmonary venous hypertension
■ Septal (Kerley B) lines (2) – a sign of interstitial
oedema – see next picture
■ Airspace shadowing (3) – due to alveolar
oedema – acutely in a peri-hilar (bat's wing)
distribution
■ Blunt costophrenic angles (4) – due to pleural
effusions
31.
32. Electrocardiogram
■ Not useful for diagnosis
– Early recognition of arrhythmias – atrial fibrillation
– Signs of ischaemia or injury
33. ■ Irregularly irregular rhythm.
■ No P waves.
■ Absence of an isoelectric baseline.
■ Variable ventricular rate.
■ QRS complexes usually < 120 ms
34. Routine
■ Complete blood count to evaluate anaemia
■ Basic metabolic panel
– Electrolytes
– Renal status
35. Cardiac biomarkers
■ It is done when cause of
dyspnoea is still unclear
after standard
evaluation
■ This test will detect
ongoing myocyte injury,
which may be clinically
silent
36. Bedside ultrasound
1. Determine cause of dyspnoea e.g. tamponade
2. Determine LV function and volume status
3. RWMA
4. Valvular abnormality
Focused on
1. Signs of pulmonary congestion
2. Sign of volume overload
3. LV ejection fraction
37. Signs of pulmonary congestion
■ Sonographic B-lines
– Dx – >2 B-lines in
any sonographic
windows along the
anterior and
posterior chest
38. Signs of volume overload
■ IVC >2 cm diameter
■ Collapsibility index <50%
– Indicates raised in central venous pressure
AHF : AMI, CHF : Dilated cardiomyopathy
SD : impairment of contractility, with stroke output reduced and forward flow compromised, DD : primary problem with ability of the ventricles to relax and fill normally
Cyanosis due to excessive adrenergic activity
Edema: B/L pedal. Presacral, scrotal in bedridden
Diminished PP due to reduced stroke volume
Cold extremities due to peripheral vasoconstriction
V waves -TR
Creps/rales – pulmo edmea
May pulsate during systole if TR is present
Ascites and jaundice are late signs
Increased pressure in the hepatic veins and the veins draining the peritoneum
Impairment of hepatic function secondary to hepatic congestion and hepatocellular hypoxemia -- Jaundice
If CXR and ECG are normal = decrease likelihood of heart failure
Airspace shadowing is due to alveolar oedema caused by fluid filling the alveoli and small airways
Bat's wing or butterfly pulmonary opacities refer to a pattern of bilateral perihilar shadowing
caused by thickening of the interlobular septa which separate the secondary lobules at the periphery of the lungs
Ashman’s Phenomenon
Anemia may be the cause of S.O.B or exacerbate it
B lines representing thickened inter-alveolar/interlobular septa
Collapse during respiration
highly correlated with pulmonary capillary wedge pressure and are specific for acute heart failure
Measurement of IVC diameter in different phases of respiration differentiates normal subjects from patients with elevated right atrial pressure, cyclic variations in pleural pressure, which are transmitted to the right atrium, produce cyclic variations in venous return, which is increased by inspiration, leading to an inspiratory reduction of about 50% in IVC diameter
12-24h – complete symptoms resolution with standard theraphy