HEART FAILUREWHAT A FAMILY PHYSICIAN NEED TO KNOW

Prepared by : Dr. Ahmed Ibrahim Eldesouky AbouelelaFamily Medicine RegistrarMBBch, Msc, MRCGP.int

What a Family Physician need to know Terrifying informations. Basic informations. Role of family physician.

Terrifying Informations Heart failure is the leading cause of hospitalization of

patients > 65 years in age. > 15million new cases of HF estimated each year worldwide. Approximately 50% of patients with HF die within 5 years of diagnosis. Symptomatic HF has worse prognosis than majority of cancers. The most common cause of complications of heart

failure is poor compliance to treatment.

Basic Definition

Failure of the heart to provide the body tissue by its need of blood and subsequently oxygen and

nutrients

Heart Failure Classification

Acute vs. Chronic Systolic vs. Diastolic Right sided vs. Left sided Right ventricular vs. Left ventricular vs. Biventricular Preload vs. Afterload Low cardiac output vs. High cardiac out put Low ejection fraction vs. Normal ejection fraction

Acute versus Chronic Acute heart failure develops rapidly can be immediately life

threatening due to lack of time to undergo compensatory adaptations.

may result from cardiopulmonary by-pass surgery, acute infection (sepsis), acute myocardial infarction, valve dysfunction, severe arrhythmias, etc.

can often be managed successfully by pharmacological or surgical interventions. 

Chronic heart failure a long-term condition

(months/years) that is associated with the heart undergoing adaptive responses (e.g., dilation, hypertrophy) to a precipitating cause.

These adaptive responses, however, can be deleterious in the long-term and lead to a worsening condition.

Systolic versus Diastolic

Systolic– “can’t pump” Aortic Stenosis HTN Aortic Insufficiency Mitral Regurgitation Muscle Loss

IschemiaFibrosisInfiltration

Diastolic- “can’t fill” Mitral Stenosis Tamponade Hypertrophy Infiltration Fibrosis

Left versus Right Failure

Left Heart Failure Dyspnea Decrease exercise

tolerance Cough Orthopnea Pink, frothy sputum

Right Heart Failure Decrease exercise

tolerance Edema Hepatomegaly Ascites

Functional classification

NYHA Classification of heart failure

Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.

Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.

Class III: marked limitation of any activity; the patient is comfortable only at rest.

Class IV: any physical activity brings on discomfort and symptoms occur at rest.

New classification of heart failure

• Stage A: Asymptomatic with no heart damage but have risk factors for heart failure

• Stage B: Asymptomatic but have signs of structural heart damage

• Stage C: Have symptoms and heart damage

• Stage D: End stage disease

ACC/AHA guidelines, 2001

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

Causes

HypertensionCongenital heart defectsValvular heart diseasesHeart attackSevere lung diseaseDiabetesSevere anemiaOveractive thyroid gland (hyperthyroidism)Abnormal heart rhythms(Arrhythmias)

Pathophysiology

Symptoms and Signs

• Fatigue, effort intolerance • Dyspnea on exertion or at rest• Difficulty breathing when lying flat (Orthopnea)• Swelling in feet, ankles, legs or abdomen• hepatomegaly• Weight gain• Heart palpitations• May feel like the heart is racing or throbbing• Coughing that produces white or pink blood-tinged sputum• Feeling of being full or sick to your stomach• Memory loss or feeling of disorientation• Relative or caregiver may notice this first

Symptoms and Signs

Complication

Kidney damage or failure. Heart valve problems.  Heart rhythm problems.  Liver damage.

Diagnosis

Brain Natriuretic Peptide ( BNP test ) Echo Chest X ray ECG Lab

BNP(Brain Natriuretic Peptide) Test

BNP(Brain Natriuretic Peptide) Test Used in ER departments Good negative correlation Need baseline for positivity

Diagnostic of CHF with Sensitivity 90% Specificity 76% Predictive accuracy 83%

BNP < 100 pg/L – 98% negative predictive accuracy

Treatment

• ACE Inhibitors• ARBs• Diuretics• Aldosterone blockade• Potassium• Beta-blockers• Vasodilators• Digitalis preparations• Device therapy ( Biventricular (BiV) pacers /

Intracardiac defibrillators (ICD’s)• Surgery and other Medical Procedures

Heart Failure Treatments: Medication Types

•ACE inhibitor (angiotensin-converting enzyme)

•ARB (angiotensin receptor blockers)

•Beta-blocker

•Digoxin

•Diuretic

•Aldosterone blockade

Type What it does•Expands blood vessels which lowers

blood pressure, neurohormonal blockade

•Similar to ACE inhibitor—lowers blood pressure

•Reduces the action of stress hormones and slows the heart rate

•Slows the heart rate and improves the heart’s pumping function (EF)

•Filters sodium and excess fluid from the blood to reduce the heart’s workload•Blocks neurohormal activation and controls volume

Heart Failure Treatments:Types and Mechanisms Diuretics and ACEiReduce load

B blockersLimit speed and Thus save energy

Heart Failure Treatments: Types and Mechanisms DigitalisMotivate heart

DevicesIncrease efficiency

Role of Family Physician

Prevention

New classification of heart failure

• Stage A: Asymptomatic with no heart damage but have risk factors for heart failure

• Stage B: Asymptomatic but have signs of structural heart damage

• Stage C: Have symptoms and heart damage• Stage D: End stage disease

ACC/AHA guidelines, 2001

Prevention

1ry prevention 2ry prevention 3ry prevention

1ry prevention

Heart failure can’t be primarily prevented but still life style modification is recommended to those who has more than one risk factor

Risk factors

High blood pressure. Coronary artery disease.  Heart attack. Diabetes and Some diabetes medications.  COPD. Sleep apnea.  Obesity. Alcohol use.  Tobacco use. Congenital heart defects. Valvular heart disease.  Irregular heartbeats. 

Life style modification

Stop smoking.  Stop alcohol. Check legs, ankles and feet for swelling daily.  Eat a healthy diet, Restrict salt in diet.  Maintain a healthy weight. Consider getting vaccinations.  Control fats and cholesterol.  Be active. Reduce stress. Sleep well.

2ry prevention

Assessing risk factors Applying Modified Framingham Criteria for

Heart Failure diagnosis Go to specific diagnosis investigation

(BNP or echo ) for definite diagnosis.

Risk factors

High blood pressure. Coronary artery disease.  Heart attack. Diabetes and Some diabetes medications.  COPD. Sleep apnea.  Congenital heart defects. Valvular heart disease.  Alcohol use.  Tobacco use.  Obesity. Irregular heartbeats. 

Modified Framingham Criteria Diagnosis for Heart Failure

Major criteria Minor criteria Neck vein distension PND or Orthopnea Cardiomegaly on CXR Acute pulmonary edema Pulmonary rales Positive

abdominojugular test (Hepatojugular reflux)

Third heart sound (S3 Gallop rhythm)

Bilateral ankle edema Night cough Dyspnea on exertion Hepatomegaly Pleural effusion Tachycardia (> 120

beats/min)

Modified Framingham Criteria Diagnosis for Heart Failure Interpretation: heart failure diagnosis

requires 1 major criteria and 2 minor criteria

Efficacy: Sensitive but not specific Test sensitivity: 97%Test specificity: 79%

Life style modification

Stop smoking.  Stop alcohol. Check your legs, ankles and feet for swelling daily.  Eat a healthy diet, Restrict salt in your diet.  Maintain a healthy weight. Consider getting vaccinations.  Control fats and cholesterol.  Be active. Reduce stress. Sleep well.

3ry prevention

Insure good compliance to treatment.

Life style modification. Appropriate timing of surgery or

angioplasty for ischemic or valvular heart disease.

Home massages

Heart failure is one of the professional killer diseases.

Heart failure is malignant than malignancy. The most common cause of heart failure

complication is poor compliance to treatment. Asymptomatic patient with no heart damage but

have risk factors for heart failure is consider to be Stage A.

Main role of family physician is prevention.

REFERENCES

Up To Date Mayo Clinic J M 6th edition Medscape Pubmed

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