Physiology Med-I

October 29, 2014

Group 3-A
Congestive Heart Failure
-

I.

is a clinical syndrome that occurs in patient who, because of an inherited or

acquired abnormality of cardiac structure and /or function develop a constellation
of clinical symptoms and signs that lead to frequent hospitalization, a poor quality
of life, and shortened life expectancy. (Harrison)
heart is unable to pump blood at Rate sufficient to meet metabolic demand of
the tissue or can do so ONLY at an elevated filling pressure. (Robbins)
inability of the heart to pump the amount of oxygenated blood necessary to affect
venous return and to meet the metabolic requirements of the body.

Epidemiology
a. General Incidence Rate
- Growing problem worldwide
- Prevalence follow an exponential pattern, rising with age, and affects 6-10% of
people over the age of 65
- Incidence lower in women than in men
- Arise primarily in the setting of depressed LV ejection fraction
b. World Health Organization
- More than 23 million people worldwide suffer from heart failure
c. Incidence in the Philippines
- Out of 86,241,697 people in the Philippines, 1,521,912 have congestive heart
failure
- Heart failure is the 6th leading cause of mortality in the Philippines, affecting
males more often than Philippines

II.

Etiology
a. Categories
- Heart Failure with depressed Ejection fraction Systolic Failure
o Heart is weak and cannot expel the appropriate amount of blood with each
beat
o Diminished pumping ability due to muscle weakening.
- Heart Failure with preserved Ejection fraction (>40-50%) Dystolic Failure
o Heart does not fill properly
o Heart is too stiff and cant enlarge fast enough to accept the appropriate
amount before contraction.

III.

Forms of Heart Failure

a. Left sided Failure
- Primarily result from congestion of the pulmonary circulation
- Stasis of blood in the left-sided chamber
- Hypoperfussion of tissues leading to organ dysfunction
- Mostly caused by:
o Ischemic heart disease
o Hypertension
o Aortic and mitral disease
o Myocardial disease
- Can be divided into:
o Left sided systolic failure
o Left sided diastolic failure
b. Right sided Failure
- Most commonly caused by Left sided heart failure
- Pure right sided heart failure:
o Occurs in patients with disorders affecting lungs
o Referred to as Cor Pulmonale
- Pulmonary congestion is minimal
- Engorgement of systemic and portal venous system is pronounced

IV.

Pathogenesis
- Heart failure begins after an index event produces an initial decline in the hearts
pumping capacity. After this initial decline in pumping capacity, a variety of
compensatory mechanisms are activated, including the adrenergic nervous
system, the renin angiotensin-aldosterone system, and the cytokine system. In
the short term, these systems are able to restore cardiovascular function to a
normal homeostatic range with the result the patient remains asymptomatic.
However, with time the sustained activation of these system can lead to
secondary end-organ damage within the ventricle, with worsening left ventricular
remodeling and subsequent cardiac decompensation

hypertrophy

Systolic Failure
Diastolic Failure
Inability of the ventricle to contract
Inability of the ventricle to relax and fill
normally
normally
Symptoms resulting from inadequate
Symptoms from elevated filling pressures
cardiac output.
Ejection fraction <40%
Ejection fraction > 50%
Systolic and diastolic failure co-exist in most patients with HF

Low Output Heart Failure

Cardiac output at rest <2.2 L/min per m2
(lower limit of normal) and fails to increase
normally with exertion
Seen after MI, hypertension, dilated
cardiomyopathy, and valvular or pericardial
disease.
Often accompanied by vasodilation and
warm extremities

High Output Heart Failure

Cardiac output >3.5 L/min per m2 or upper
limit of normal (before development of
heart failure)
Seen in hyperthyroidism, anemia,
pregnancy, arteriovenous fistula.

Left-sided HF
Left ventricle is hemodynamically
overloaded and/ or weakened, resulting in
pulmonary congestion (dyspnes,
orthopnea)

Right-sided HF
Abnormality primarily affecting right
ventricle, resulting in edema, congestive
hepatomegaly and systemic venous
distention

Usually with underlying heart disease

a.
-

V.

Stages of Congestive Heart Failure (New York Heart Association)

Stage I None- no symptoms from ordinary activities
Stage II Mild- comfortable at rest or during mild exertion
Stage III Moderate- symptomatic with any anxiety
Stage IV Severe- Symptomatic at rest. Confined to bed or chair.

Diagnosis
a. Modified Framingham Criteria for the Diagnosis of Chronic Heart Failure
- Major Criteria
o Neck Vein Distention
o Orthopnea or paroxysmal nocturnal dyspnea
o Crackles (> 10cm above base of lung)
o Cardiomegaly on chest radiograph
o S3 gallop
o Central venous pressure >12mmHg
o Left Ventricular dysfunction on echocardiogram
o Weight loss >4.5 kg in response to CHF treatment
o Acute pulmonary edema
- Minor Criteria
o Bilateral ankle edema
o Night cough
o Dyspnea on exertion
o Hepatomegaly
o Pleural effusion
o Tachycardia (>120 beats/min)

*Diagnosis of chronic heart failure (CHF) requires two of the major criteria or one the
major plus two of the minor criteria
b. Blood Test- N-terminal pro-b-type natriuretic peptide can help in diagnosing heart
failure.
c. Chest X-ray- enlarged heart and fluid build up in lungs.
d. Echocardiogram- helps distinguish systolic heart failure from diastolic heart
failure. Can help determine how well the heart is pumping by measuring the
percentage of blood pumped out of the hearts main pumping chamber with each
heartbeat (ejection fraction). It can also look for valve problems or evidence of
previous heart attacks, as well as some unusual causes of heart failure.
VI.

Treatment
a. Pharmacologic

Angiotensin- converting enzyme (ACE) inhibitor: they are a type of vasodilator

that lower blood pressure and improve blood flow and decrease workload of the
heart.
- Angiotensin II receptor blockers:
- Digoxin (Lanoxin) : increases the strength of heart muscle contractions, slow
heartbeat.
- Beta Blockers: slows heart rate and reduces blood pressure. It also limits or
reverses some of the damage to your heart if you have systolic heart failure
- Diuretics: decrease fluid in you lungs to help breathe more easily.
- Aldosterone Antagonist: potassium sparing diuretics but also have additional
properties that may reverse scarring of the heart and help people with severe
systolic heart failure live longer.
- Inotropes: improve heart pumping function and maintain blood pressure.
b. Non-Pharmacologic
- Stop smoking
- Weigh yourself daily
- Restrict salt in the diet
- Maintain a healthy weight
- Limit fats and cholesterol
- Limit alcohol and fluids
- Be active
- Reduce stress
- Sleep easy