CHF/CCF/HF

1. Congestive Heart
Failure
Presented To : Dr. Abel
Presented By : Anish Kumar. K
Rajiv Gandhi University
Of Science and Technology
Clinical Rotation :Internal Medicine
Date:2015/10/27

2. Results from any structural or functional abnormality
that impairs the ability of the heart to eject blood (Systolic
Heart Failure) or to fill with blood (Diastolic Heart Failure).
Heart's pumping power is weaker than normal.
With heart failure , blood moves through the heart
and body at a slower rate, and pressure in the heart
increases.
As a result, the heart cannot pump enough oxygen
and nutrients to meet the body's needs.
Congestive Heart Failure (CHF)
Congestive Cardiac Failure(CCF)
Heart Failure (HF)

3. Congestive Heart Failure
Heart Failure can divided:
- Right Sided Heart Failure
- Left Sided Heart Failure
Can be Either From,
Diastolic Dysfunction(Inability to relax)
Systolic Dysfunction (Inability to Contract)

4. Congestive Heart Failure
Etiology
-Increase in Pulmonary pressure results fluid in alveoli
(PULMONARY EDEMA)
Increase in Systemic pressure results in fluid in tissues
(PERIPHERAL EDEMA)
Health conditions that either damage the heart or make it
work too hard
- Coronary Artery Diseases (CAD)
-Myocardial Infarction.
-Heart muscle diseases (cardiomyopathy)
-Heart inflammation (myocarditis)

5. Congestive Heart Failure
Risk Factors
• Coronary artery Diseases
• Myocardial Infarction
• Hypertension
• Diabetes
• Heart Valve Disease( e.g.Aortic Stenosis)
• Smoking
• Obesity
• Cardiomyopathy (Heart Muscle Diseases)
1)Dialated Cardiomyopathy (e.g. Alcohol,Viral Infections)
2)Hypertrophic Cardiomyopathy (Thickening of Heart Muscle
,septum between Rt and Lt Ventricle )
3)Restrictive Cardiomyopathy (Heart Muscles are rigid and unable
to expand e.g Fibrosis)

6. Congestive Heart Failure
Decreased Blood Pressure and
Decreased Renal perfusion
Stimulates the Release
of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure
LV Dysfunction causes
Decreased cardiac output

7. Congestive Heart Failure
Pathophysiology
In order to maintain normal cardiac output, several
compensatory mechanisms play a role as under:
Compensatory enlargement in the form of cardiac
hypertrophy, cardiac dilatation, or both.
Tachycardia due to activation of neurohumoral system.
e.g. release of norepinephrine and atrial natrouretic peptide,
activation of renin-angiotensin aldosterone mechanism.

8. Congestive Heart Failure
STARLING’S LAW
Within limits, the force of ventricular contraction is a
function of the end-diastolic length of the cardiac
muscle, which in turn is closely related to the ventricular
end-diastolic volume.
This is achieved by increasing the length of sarcomeres in
dilated heart
Increases the myocardial contractility and thereby attempts
to maintain stroke volume.

9. Congestive Heart Failure
•Heart failure results in DEPRESSION of the
ventricular function curve.
•COMPENSATION in the form of stretching of
myocardial fibers results.
•Stretching leads to cardiac dilatation which
occurs when the left ventricle fails to eject its
normal end diastolic volume

10. Congestive Heart Failure
Sympathetic nervous system stimulation
Renin-angiotensin system activation
Myocardial hypertrophy
Altered cardiac Rhythm
Compensatory Mechanisms

11. Congestive Heart Failure

12. Congestive Heart Failure

13. Congestive Heart Failure
Ventricular remodeling
Altered cardiac rhythm

14. Congestive Heart Failure
Types of Heart Failure
• Low-Output Heart Failure
– Systolic Heart Failure:
– decreased cardiac output
– Decreased Left ventricular ejection fraction
– Diastolic Heart Failure:
– Elevated Left and Right ventricular end-diastolic pressures
– May have normal LVEF
• High-Output Heart Failure
– Seen with peripheral shunting, low-systemic vascular resistance,
hyperthryoidism, beri-beri, carcinoid, anemia
– Often have normal cardiac output
• Right-Ventricular Failure
– Seen with pulmonary hypertension, large RV infarctions.

15. Congestive Heart Failure
Clinical Features
Left Sided Heart Failure:
1) Pulmonary Edema
a) Dyspnea (SOB)
b)Orthopnea
c)Paroxysmal Nocturnal Dyspnea
2)Decreased forward Perfusion
Activated Renin Angiotensin Aldosterone System, which cause fluid retention
and worsenen CHF.

16. Congestive Heart Failure
Clinical Features
Right Sided Heart Failure:
Most common cause of cause of Right Heart Failure is Left side
Heart Failure.
a) Dyspnea(SOB)
b)Jugular Venous Distention
c)Pitting Edema
d)Ascitis
e)Nutmeg Liver “Hepatomegaly”

17. Congestive Heart Failure
Physical Examination
• S3 gallop
– Low sensitivity, but highly specific
• Cool, pale, cyanotic extremities
– Have sinus tachycardia, diaphoresis and peripheral vasoconstriction
• Crackles or decreased breath sounds at bases (effusions) on lung
exam
• Elevated jugular venous pressure
• Lower extremity edema
• Ascites
• Hepatomegaly
• Splenomegaly
• Displaced PMI
• Apical impulse that is laterally displaced past the midclavicular line is usually
indicative of left ventricular enlargement>

18. Congestive Heart Failure
Diagnosis
1)Echocardiogram
-Distinguish systolic from Diastolic dysfunction by measuring Ejection Fraction
-Determining Myocardial Ischemia is the precipitating cause.
-Identify Valve Diseases.
2)B Type Natriuretic Peptide (BNP)
-Secreted by the Ventricles
-Differentiate between causes of dyspnea due to heart Failure from the other cause of
dyspnea.
3)Chest Xrays
• -Determine any Cardiomegaly. Cephalization of the pulmonary vessels
• Kerley B-lines
• Pleural effusions
4)EKG
-To Identify arrhythmias,Ischemic Heart Diseases,Right and Left ventricular
Hypertrophy, and presence of conduction delays or abnormalities.

19. Congestive Heart Failure

20. Congestive Heart Failure
Lab Investigations
• CBC
– Since anemia can exacerbate heart failure
• Serum electrolytes and creatinine
– before starting high dose diuretics
• Fasting Blood glucose
– To evaluate for possible diabetes mellitus
• Thyroid function tests
– Since thyrotoxicosis can result in A. Fib,
and hypothyroidism can results in HF.
• Iron studies
– To screen for hereditary hemochromatosis as cause of heart failure.
• ANA
– To evaluate for possible lupus
• Viral studies
– If viral mycocarditis suspected

21. Congestive Heart Failure
• BNP
– With chronic heart failure, atrial mycotes secrete
increase amounts of atrial natriuretic peptide (ANP)
and brain natriuretic pepetide (BNP) in response to
high atrial and ventricular filling pressures
– Usually is > 400 pg/mL in patients with dyspnea due
to heart failure.

22. Congestive Heart Failure
Cardiac Testing
• Exercise Testing
– Should be part of initial evaluation of all patients with CHF.
• Coronary arteriography
– Should be performed in patients presenting with heart failure who have
angina or significant ischemia
– Reasonable in patients who have chest pain that may or may not be
cardiac in origin, in whom cardiac anatomy is not known, and in
patients with known or suspected coronary artery disease who do not
have angina.
– Measure cardiac output, degree of left ventricular dysfunction, and left
ventricular end-diastolic pressure.
• Endomyocardial biopsy
• Not frequently used
• Really only useful in cases such as viral-induced cardiomyopathy

23. Congestive Heart Failure
Classification of Heart Failure
• New York Heart Association (NYHA)
– Class I – symptoms of HF only at levels that would limit normal
individuals.
– Class II – symptoms of HF with ordinary exertion
– Class III – symptoms of HF on less than ordinary exertion
– Class IV – symptoms of HF at rest
• Guidelines
– Stage A – High risk of HF, without structural heart disease or
symptoms
– Stage B – Heart disease with asymptomatic left ventricular dysfunction
– Stage C – Prior or current symptoms of HF
– Stage D – Advanced heart disease and severely symptomatic or
refractory HF

24. Congestive Heart Failure
Chronic Treatment of Systolic Heart Failure
• Correction of systemic factors
– Thyroid dysfunction
– Infections
– Uncontrolled diabetes
– Hypertension
• Lifestyle modification
– Lower salt intake
– Alcohol cessation
– Medication compliance
• Maximize medications
– Discontinue drugs that may contribute to heart failure
(NSAIDS, antiarrhythmics, calcium channel blockers)

25. Congestive Heart Failure
Pharmacological Therapy
1. Loop diuretics.
2. ACE inhibitor (or Angiotensin Receptor2 Blockers if
not tolerated).
3. Beta blockers.
4. Digoxin.
5. Hydralazine, Nitrate.
6. Potassium sparing diuretcs.

26. Congestive Heart Failure
• Loop diuretics
• Furosemide, buteminide
• For Fluid control, and to help relieve symptoms
• Potassium-sparing diuretics
• Spironolactone, eplerenone
• Help enhance diuresis
• Maintain potassium
• Shown to improve survival in CHF

27. Congestive Heart Failure
ACE Inhibitors
• Improve survival in patients with all severities
of heart failure.
• Begin therapy low and titrate up as possible:
• Enalapril –
• Captopril
• Lisinopril
• If cannot tolerate, may try ARB(Angiotensin II
receptor blockers)

28. Congestive Heart Failure
Beta Blockers
• Certain Beta blockers (carvedilol, metoprolol, bisoprolol)
can improve overall and event free survival in NYHA class
II to III HF, probably in class IV.
• Contraindicated:
– Heart rate <60 bpm
– Symptomatic bradycardia
– Signs of peripheral hypoperfusion
– COPD, asthma
– PR interval > 0.24 sec, 2nd or 3rd degree block

29. Congestive Heart Failure
Hydralazine plus Nitrates
• Dosing:
– Hydralazine
– Started at 25 mg po TID, titrated up to 100 mg po TID
– Isosorbide dinitrate
– Started at 40 mg po TID/QID
• Decreased mortality, lower rates of
hospitalization, and improvement in quality of
life.

30. Congestive Heart Failure
Digoxin
• Given to patients with HF to control symptoms
such as fatigue, dyspnea, exercise intolerance
• Shown to significantly reduce hospitalization
for heart failure, but no benefit in terms of
overall mortality.

31. Congestive Heart Failure
Statin Therapy
• Statin therapy is recommended in CHF for the
secondary prevention of cardiovascular
disease.
• Some studies have shown a possible benefit
specifically in HF with statin therapy
• Improved LVEF
• Reversal of ventricular remodeling
• Reduction in inflammatory markers (CRP, IL-6, TNF-
alphaII)

32. Congestive Heart Failure
Treating Congestive Heart failure
• Upright position
• Nitrates
• Lasix
• Oxygen
• ACE inhibitors
• Digoxin
• Fluids(decrease)
• After load (decrease)
• Sodium retention
• Test (Dig level, ABG’s, Potassium level)

33. Congestive Heart Failure
Medications to avoid In HF
• NSAIDS
– Can cause worsening of preexisting HF
• Thiazolidinediones
– Include rosiglitazone (Avandia), and pioglitazone (Actos)
– Cause fluid retention that can exacerbate HF
• Metformin
– People with HF who take it are at increased risk of potentially
lactic acidosis

34. Congestive Heart Failure
Implantable Cardioverter-Defibrillators for HF
• Sustained ventricular tachycardia is associated with
sudden cardiac death in HF.
• About one-third of mortality in HF is due to sudden
cardiac death.
• Patients with ischemic or nonischemic cardiomyopathy,
NYHA class II to III HF, and LVEF ≤ 35% have a
significant survival benefit from an implantable
cardioverter-defibrillator (ICD) for the primary
prevention of SCD.

35. Congestive Heart Failure
Management of Refractory Heart Failure
• Inotropic drugs:
– Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin
• Mechanical circulatory support:
– Intraaortic balloon pump
– Left ventricular assist device (LVAD)
• Cardiac Transplantation
– A history of multiple hospitalizations for HF
– Escalation in the intensity of medical therapy
– A reproducable peak oxygen consumption with maximal
exercise (VO2max) of < 14 mL/kg per min. (normal is 20
mL/kg per min. or more) is relative indication, while a
VO2max < 10 mL/kg per min is a stronger indication

37. Congestive Heart Failure