CONGESTIVE HEART FAILURE

M.ASHOKKUMAR DEPT OF PHARMACY PRACTICE SRM COLLEGE OF PHARMACY

HEART ANATOMY AND PHYSIOLOGY

The heart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.

 The external structures of the heart include the ventricles, atria, arteries, and veins.  Arteries carry blood away from the heart while veins carry blood into the heart.  The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide.  The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

The Right Side of the Heart

 The right system receives blood from the veins of the whole body. This is "used" blood, which is poor in oxygen and rich in carbon dioxide.

The right atrium is the first chamber that receives blood. The chamber expands as its muscles relax to fill with blood that has returned from the body. The blood enters a second muscular chamber called the right ventricle. The right ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs. The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled.

The Left Side of the Heart The left system receives blood from the lungs. This blood is now oxygen rich. The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart. It is received from the lungs in the left atrium, the first chamber on the leftside. Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body. The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body. This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement). The lower number (diastolic blood pressure) is measured when the left ventricle relaxes to refill with blood between beats. Blood leaves the heart through the ascending aorta, the major artery that feeds blood to the entire body.

The Valves Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart: The tricuspid regulates blood flow between the right atrium and the right ventricle. The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs. The mitral valve regulates blood flow between the left atrium and the left ventricle. The aortic valve allows blood to flow from the left ventricle to the ascending aorta. The Heart's Electrical System.  The heartbeats are triggered and regulated by the conducting system, a network of specialized muscle cells that form an independent electrical system in the heart muscles. These cells are connected by channels that pass chemically caused electrical impulses.

CHF DEFINITION
Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. This can result from:
narrowed arteries that supply blood to the heart muscle

coronary artery disease

 past heart attack, or myocardial infarction, with scar tissue that

interferes with the heart muscle's normal work

 high blood pressure and/or myocarditis

 heart

valve disease due to past rheumatic fever or other

causes primary disease of the heart muscle itself, called cardiomyopathy.

 heart defects present at birth congenital heart defects. infection of the heart valves and/or heart muscle itself -

endocarditis and/or myocarditis Heart failure also affects the kidneys' ability to dispose of sodium and water. The retained water increases the edema. o Predisposing Factors o Infection o Anaemia o Thyrotoxicosis

Symptoms Heart fail re t icall evel s sl l and is a c r nic, l ng-ter c nditi n, alt gh you may experience a sudden onset of symptoms, known as acute heart failure. The term "congestive heart failure" comes from blood backing up into or congesting the liver, abdomen, lower extremities and lungs
Type of heart failure Signs and symptoms Chronic heart failure Fatigue and weakness (A long-term condition with signs and Rapid or irregular heartbeat symptoms that persist.) Shortness of breath (dyspnea) when you exert yourself or when you lie down Reduced ability to exercise Persistent cough or wheezing with white or pink blood-tinged phlegm Swelling (edema) in your legs, ankles and feet Swelling of your abdomen (ascites) Sudden weight gain from fluid retention Lack of appetite and nausea Difficulty concentrating or decreased Alertness

Acute heart failure (An emergency situation that occurs when something suddenly affects your heart's ability to function.)

Signs and symptoms similar to those of chronic heart failure but more severe, and start or worsen suddenly Sudden fluid buildup Rapid or irregular heartbeat with palpitations that may cause the heart to stop beating Sudden, severe shortness of breath and coughing up pink, foamy mucus Chest pain if caused by a heart attack

Part f ur heart affected b heart failure Left-sided heart failure

De cri ti n Most common form of heart failure. Fluid and blood may back up in your lungs, causing shortness of breath Often occurs with left-sided heart failure. Fluid and blood may back up into your abdomen, legs and feet, causing swelling. The left ventricle can't contract vigorously, indicating a pumping problem

Right-sided heart failure

Systolic heart failure

Diastolic heart failure The left ventricle can't relax or fill fully, (also called heart failure Indicating a filling problem. with normal ejection fraction)

Risk factors
A single risk factor may be enough to cause heart failure, but a combination of factors increases your risk. Risk factors include: High blood pressure. Your heart works harder than it has to if your blood pressure is high. Coronary artery disease. Narrowed arteries may limit your heart's supply of oxygen-rich blood, resulting in weakened heart muscle. Heart attack. Damage to your heart muscle from a heart attack may mean your heart can no longer pump as well as it should. Irregular heartbeats. These abnormal rhythms can create extra work for your heart, weakening the heart muscle. Diabetes. Having diabetes increases your risk of high blood pressure and coronary artery disease. Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure. Don't stop taking these medications on your own, though. If you're taking them, discuss with your doctor whether you need to make any changes. Sleep apnea. The inability to breathe properly at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart. Congenital heart defects. Some people who develop heart failure were born with structural heart defects. Viruses. A viral infection may have damaged your heart muscle. Alcohol use. Alcohol can weaken heart muscle and lead to heart failure.

PATHOPHYSIOLOGY

Causes: Myocarditis Ventricular aneurysm Cardiac temponade Pericarditis Hypertension

Tachycardia Ventricular dilatation Myocardial hypertrophy

Fluid overload

Water reabsorption Decrease cardiac output Increase ADH Decrease renal perfusion Increase Osmotic pressure Increase sodium retention

Left sided Congestive Heart Failure

Causes Myocardial Infarction Hypertension Aortic stenosis insufficiency Mitral stenosis insufficiency Bloods dams back into the pulmonary capillary bed Pressure at the pulmonary capillary bed Pulmonary edema Reduced myocardial contractility Increases cardiac workload Decreased diastolic filling Obstructions of left atrial emptying

Left sided CHF

Left atrial pressure

Stroke volume decreases

Tissue perfusion decreases Cellular hypoxia

Blood flows to the kidney RAAS Stimulation Vasoconstriction and reabsorption of Na & water Extra cellular fluid Volume Total blood vol Systemic BP

Signs &symptoms

Right Sided congestive Heart Failure

Causes: LSCHF Pulmonary Embolism Right ventricular infarction Congenital septal defects

Reduced myocardial contractility

Increases cardiac workload

Decreased diastolic filling Obstruction of right atrial emptying Contraction of right sided atrial filling

Increase right atrial pressure

Right sided CHF

Blood drains back from RV to RA

s/s: Neck vein engorgement hepatomegaly Portal hypertension ascites Peripheral edema Spleenomegaly Jaundice

Increased pressure in the veins

Te t & diagn

Bl d te t . Sample of your blood to check your kidney and thyroid function and to look for indicators of other diseases that affect the heart. Check your blood for specific chemical markers of heart failure, such as a hormone called brain natriuretic peptide (BNP). Although first identified in the brain, BNP is secreted by the heart at high levels when it's injured or overworked. Chest X-ray. X-ray images help to see the condition of lungs and heart. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs. Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Impulses are recorded as waves and displayed on a monitor or printed on paper. This test helps to diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure

Echocardiogram. An important test for diagnosing and monitoring heart failure is the echocardiogram. An echocardiogram also helps distinguish systolic heart failure from diastolic heart failure, in which the heart is stiff and can't fill properly. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors determine how well your heart is pumping by measuring the percentage of blood pumped out of your heart's main pumping chamber (the left ventricle) with each heartbeat. This measurement is called the ejection fraction.

Ejection fraction. Your ejection fraction is measured during an echocardiogram. An ejection fraction is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment. In a healthy heart, the ejection fraction is about 60 percent meaning 60 percent of the blood that fills the ventricle is pumped out with each beat.

TREATMENT
Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens or dilates blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten). ACE inhibitors also blunt some of the effects of hormones that promote salt and water retention. ACE inhibitors can cause an irritating cough in some people. It may be best to put up with the cough, if you can, to gain the medication's benefits. But be sure to discuss this with your doctor. Switching to another ACE inhibitor or an angiotensin II receptor blocker (ARB) may relieve the problem. Angiotensin II (A-II) receptor blockers (ARBs). These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the beneficial effects of ACE inhibitors, but they don't cause a persistent cough. They may be an alternative for people who can't tolerate ACE inhibitors. Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with the condition.

Beta blockers. This class of drug slows your heart rate and reduces blood pressure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta). These medicines also reduce the risk of some abnormal heart rhythms. Beta blockers may reduce signs and symptoms of heart failure and improve heart function.

Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for heart failure include bumetanide (Bumex) and furosemide (Lasix). The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium,

Aldosterone antagonists. These drugs include spironolactone (Aldactone)

and

eplerenone (Inspra). They're primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart and may help people with severe heart failure live longer. Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous level.

MONITORING AND SELF CARE If you have heart failure, your doctor will monitor you closely. You will have follow up appointments at least every 3 to 6 months and tests to check your heart function. For example, an ultrasound of your heart (echocardiogram) will be done once in awhile to see how well your heart pumps blood with each beat. You will need to carefully monitor yourself and help manage your condition. One important way to do this is to track your weight on a daily basis. Weigh yourself at the same time each day and on the same scale, with little to no clothes on. Weight gain can be a sign that your body is holding onto extra fluid and your heart failure is worsening. Talk to your doctor about what you should do if your weight goes up or if you develop more symptoms.

Other important measures include: Take your medications as directed. Carry a list of medications with you wherever you go. Limit salt intake. Do not smoke. Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan for your degree of heart failure. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well. Lose weight if you are overweight. Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest as well. Keep your feet elevated to decrease swelling