Download MBBS Cardiology PPT 2 Heart Failure Lecture Notes

HEART FAILURE

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RULES

40 MINUTES

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Are we missing the point?

Despite timely PPCI with STEMI

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mortality decreased to 7%

but heart failure increased to 22%

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(1 year after event)

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WHAT IS EXPECTED TO KNOW?

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? Definitions

? HEMODYNAMICS

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? Etiology

? CLINICAL RECOGNITON &

? Types

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DIFFERENTIATION

? Symptoms

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? ASSESSING SEVERITY

? Signs

? ORDERING TESTS

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? Medical Tx

? IMMEDIATE MANAGEMENT

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? Surgical Tx

? LONG TERM MANAGAMENT

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WHAT HAPPENS IN HEART FAILURE?

SVC 5

PV 10

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SVC 8

PV 25 PCWP 25

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RA 5

LA 10

RA 8

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LA 25

RV 25/0-5

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LV 120/0-10

RV 40/0-8 LV 100/0-25

PA 25/10

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AO 120/80

PA 40/25 AO 100/60

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NORMAL

AHF: LVEDP 25

LVEDP=mLAP=mPCWP CPP=DBP-LVEDP

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SVC 5

PV 12 PCWP 12

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SVC 5

PV 20 PCWP 20

RA 5

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LA 12

RA 5

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LA 20

RV 30/0-5

LV 10/0-12

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RV 40/0-5

LV 10/0-20

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PA 30/12

AO 100/70

PA 40/20

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AO 80/60

COMPENSATED HF

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DECOMPENSATED HF

LVEF reduced: Perfusion Low 5

CLINICAL RECOGNITION

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LEFT HEART FAILURE

RIGHT HEART FAILURE

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? DOE

? SWELLING

? ORTHOPNEA (LAP>24)

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? ABDOMINAL PAIN

? BENDOPNEA*

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? JVP ELEVATED

? PND (LAP>18)

? PINK FROTHY SPUTUM

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? HJR+ (PCWP> 18)

? RAPID THREADY PULSE

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? PEDAL EDEMA

? SBP LOW

ALSO

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? CARDIOMEGALY

? S3 (LVEDP>18)

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? LOW URINE OUTPUT

? BILATERAL BASAL CREPS

? CONFUSION

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? COLD EXTREMITIES

? FATIGUE

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NYHA

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MODIFIED ROSS SCALE

LAP<12

LAP 12-18

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LAP 18-24

LAP>24

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Outdoor Work

SUCK REST SUCK

Household Choirs

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DIAPHORESIS

Personal Activities

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FEEDING DIFFICULTY

PND

FTT

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Orhtopnea

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ACC/ AHA

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FRAMINGHAM CRITERIA

2 MJ/ 1MJ+2MN

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FOR CHILDREN

NADAS CRITERIA

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1 MJ/ 2MN

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VOLUME STATUS

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PERFUSION STATUS

BENDOPNEA

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HOW GOOD

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ARE THE CLINICAL SIGNS?

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FORRESTER

n

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2

>
2
.

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2
L
/
mi

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CI

n
2

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<
2
.
2
L

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/
mi

CI

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PCWP<18mmHg

PCWP>18mmHg

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STEVENSON

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ELLIS

NYHA 2

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NYHA 3

PND

NYHA 4

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Orthopnea

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TYPES!!

? ACUTE/ CHRONIC

? COMPENSATED/

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DECOMPENSATED

? SYSTOLIC/ DIASTOLIC/ both

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? HFREF/ HFPEF/ both

? LHF/ RHF/ CHF

? Mild/mod/severe

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? A/B/C/L

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GROSS, OKAY &

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SUBTLE

Batwing?HF?

Cephalization

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Pulm Venous

Congestion

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Kerley B

Batwing

Interstitial

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edema

Alveolar edema 17

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ARDS VS HF

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ACUTE ONSET SOB

ASTHMA

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RONCHI+

Pneumothx

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PCO2

Absent BS

high

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Pulmonary

Pneumonia

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Embolism

DKA

Metabolic

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acidosis

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ECG in HF

Goldberger's triad

LBBB+ Wide QRS

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LAE

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VALSALVA IN HF

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COPD VS HF

VENTILLATED:

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`'VALSALVA'

Pulse oxymetry

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Biomarkers:

Diagnosis/ prognosis

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WHAT LIES BENEATH?

LOW SALT

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B1 blockers

LOW FLUID

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DIURETICS

SNS

Ivabradine

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RAAS

NP

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ACEI

NEPRILYSIN

ARB

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INHIBITOR

MRA

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PNEUMOVAC

(ARNI)

INFLUVAC

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ESC

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GUIDELINE

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ARNI: SACUBITRIL VALSARTAN

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CARDIAC RESYNCHRONISATION THERAPY

NYHA II-IVa + LVEF< 35%

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NYHA I + LVEF <30%

LBBB + QRS>150 ms (>120ms)

NSR (AF)

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Life expectancy> 1 yr

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Ionotrops & more

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Treatment Summary

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MECHANICAL CIRCULATORY DEVICE

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MECHANICAL CIRCULATORY DEVICE

TANDEM HEART

IMPELLA

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HEARTMATE

ECMO

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HEART TRANSPLANT

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Stem cell therapy

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What causes Acute heart failure?

? <5 years: CHD (PDA>VSD)

? 5-15 years: Rheumatic carditis (h/o joint pain)

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viral (h/o fever) (MC Coxsackie)

? 15-35 years: Myocarditis (h/o fever)

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arrythmias (palpitation) (SVT>VT)

HTN

? >35 years: Ischemic (Chest pain ? ACS)

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arrhythmia (palpitation) (AF>VT>SVT)

myocarditis (fever)

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CKD

ALWAYS RULE OUT HTN CRISIS AND AF

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What causes Chronic heart failure?

? <5 years: CHD (PDA>VSD)
? 5-15 years: Rheumatic heart dis (h/o joint pain)

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viral (h/o fever) (MC Coxsackie)
? 15-35 years: RHD
CHD
? >35 years: Ischemic
CMP (r/o alcohol CMP)

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ALWAYS RULE OUT ANAEMIA, hypoThy

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Treat the underlying cause!

? Myocarditis: supportive therapy only
? Arrhythmia: DC shock (SVT 50-100J, VT 200J)

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? ACS: PTCA+S
? Anemia: keep Hb around 10
? DO NOT GIVE IV FLUID (NS) TO HF PATIENTS
? Old MI EF 35%: No role of PTCA w/o viability
? Rule out Cardiomyopathies by Echo/ Imaging

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ACUTE CHEST PAIN + SOB + NORMAL CAG

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50 yr old+ HTN + Obese Lady+ DOE

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10 year child CHF no murmer

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? HEMODYNAMICS

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Increased LVEDP ? LAP - PCWP

? CLINICAL RECOGNITON & DIFFERENTIATION

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Volume status/ perfusion status/ HTN/ anemia/ AF

? ASSESSING SEVERITY

AHA/ ACC, Killip, NYHA, CPK level

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So,

? ORDERING TESTS

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Pallor/ Hb (r/o Anemia)

very little Murmer (r/o structural heart dis)

to learn ECG and trop I (r/o ACS)

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CXR (r/o pneumothx)

actual y.. CPK (confirming HF)

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ABG (r/o Asthma/ COPD)

Echo (r/o CMP, structural heart dis)

? IMMEDIATE MANAGEMENT

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O2/ IV Diuretics/ NIV (BIPAP, CPAP)/ ionotrops

? LONG TERM MANAGAMENT

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Pharmacotherapy/ CRT/ low salt + fluid/ vaccines

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LVAD ? HTX ? Stem Cell therapy

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