Tài liệu tài liệu: Heart Failure SUY TIM

Heart Failure Trương Thanh Hương, PhD. Hanoi Medical University Definition • Heart failure is a condition in which the cardiac output is insufficient in meeting the needs of oxygen of the body in any situation. • Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. • The term "heart failure" is more accurate than "congestive heart failure" because fluid accumulation may not occur in all patients. Heart failure classification • The side of the heart involved: left-sided heart failure, right-sided heart failure. • Progress of heart failure: acute heart failure, chronic heart failure. • The change in the cardiac output: low-output heart failure, high-output heart failure. • Systolic heart failure and diastolic heart failure Causes Left-sided heart failure • Hypertension • Valvular heart diseases: aortic valve stenosis, aortic regurgitation (pured or combined), mitral regurgitation • Myocardial injury: MI, rheumatic myocarditis, intoxication, bacterial contamination, myocardial diseasesthmias • Congenital heareases: coarctation of the aorta, patent ductus arteriosus • Arrhythmias • Be noticed of mitral stenosis causes Right-sided heart failure • Left-sided heart failure • Pulmoray diseases, deformity of thorax-spine • Cardiovascular causes: – Mitral stenosis is a common cause – Tricupid and aortic valvular diseases – Congenital heart diseases (Pulmonary valve stenosis, tetralogy of Fallot): congenital heart diseases with reversed shunt, ruptured sinus of valsalva into right heart chambers, left atrial myoxoma... • Be noticed of pericardial effusions and compressive syndromes causes Two-sided heart failure • Left-sided heart failure often leads to two-sided heart failure in the longer term. • Dilated cardiomyopathy, carditis caused by rheumatic fever, myocarditis • Two-sided heart failure with high cardiac output: severve anaemia, hyperthyroidism, vitamin B1 deficiency, arteriovenous fistula... Left-sided heart failure symptoms Clinical symptoms Presenting symptoms • Dyspnea on exertion -> dyspnea at rest, orthopnea, cardiac asthma or acute pulmonary edema • Dry/loose cough or coughing up blood, cough nocturnally/on exertion Left-sided heart failure symptoms Signs • Left-laterally displaced apex, tachypnea, a gallop rhythm. • A faint apical systolic murmur indicates secondary mitral regurgitation (due to the dilatation of the left ventricle). • Signs of left-sided heart failure causes. • Wet rales heard initially in the bottom of the lung bases. Cardiac asthma: wheezing, snoring. Pulmonary edema: rales extend from the base upward. • Decreased systolic blood pressure, normal diastolic blood pressure leading to decreased hypertension difference. Left-sided heart failure symptoms NONCLINICAL SYSTOMS • Chest X-ray: cardiomegaly, bulging and prolonged left heart border caused by dialated left ventricle. Bilateral increased lung markings especially in the centre, Kerley B lines caused by edema in the interstitial of lung lymphatic system, shaped like bats wings in the centre when pulmonary edema presents. • ECG: left heart axis, left atrial hypertrophy, left ventricular hypertrophy. • Echocardiagraphy: dialated left atrium and ventricle, decreased contraction of heart walls, decreased left ventricular systolic funtion, finding out causes of left-sided heart failure. • Haemodynamic study: decreased cardiac index (normal value 23.5l/min/m2), increased left-ventricular end-diastolic pressure, grading the severity of mitral regurgitation, aortic regurgitation... right-sided heart failure symptoms Clinical symptoms Presenting symptoms – Dyspnea: increasing dyspnea without paroxysmal nocturnal dyspnea as left-sided heart failure. – Pain in the right upper quadrant caused by painful hepatomegaly. Signs – Hepatomegaly with "accordion effect". – Jugular venous distension, positive hepatojugular reflex right-sided heart failure symptoms • Signs – Increased peripheral and central venous pressure. – A blue coloration of the skin and mucous membranes: Peripheral blood stagnant -> increased deoxyhemoglobin -> light blue of the skin and mucous membranes -> cyanosis – The excess fluid accumulation in the lower limbs -> in the whole body. – Oliguria, dark urine (200-300ml/day) – Hartzer sign: dilated displaced right ventricular apex. – Tachypnea, a right-sided gallop rhythm. – A faint systolic murmur heard low on the lower left sternal border indicates tricuspid regurgitation. It becomes louder during inspiration (Rivero Carvanlho's sign). – Normal systolic blood pressure, increased diastolic blood pressure. right-sided heart failure symptoms NONCLINICAL SYMSTOMS • Chest X-ray: bulging right heart border, upward heart apex caused by dilated right ventricle. Distended pulmonary vascular bed, lung markings caused by blood stagnant. Enlarged right ventricle causes narrow light gap behind the sternum. • ECG: right heart axis, right atrial hypertrophy, right ventricular hypertrophy. • Echocardiography: enlarged right ventricle, signs of pulmonary arterial hypertension. • Haemodynamic study: increased right ventricular end-diastolic pressure (>12mmHg), pulmonary arterial hypertension. Biventricular heart failure • Constant dyspnea, the excess fluid accumulation in the whole body. • Jugular venous distension. • Increased venous pressure. • Hepatomegaly. • Pericardial effusion, pleural effusion, ascites. • Decreased systolic blood pressure, increased diastolic blood pressure. • Chest X-ray: cardiomegaly. • ECG: biventricular hypertrophy. X-Ray Image Left-sided heart failure Right-sided heart failure Electrocardiography LEFT-SIDED HEART FAILURE ECG: Left heart axis, left atrial hypertrophy, left ventricular hypertrophy RIGHT-SIDED HEART FAILURE ECG: Right heart axis, right atrial hypertrophy, right ventricular hypertrophy Echocardiography LEFT-SIDED HEART FAILURE RIGHT-SIDED HEART FAILURE Heart failure classification The ACC/AHA staging system A NYHA classification for heart failure Patients arecao atST high risk for có heart Có Nguy cơ song không bệnh tim thực but tổn hoặc có biểu hiện suy failure havekhông no structural heart tim disease or symptoms of heart failure Patients have structural heart disease B Có bệnh tim thực tổn nhưng không có biểu but have hiện suy timno symptoms of heart I failure C D Patients havetổnstructural heart Bệnh tim thực đã hoặc đang có disease biểu hiện timsymptoms of heart failure and suy have Patients have refractory heart failure Suy tim trơ, đòi hỏi phải các biện pháp điều trị đặc biệt specialized interventions requiring Patientshave haveno nolimitation limitationofof Patients physicalactivity activity physical Patients have slight limitation of physical Patients have slight limitation of activity physical activity marked limitation III Patients Có triệuhave chứng khi gắng sức nhẹ of physical activity II IV Patients have symptoms even at rest and are unable to carry any Có triệu chứng ngay cả lúcon nghỉ physical activity without discomfort TREATMENT Schematic therapy of progressive chronic heart failure The role of drugs in the treatment of heart failure • Reduce Mortality: – ACE inhibitors or ARBs – Beta blockers – Spironolactone; Eplerenone • Improve symptoms: – Diuretics – Digoxin (low dose) – Nitrates • May be harmful: use cautiously after due consideration: – – – – Inotropes and inotropic dilators Antiarrhythmics, expect Beta blockers and amiodarone Calcium channel blockers Digoxin (high dose)