Cardiac failure
Introduction
• Heart failure is a chronic condition caused by the heart not functioning
as it should or a problem with its structure. It can happen if the heart is
too weak or too stiff, or both.
• This can lead to fatigue, swelling in the legs and abdomen and
shortness of breath which can be from fluid in the lungs.
Causes of Heart failure
Heart failure has many causes or underlying risk factors.
Most he most comon causes of Heart failure.
• Heart attack (myocardial infarction) and coronary artery disease
• High blood pressure (hypertension).
Less common causes include:
• Heart valve disease
• congenital heart disease
• infection causing inflammation of the heart muscle (myocarditis)
• heart muscle disease of unknown causes
• heart rhythm disorders (arrhythmia)
• other medical conditions such as thyroid diseases or anemia
Risk Factors
Risk factors for coronary heart disease include:
• high blood pressure
• high cholesterol
• diabetes
• tobacco smoking
• physical inactivity
• not following a heart-healthy eating pattern
• overweight or obesity
• excess alcohol intake
• depression, anxiety and social isolation
Symptoms
Signs and symptoms of heart failure include the following:
• Exertional dyspnea and/or dyspnea at rest
• Orthopnea
• Acute pulmonary edema
• Chest pain/pressure and palpitations
• Tachycardia
• Fatigue and weakness
• Nocturia and oliguria
• Anorexia, weight loss, nausea
Symptoms Cont’d
• Exophthalmos and/or visible pulsation of eyes
• Distention of neck veins
• Weak, rapid, and thready pulse
• Rales, wheezing
• S 3 gallop and/or pulsus alternans
• Increased intensity of P 2 heart sound
• Hepatojugular reflux
• Ascites, hepatomegaly, and/or anasarca
• Central or peripheral cyanosis, pallor
Diagnosis
Heart failure criteria, classification, and staging
• The Framingham criteria for the diagnosis of heart failure consists of the
concurrent presence of either two major criteria or one major and two minor
criteria.
Major criteria comprise the following:
• Paroxysmal nocturnal dyspnea
• Weight loss of 4.5 kg in 5 days in response to treatment
• Neck vein distention
• Rales
• Acute pulmonary edema
Diagnosis Cont’d
• Hepatojugular reflux
• S 3 gallop
• Central venous pressure greater than 16 cm water
• Circulation time of 25 seconds or longer
• Radiographic cardiomegaly
• Pulmonary edema, visceral congestion, or cardiomegaly at autopsy
Diagnosis Cont’d
Minor criteria (accepted only if they cannot be attributed to another medical
condition) are as follows:
• Nocturnal cough
• Dyspnea on ordinary exertion
• A decrease in vital capacity by one third the maximal value recorded
• Pleural effusion
• Tachycardia (rate of 120 bpm)
• Hepatomegaly
• Bilateral ankle edema
NYHA classification
The New York Heart Association (NYHA) classification system categorizes
heart failure on a scale of I to IV, [2] as follows:
• Class I: No limitation of physical activity
• Class II: Slight limitation of physical activity
• Class III: Marked limitation of physical activity
• Class IV: Symptoms occur even at rest; discomfort with any physical activity
Stages of Heart Failure
The American College of Cardiology/American Heart Association
(ACC/AHA) staging system is defined by the following four stages [3] :
• Stage A: High risk of heart failure but no structural heart disease or
symptoms of heart failure
• Stage B: Structural heart disease but no symptoms of heart failure
• Stage C: Structural heart disease and symptoms of heart failure
• Stage D: Refractory heart failure requiring specialized interventions
Stages of Heart Failure Cont’d
Additional ACC/AHA/ and Heart Failure Society of America (HFSA) disease-staging
terminology characterizes the syndrome as a continuum
• "At risk for HF" for stage A: Applied to asymptomatic patients with risk factors such
as diabetes or hypertension but no known cardiac changes
• "Pre-HF" for stage B: Adds cardiac structural changes or elevated natriuretic
peptides, still in the absence of symptoms
• "Symptomatic HF" for stage C: Structural disease with current or previous symptoms
• "Advanced HF" for stage D: Characterized by severe debilitating symptoms or
repeated hospitalizations even with guideline-directed medical therapy (GDMT)
Testing
The following tests may be useful in the initial evaluation for suspected
heart failure
• Complete blood cell (CBC) count
• Iron studies
• Urinalysis
• Electrolyte levels
• Renal and liver function studies
• Fasting blood glucose levels
• Lipid profile
• Thyroid stimulating hormone (TSH) levels
Imagings
• Electrocardiography
• Chest radiography
• Two-dimensional (2-D) echocardiography
• Nuclear imaging [10]
• Maximal exercise testing
• Pulse oximetry or arterial blood gas
• Noninvasive stress testing.
Management
Treatment includes the following:
• Nonpharmacologic therapy: Oxygen and noninvasive positive
pressure ventilation, dietary sodium and fluid restriction, physical
activity as appropriate, and attention to weight gain
• Pharmacotherapy: Diuretics, vasodilators, inotropic agents,
anticoagulants, beta blockers, ACEIs, ARBs, CCBs, digoxin, nitrates, B-
type natriuretic peptids, I(f) inhibitors, ARNIs, soluble guanylate
cyclase stimulators, SGLT2Is, and MRAs
Surgical options
Surgical treatment options include the following:
• Electrophysiologic intervention
• Revascularization procedures
• Valve replacement/repair
• Ventricular restoration
• Extracorporeal membrane oxygenation
• Ventricular assist devices
• Heart transplantation
References
• The hearrt.org, Medscape.
https://emedicine.medscape.com/article/163062-overview?form=fpf
• https://www.betterhealth.vic.gov.au/health/
conditionsandtreatments/congestive-heart-failure-chf#about-heart-
failure
• https://www.heartandstroke.ca/heart-disease/conditions/heart-
failure
