Heart failure & Cor pulmonale

Definition

Clinical syndrome that describes when the heart cannot maintain adequate amount of C.O or can do so at the expense of elevated filling pressure

Preload-Volume and pressure of blood in ventricle at the end of diastole

Afterload-Volume and pressure of blood in ventricle during systole

HF depends on preload ,afterload ,force of contraction

Causes

1.Decreased FOC-MI ,myocarditis ,cardiomyopathy

2.Ventricular outflow obstruction-HTN ,AS ,PS

3.Ventricular inflow obstruction-MS ,TS

4.Volume overload-ASD ,VSD ,MR ,PR

5.High output cardiac failure-Anaemia ,thyrotoxicosis ,beri beri ,arterio-venous shunt

6.Failure of ventricular relaxation/Diastolic dysfunction-Constrictive pericarditis ,restrictive cardiomyopathy ,LVF with fibrosis ,cardiac temponade

7.Arrhythmia-AF ,VF

[HFcompensatory mechanisms- (+) RAAS ,(+)sympathetic activity ,(+)endothelin  , (+)ADH {ADH(-)<--- ANP/BNP} ]

MS never cause pulmonary edema]

LVI/MI cause pulmonary edema]

Acute HF-AMI ,VF ,transfusion ,severe anemia ,massive pulmonary embolism]

Types

1.According to side

        
 Left sided HF [Pulmonary edema ,pleural effusion ,cardiomegaly found]

          
Right sided HF [High JVP ,hepatomegaly ,leg edema ,ascitis found]

          
Biventricular HF-Occurs in IHD/Dilated cardiomyopathy ,hyperdynamic circulation(Severe anemia ,thyrotoxicosis ,AV shunt ,beriberi)

2.According to mechanism

         
 Systolic dysfunction

          
Diastolic dysfunction

3.According to duration

         Acute HF(Acute MI)

         Chronic HF

         Acute on chronic HF-

• Added ischemia
• Concurrent illness
• Arrhythmia
• Inadequate reduction of therapy
• Negative inotropic drugs(Beta blocker to reduce force of contraction)
• Drugs causing salt and water retention(Steroid ,NSAIDs)
• Pulmonary edema(Right sided HF) [Left sided HF/embolism causes stroke]
• Condition increasing metabolic activity-Anaemia ,pregnancy ,thyrotoxicosis
• I/V volume overload   

4.According to CO-

• High output failure(Heart fails to maintain sufficient circulation despite increased CO)     Hyperdynamic circulation and Gm -ve septicemia
• Low output failure(Heart fails to maintain sufficient circulation with low CO)

• IHD/cardiomyopathy ,pericardial disease

 Note:

LVF-Bilateral basal crepitation ,gallop rhythm ,pulsus alternans

RVF-Raised JVP ,enlarged tender liver ,leg edema

Clinical features

1.Symptoms

• Exertional breathlessness or dyspnoea
• Orthopnoea(Dyspnoea occuring at recumbent position. Relieved by sitting upright position)
• Nocturnal cough
• Nocturia
• PND(Acute episode of severe breathlessness and coughing/wheezing awakening patient from sleep at night. Not relieved by upright position)
• Cheyne-stroke respiration(Episodic respiration.Due to diminished sensitivity of respiratory centre to PCO2)

2.Signs

General physical examination-

         Pulse-Diminished

         BP-Systolic BP raised in early HF ,but gradually decreases

         R.R-Laboured

         Temperature-Cool periphery

         Raised JVP

Systemic examination(CVS)-

         Gallop rhythm(By 3rd heart sound) [Volume overload]

         Left parasternal heave if right ventricular hypertrophy

·          

      Note:

      Cardiac cachexia-With severe chronic HF, there may be marked weight loss and

cachexia. due to -

• 1.Intestinal venous congestion>Malabsorption 
• 2.Increased metabolic activity 
• 3.Poor tissue nutrition due low CO

Bilateral leg swelling-CCF ,nephrotic syndrome ,CLD ,hypoproteinemia ,myxedema

Unilateral leg swelling-Lymphedema ,DVT ,angioneurotic edema ,ruptured baker's cyst]

Complication

1.Renal failure-Due to Low C.O

2.Hypokalemia-Due to RAAS activation

3.Hyperkalemia-Due to spironolactone use

4.Hyponatremia-Due to severe HF/High ADH

5.Embolism

6.Arrhythmia-Due to electrolyte imbalance

Treatment

• Diuretics
• Vasodilator
• ACEi
• Angiotensin 2 blocker

Cor pulmonale/Pulmonary heart disease

• Right ventricular  dilatation ,with/without hypertrophy
• Acute cor pulmonale occurs in massive pulmonary embolism that has Right ventricular dilatation and Right ventricular failure  without Right ventricular hypertrophy
• Chronic cor pulmonale is the conventional definition ,having Right ventricular dilatation and Right ventricular hypertrophy
• Symptoms-Dyspnoea ,abdominal pain ,ascitis

• Signs-Raised JVP , hepatomegaly ,leg edema