Heart failure (HF) is a clinical

syndrome in which an abnormality of cardiac structure or function is responsible for the inability of the heart to eject or fill with blood at a rate commensurate with the requirements of the metabolizing tissues.

HF results in a constellation of clinical manifestations, including, in various combinations, circulatory congestion, dyspnea, fatigue, and weakness.

The severity of the clinical manifestations are commonly described according to criteria developed by the New York Heart Association.

The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure. It places patients in one of four categories based on how much they are limited during physical activity; the limitations/symptoms are in regards to normal breathing and varying degrees in shortness of breath and or angina pain: NYHA Class I Symptoms

No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Marked limitation in activity due to symptoms, even during less-thanordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest.

II

III

IV

Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

CAUSES OF HEART FAILURE UNDERLYING CAUSES Although HF may occur as a consequence of most
forms of heart disease, in the United States and Western Europe, ischemic heart disease is responsible for about three-quarters of all cases. Cardiomyopathies are second in frequency, while congenital, valvular, and hypertensive heart disease are less common causes.

PRECIPITATING CAUSES In evaluating patients with HF, it is important to identify not only the underlying but also the precipitatingcause .
Frequently, clinical manifestations of HF are seen for the first time in the course of an acute disturbance that places an additional load on a myocardium that is chronically excessively burdened. Such a heart may be adequately compensated under normal circumstances but have little additional reserve, the additional load imposed by a precipitating cause results in further deterioration of cardiac function.

Patients with pulmonary vascular congestion due to left ventricular failure are more susceptible to pulmonary infection than are normal persons; however, any infection may precipitate HF. The resulting fever, tachycardia, hypoxemia, and the increased metabolic demands may place a further burden on an overloaded, but compensated, myocardium of a patient with chronic heart disease.

The ten most common precipitating causes are described below. 1. Infection.

2. Arrhythmias. These are among the most frequent precipitating causes of HF. They exert a deleterious effect on cardiac function through a variety of mechanisms:

(a) Tachyarrhythmias reduce the time available for ventricular filling, contributing especially to diastolic HF; they may also cause ischemic myocardial dysfunction in patients with ischemic heart disease.

(b) The dissociation between atrial and ventricular contractions characteristic of many brady- and tachyarrhythmias results in the loss of the atrial booster pump mechanism, i.e., the atrial kick, thereby raising atrial pressures.

(c) Cardiac performance may become further impaired because of the loss of normally synchronized ventricular contraction in any arrhythmia associated with abnormal intraventricular conduction (see resynchroniz ation therapy below).

(d) Slowing of the heart rate associated with complete atrioventricular block or other severe bradyarrhythmias reduces cardiac output unless stroke volume rises reciprocally; this compensatory response is limited in myocardial dysfunction, even in the absence of overt HF.

3. Physical, Dietary, Fluid, Environmental, and Emotional Excesses. 4. Myocardial Infarction. 5. Pulmonary Embolism. 6. Anemia. 7. Thyrotoxicosis and Pregnancy. 8. Aggravation of Hypertension. 9. Rheumatic, Viral, and Other Forms of Myocarditis. 10. Infective Endocarditis.

FORMS OF HEART FAILURE HF may be described as systolic or diastolic, high-output or low-output, acute or chronic, right-sided or left-sided, and forward or backward. SALT AND WATER RETENTION

CLINICAL MANIFESTATIONS OF HEART FAILURE RESPIRATORY DISTURBANCES Dyspnea, Orthopnea, Paroxysmal(Nocturnal ) Dyspnea, Cheyne-Stokes Respiration,

OTHER SYMPTOMS Fatigue and Weakness

Abdominal Symptoms Anorexia and nausea associated with abdominal pain and fullness are frequent complaints and may be related to the congested liver and portal venous system.

CerebralSymptoms Patients with severe HF, particularly elderly patients with cerebral arteriosclerosis, reduced cerebral perfusion, and arterial hypoxemia, may develop alterations in the mental state characterized by confusion, difficulty in concentration, impairment of memory, headache, insomnia, and anxiety. Nocturia is common in HF and may contribute to insomnia.

PHYSICAL FINDINGS Pulmonary Rales Cardiac Edema Hydrothorax and Ascites Congestive Hepatomegaly Jaundice , Cardiac Cachexia

Other Manifestations With reduction of blood flow, the skin, especially in the extremities, may be cold, pale, and diaphoretic. Urine flowis depressed, contains albumin, has a high specific gravity, and a low concentration of sodium. In addition, prerenal azotemia may be present. In patients with long-standing severe HF, depression and sexual dysfunction are common.

DIFFERENTIAL DIAGNOSIS The diagnosis

Framingham Criteria for Diagnosis of Congestive Heart Failurea MAJOR CRITERIA Paroxysmal nocturnal dyspnea Neck vein distention Rales Cardiomegaly Acute pulmonary edema S3 gallop Increased venous pressure (16 cmH2O) Positive hepatojugular reflux MINOR CRITERIA Extremity edema Night cough Dyspnea on exertion Hepatomegaly Pleural effusion Vital capacity reduced by one-third from normal Tachycardia (120 bpm) MAJOR OR MINOR Weight loss 4.5 kg over 5 days treatment

TREATMENT
A simple rule for the treatment of all patients with HF cannot be formulated because of its varied etiologies, hemodynamic features, clinical manifestations, and severity. The treatment of HF may be divided into five components: (1) general measures; (2) correction of the underlying cause; (3) removal of the precipitating cause; (4) prevention of deterioration of cardiac function; and (5) control of the congestive HF state.

PROGNOSIS The prognosis in patients with HF depends primarily on the nature of the underlying heart disease and on the presence or absence of a precipitating factor that can be treated.

Harrisons Principle in Internal Medicine 16th Ed,

216 HEART FAILURE AND COR PULMONALE Eugene Braunwald HEART FAILURE 1367-1377