CARDIAC FAILURE

1. CARDIAC FAILURE TOPICS INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE Return to Cardiovascular Pathology Index Page Brian Angus Pathology Department University of Newcastle upon Tyne

2. INTRODUCTION • very common clinical problem • due to many types cardiac disease • prognosis poor - median survival 3 yrs

3. SIDE OF HEART AFFECTED The heart works as a unit with both ventricles contracting in unison. Heart failure usually involves both the right and left sides, giving symptoms and signs related to both - congestive cardiac failure. Sometimes left or right heart failure predominates, for example RHF in chronic obstructive airways disease, and acute LVF in myocardial infarction. In the ensuing slides we will consider right and left heart failure separately.

4. SIDE OF HEART AFFECTED LEFT pulmonary congestion and oedema - breathlessness RIGHT peripheral oedema hepatic congestion raised JVP CONGESTIVE : R & L Note: chronic LHF leads to RHF

5. CAUSES OF CARDIAC FAILURE • ischaemic heart disease • systemic hypertension • valvular heart disease • congenital heart disease • lung disease COAD (cor pulmonale) • Rarities e.g. cardiomyopathy

6. LEFT HEART FAILURE: EFFECTS Acute LHF - Pulmonary oedema Frothy blood stained sputum ChronicLHF - Dyspnoea on exertion Poor renal perfusion - Renin-angiotensin system activated

7. LEFT HEART FAILURE: THE RENIN-ALDOSTERONE-ANGIOTENSIN SYSTEM Poor renal perfusion is sensed by the juxtaglomerular apparatus, which secretes renin. Renin converts angiotensinogen in the blood to angiotensin1. This in turn is converted by ACE (angiotensin converting enzyme) to angiotensin2, which increases blood pressure directly by vasoconstriction and by increasing adrenal secretion of aldosterone. ACE inhibitors are used to treat heart failure as well. as hypertension. Diuretic drugs are another mainstay of treatment.

8. THE RENIN ANGIOTENSIN ALDOSTERONE SYSTEM JGA RENIN ANGIOTENSINOGEN ANGIOTENSIN 1 ANGIOTENSIN 2 ADRENAL ACE ALDOSTERONE VASOCONSTRTICTS ACE INHIBITORS Na RETENTION INCREASED BP

9. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

10. RIGHT HEART FAILURE: EFFECTS Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities

11. RIGHT HEART FAILURE: EFFECTS 1 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows the “nutmeg” liver of chronic venous congestion

12. RIGHT HEART FAILURE: EFFECTS 2 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows pitting oedema of the ankle. An indentation has been left by firm digital pressure

13. RIGHT HEART FAILURE: EFFECTS 3 Hepatic congestion: nutmeg appearance Raised JVP Oedema - Tissues: Ankles and sacrum Pleural and peritoneal cavities The photograph shows bilateral pleural effusions.

14. PLEURAL EFFUSIONS

15. RIGHT HEART FAILURE: COR PULMONALE Cor pulmonale is the term given to heart failure due to lung disease, such as chronic obstructive airways disease.

16. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

17. CONGESTIVE CARDIACFAILURE:EFFECTS Congestive = Combined R & L Most cases are congestive but sometimes features of R or L CF predominate

18. CONGESTIVE CARDIACFAILURE:CLINICAL FEATURES SUMMARY dyspnoea oedema venous congestion raised JVP mild hepatomegaly

19. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

20. CARDIAC FAILURE DIAGNOSIS • History • Examination • Chest X-RAY • ECG • Echocardiography • BNP BNP = B type natriuretic peptide. Hormone released into plasma by steressed myocytes in CF

21. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

22. DYSPNOEA Dyspnoea (breathlessness) occurs in left heart failure. At first the pulmonary vascular beds become congested. Later fluid builds up in the interstitium (the space between capillary endothelial cells and alveolar lining cells), and this is known as interstitial oedema. Finally fluid enters the alveoli giving pulmonary oedema as shown in the radiograph.

23. PULMONARY OEDEMA

24. DYSPNOEA In the early stages of pulmonary oedema, crepitations (fine crackles) are heard on auscultation. In severe pulmonary oedema frothy sputum can be produced. Occaisionally this can be bloodstreaked, for example in pulmonary oedema due to mitral stenosis.

25. DYSPNOEA: SPECIAL TYPES On lying down dependent vascular and extravascular fluid enters the central circulation. In heart failure the heart cannot cope with the increase load and pulmonary congestion and oedema result

26. DYSPNOEA: SPECIAL TYPES The two clinical syndromes associated with this are: Orthopnoea: dyspnoea on lying down flat. Paroxysmal nocturnal dyspnoea: intermittent attacks of dyspnoea while in bed. The patient typically goes to an open window gasping for breath and waits for recovery.

27. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

28. CARDIAC FAILURE: AGE DIFFERENCES Babies and old people sometimes do not give classical symptoms and signs of heart failure. Babies typically show rapid breathing (tachypnoea), rapid heartbeat (tachycardia) and poor feeding. Old people can simply be lethargic with nausea and vomiting.

29. CARDIAC FAILURE INTRODUCTION CAUSES LEFT HEART FAILURE RIGHT HEART FAILURE CONGESTIVE CARDIAC FAILURE DIAGNOSIS DYSPNOEA AGE EFFECTS HIGH OUTPUT FAILURE

30. CARDIAC FAILURE: HIGH OUTPUT FAILURE In most cases of heart failure the cardiac output is low. In rare situations, there may be no intrinsic heart disease, but the heart is put under such a high load that it cannot cope and eventually fails. This is known as high output failure. Examples of this include very severe anaemia and hyperthyroidism. Massively enlarged thyroid gland in hyperthyroidism.

31. END OF PRESENTATION Return to Cardiovascular Pathology Index Page