Grading of Heart Failure: How much activity is permitted by heart failure!
I = Patient can perform routine activities without any discomfort.
II = Patient feels mild discomfort in performing routine activities and this slightly
restricts his daily activities.
III = There is moderate to severe restriction of routine daily activities due to
breathlessness. At rest he is without any discomfort.
IV = Patient is breathless even at rest.
(These are New York Heart Association guidelines)
| NYHA classification of heart failure Class I: asymptomatic No limitation in physical activity despite presence of heart disease. This can be suspected only if there is a history of heart disease which is confirmed by investigationsfor example, echocardiography Class II: mild Slight limitation in physical activity. More strenuous activity causes shortness of breath for example, walking on steep inclines and several flights of steps. Patients in this group can continue to have an almost normal lifestyle and employment Class III: moderate More marked limitation of activity which interferes with work. Walking on the flat produces symptoms Class IV: severe Unable to carry out any physical activity without symptoms. Patients are breathless at rest and mostly housebound |
Types of Heart Failure
Many Parameters
A Systolic or Forward Heart Failure: Basically enough pressure is not being
created by myocardium to propel blood in systemic circulation. Myocardial function
is compromised due to any reason. Infarction is one example.
Diastolic Heart Failure: Myocardium is stiff, cannot dilate. There can be
multiple reasons, like amyloid deposition, fibrosis etcetera are many cardiomyopathies
in this etiology. Filling of heart is restricted. This reduces force of contraction.
Fourth heart sound is audible. No third heart sound is usually present. Murmurs
are more common. Eiosinophilia may be associated with many myopathies.
B High Output Failure: Circulating blood volume is increased for prolonged
periods of time. Heart cannot maintain adequate pressure due to increased load.
Thyrotoxicosis, Anaemia & Beri Beri is few examples.
Low Output Failure:
C Hypertrophy Heart Failure: There are many inherited myopathies where myocardium
is hypertrophied and it impairs filling which leads to failure.
D Right Heart Failure/Left Heart Failure. Left heart failure eventually leads
to right heart failure. Therapy remains the same.
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Right Heart Failure
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Left Heart Failure |
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Symptoms and Signs
Symptoms
Following are the main symptoms.
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* Breathlessness
* Oedema, Swelling.
* Weakness
* Lethargy
* Tachycardia
* Palpitations
* Giddiness
* Symptoms of Primary diseases.
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There is a long list of other symptoms. Whenever heart failure is present above
mentioned first two symptoms are usually present even when patient presents with
some other complaint.
Breathlessness
A long list of causes is present. At times difficulty arises to differentiate the
origin of this symptom. Is this due o cardiac failure or due to Lung disease? Following
features should be elicited by cross-questioning.
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Breathlessness due to cardiac origin |
Breathlessness due to lung disease |
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Most important feature is relation to exertion. Severity of symptom is related to degree of exertion. |
Here important feature is level of bronchospasm which is related to
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Problem persists for most of the times. |
Even if it is continuous now, it used to be episodic in the past. |
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Cough is not productive |
Cough may be productive |
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Patient feels better while lying down |
Patient feels better sitting up. |
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There is usually no wheezing. |
Wheezing may be audible. Whistles. |
Signs of Heart Failure
Swelling, edema or bloated ness
Tachycardia
Gallop Rhythm
Wheezing or crackles may be present.
Heart Murmurs may be present
Engorged Neck Veins.
Investigations
Impression of Prof Bilal Zikerya is that delay in early detection of heart failure
patients is due to delay in ordering two basic investigations.
* X-ray Chest
* ECG
For early detection all patients who raise little bit of suspicion of heart failure,
where physician has the impression that breathlessness may be of cardiac origin,
and there are risk factors predisposing to heart failure, these two investigations
should be ordered immediately.
X-ray Chest
In the present of normal size of heart: Features of left ventricular failure should
be looked for. These are pulmonary congestion, typical batwing shadowing or upper
lobe congestion.
Where size of heart is enlarged: Other features of heart failure should be searched
for.
ECG
All patients who are suspected of heart failure or who have any risk factor should
have ECG done at earliest. Signs of ischaemia, heart enlargement or any silent infarction
may be picked up.
Patients who are diagnosed as patients of heart failure on history, examination,
Xray chest and ECG should have following baseline investigations.
* Urine: Routine Analysis.
* Sugar: Blood Levels.
* Lipid profile
* Renal Profile: Serum Creatinine and blood urea in addition to electrolytes. Whenever
therapy is started for heart failure, it is preferable to repeat the renal profile
after 2 weeks to estimate any disturbance in renal function being caused by diuretics
or ACE inhibitors.
* CBC: Anaemia is quite common and it is being overlooked.
If response to therapy is not as expected then
* ETT
* Echocardiography
* Pulmonary Function Tests
Should be ordered to further define the cause of symptoms.
Echocardiography can be ordered to quantify heart failure and to look into the causes
of heart failure even when diagnosis of heart failure is established without this
investigation. Diagnosis of heart failure can be established without echocardiography.
Common Risk Factors for Heart Failure
* Hypertension
* Ischaemic Heart Disease
* Valvular Heart Disease
* Cardiomyopathies
* Rheumatic Heart Disease
Evaluation of Heart Failure
* First of all remediable causes, like Valvular heart disease, should be ruled out.
If any is present then surgery should be advised at appropriate time without delay.
* Look for Ischaemic Heart Disease.30-40% infarctions may be silent. I H D should
be properly evaluated by proper persons to judge whether any by-pass surgery can
be beneficial or not.
* A functional grading should be done according to NYHA criteria. This should help
to monitor and evaluate therapy and measure the prognosis.
* All etiologies which can be of primary importance or detrimental in nature like
Diabetes, Hypertension or renal failure should be properly assessed and managed.
Therapeutic Tools
Diuretics
Following diuretics can be used according to the amount of diuresis needed.
Loop Diuretic: Frusamide; Most powerful diuretic. Potassium supplements should be
routinely added. If BP is below 90/60 initially in heart failure then it is better
to admit the patient and give the diuretics in combination with inotropic drugs
like dobutamide. Frusamide can be combined with potassium sparing diuretics.
Thiazides: These are less powerful. Loss of potassium is less. So where diuresis
is intended to be mild these can be used instead of frusamide.
Spironolactone: There is now increased interest in this diuretic. Diuretic effect
is very mild but this has the capacity to delay or minimize fibrosis in myocardium.
ACE Inhibitors
These should be used in all kinds of heart failure. Wherever there is major metabolic
disturbance like in Diabetes, these are more beneficial. In diabetics renal profile
can be repeated after 2 weeks of use to assess any disturbance caused by ACE Inhibitors.
ARBs like Losartan
These can be used in place of ACE inhibitors where tolerance is a problem with the
liters due to cough. Equally effective.
Betablockers
These should be used in all patients of heart failure where there is sympathetic
overstimulation. Resting Tachycardia is one such indication. These should not be
used in Valvular heart disease. Care should be observed in patients of systolic
dysfunction. Beta-blockers should be titrated very slowly, starting with slowest
possible dose. Carvedilol (Dimitone) is probably the best studied for this use.
Metoprolol is another alternative.
Nitrates, Vasodilators, Calcium Chanel Blockers
These can be used in heart failure. Mild beneficial effects are there. CCBs are
not much effective. Where ACE inhibitors cannot be used due to cough then one of
these can be added.
Digoxin
Current opinion in the west is that Digoxin should be used only in those patients
of heart failure where atrial fibrillation is also present. In Pakistan due to poor
economic conditions it should be used on wider scale.
In Emergencies
If heart failure is ascertained then Diuretic and Oxygen should be started immediately
pending other investigations. But if diagnosis is in doubt and patient is in acute
distress then it is better to nebulize the patient, give oxygen and start investigating
patient immediately.
In Pregnancy
ACE inhibitors are absolutely contraindicated. Nitrates can be used at any stage.
Diuretics have to be used if acute heart failure is there and gyaenocologists suggest
prolonging the gestation.
Few terms about the Myocardium
In the background of I H D & Heart Failure
Remodeling: After infarction myocardium reorganizes itself. There has to be fibrosis.Remodelling
refers to this reorganisation.Spironolactone and ACE inhibitors are known to have
beneficial effects in this regard.Vasodilators like amlodipine and nitrates may
also be useful.
Hibernatin: After AMI when remaining cardiac function is correlated with the loss
of myocardial tissue, sometimes it is seen that function is much more disturbed
then the estimated loss of myocardium suggests. Angiography and other investigations
suggest certain areas where blood supply is not completely lost but it is reduced
to the levels where myocardium is alive but has gone to low metabolic state due
to ischaemia. Function of these areas is not appropriate. These areas are said to
have gone into hibernation. Effective therapeutic measures can be taken to bring
these areas to full function.
Stunning: It refers to similar state of affairs, as in hibernation in the adjoining
areas of infarction. Here function is impaired due to Ischaemic but cells do not
die.
Processes of remodelling, hibernation, and stunning take months to stabilize.