5. Diastolic failure
• Inability of the ventricle to relax and fill
normally causing increase of filling pressures.
• EF is >50%.
Common causes are:
• constrictive pericarditis
• cardiac tamponade
• restrictive cardiomyopathy
• arterial hypertension
Systolic and diastolic failure usually coexist.
11. Low output heart failure
• Cardiac output is decreased and fails
to increase normally with exertion.
Causes can be devided into three
groups:
• pump failure
• excessive preload
• chronic excessive afterload
13. Excessive preload
• mitral regurgitation
• fluid overload (for example, NSAID causing
fluid retention)
Fluid overload may cause left ventricular failure in
a normal heart if renal excretion is impaired or big
volumes are involved (iv. infusion running too
fast).
More common situation is if there is simultaneous
compromise of cardiac function, and in elderly.
14. High output heart failure
This is rare.
Output is normal or increased in
the face of high needs.
Failure occurs when cardiac
output fails to meet these needs.
15. Causes
• anaemia
• pregnancy
• hyperthyroidism
• Paget´s disease
• arteriovenous malformation
• beri beri
First there are symptoms of right ventricular
failure, later on left ventricular failure develops.
16. Framingham criteria for CCF
Diagnosis requires the
simultaneous presence of
at least 2 major criteria or
1 major criterion in
conjunction with 2 minor
criteria.
17. Major criteria
• paroxysmal nocturnal dyspnoea
• crepitations
• S3 galop
• cardiomegaly (cardiothoracic ratio >50% on chest
radiography)
• increased central venous pressure (>16 cmH20 at right
atrium)
• weight loss >4,5 kg in 5 days in response to treatment
• neck vein distention
• acute pulmonary oedema
• hepatojugular reflux
18. Minor criteria
• bilateral ankle oedema
• dyspnoea on ordinary exertion
• tachycardia >120 bpm
• decrease in vital capacity by third from
maximum recorded
• nocturnal cough
• hepatomegaly
• pleural effusion
21. Brain natriuretic peptide (BNP)
• Plasma BNP is closely related to left
ventricle pressure.
• In myocardial infarction and left ventricle
dysfunction, both BNP and ANP (atrial
natriuretic peptide) can be released in
large quantities.
• Secretion is also increased by
tachycardia, glucocorticoids and thyroid
hormones.
22. Brain natriuretic peptide (BNP)
• Vasoactive peptides (endothelin-1,
angiotensin II) also influence secretion.
• ANP and BNP increase glomerular
filtration rate and decrease renal sodium
resorption.
• Both ANP and BNP decrease preload by
relaxing smooth muscle.
• ANP partly blocks secretion of renin and
aldosterone.
23. Brain natriuretic peptide (BNP)
• Plasma BNP reflects myocyte stretch.
• BNP is used to diagnose heart failure.
• Increased levels of BNP distinguishes heart
failure from other causes of dyspnoea.
BNP is highest in decompensated
heart failure
• intermediate in left ventricular
dysfunction
• lowest if no heart failure or LV dysfunction
24. Brain natriuretic peptide (BNP)
• BNP is higher in systolic dysfunction than in
isolated diastolic dysfunction.
• It is highest in CCF.
• BNP increases in proportion to right
ventricular dysfunction: primary pulmonary
hypertension, cor pulmonale, pulmonary
embolism and congenital heart disease.
• BNP levels rise more in left ventricular
disorders.
25. Brain natriuretic peptide (BNP)
The higher the BNP, the higher
the cardiovascular and all-
cause mortality.
High levels of BNP in heart
failure is also associated with
sudden death.
34. ECG
It may indicate cause:
• ischaemia
• myocardial infarction
• ventricular hypertrophy
35. Echocardiography
It is the key investigation.
It may indicate the cause (MI, valvular
heart disease) and can confirm the
presence or absence of left ventricle
dysfunction.
36. Management of acute heart failure
• Oxygen if there is no pre-existing lung disease.
• Iv. access and ECG monitor: treat if any
arrhythmias.
• Furosemide 40-80 mg. iv. slowly.
• Nitroglycerine spray 2 puffs if systolic blood
pressure is more than 90 mmHg.
• Dose of furosemide can be repeated if the
patient is worsening.
• Opiates!
37. CHRONIC HEART FAILURE
MANAGEMENT
NYHA classification of heart failure
NYHA I Heart disease present, but no undue dyspnoea from ordinary
activity.
NYHA II Comfortable at rest, dyspnoea on ordinary activities.
NYHA III Less than ordinary activity causes dyspnoea, which is limiting.
NYHA IV Dyspnoea present at rest, all activity causes discomfort.
38. Management
• Smoking cessation!
• Less salt!
• Optimization of weight and nutrition!
• Treatment of cause: dysrhythmias, valve
disease.
• Treatment of exacerbating factors: anaemia,
thyroid disease, infection, hypertension.
• Avoiding exacerbating factors: NSAID (fluid
retention) and verapamil (negative inotrope).
39. Diuretics
• Diuretics can reduce the risk of death and
worsening heart failure.
• Loop diuretics: furosemide 40 mg divided into
two doses per os (every 12 hours).
• Dose can be increased if necessary.
• Side effects: hypokalemia, renal impairment.
• In refractory oedema, thiazide can be added.
• It is very important to monitor electrolytes,
especially K+ !
40. ACE-inhibitors
ACE-i are very usefull in patients with left
ventricular systolic dysfunction.
If cough is a problem, an angiotensin receptor
blocker may be used instead of ACE-i.
Most dangerous side effect of both ARB and
ACE-i is hyperkalemia.
42. Spironolactone
• Spironolactone 25 mg per os
once a day decreases mortality
rate by 30% when added to
conventional therapy.
• Eplerenone has less side effects
than spironolactone.
45. Literature
• Oxford Handbook of Clinical Medicine.
Longmore M. Wilkinson I. B. Baldwin A.
Elizabeth W. Ninth edition.
• Medscape.com
• Radiopaedia.org
• ProProfs.com
• www.med-ed.virginia.edu