Hello, welcome everybody, this is doctor Bolad, board certified physician in cardiology, interventional
cardiology and internal medicine, certified by the American Board of Internal Medicine.
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Today I will talk to you about heart failure. This is a common clinical syndrome identified
by the presence of current or prior characteristic symptoms, such as shortness of breath and
fatigue, and evidence of cardiac dysfunction as a cause of these symptoms. From a hemodynamic
perspective, heart failure is a disorder in which the heart cannot pump blood to the body
at a rate keeping pace with its needs. Patients with heart failure may or may not have associated
physical signs, such as those related to fluid retention.
Heart failure is caused by a number of conditions, including left ventricular dysfunction, right
ventricular dysfunction, valvular heart disease, pericardial disease, obstructive lesions in
the heart or great vessels, or high-output heart failure.
Heart failure caused by left ventricular dysfunction is commonly categorized according to left
ventricular ejection fraction, commonly as assessed by the echocardiogram:
1- Left ventricular ejection fraction equal to or less than 40 percent on the echocardiogram
is known as heart failure with reduced ejection fraction (abbreviated as HFrEF).
2- Left ventricular ejection fraction of 41 to 49 percent on the echocardiogram is heart
failure with mid-range ejection fraction (abbreviated as HFmEF).
3- Left ventricular ejection fraction equal to or more than 50 percent on the echocardiogram
is heart failure with preserved ejection fraction (abbreviated as HFpEF) . This can also be
due to diseases of the muscle of the heart, referred to as cardiomyopathy , which can
be either restrictive, hypertrophic, or due to noncompaction.
The commonest causes of heart failure are left-sided, meaning that it is caused by diseases
affecting the left ventricle. Heart failure is labelled as right-sided when it is caused
by right heart conditions, like for example pulmonary hypertension, pulmonic valve dysfunction
or tricuspid valve dysfunction. Left heart failure and right heart failure may each occur
separately or concurrently. Left heart failure is a common cause of right heart failure and
most patients with right heart failure have some element of left heart failure.
Symptoms of heart failure include those due to excess fluid accumulation and include shortness
of breath on exertion, shortness of breath when lying flat, leg swelling, pain from liver
congestion, and abdominal discomfort due to distention from fluid accumulation in the
abdominal cavity. Symptoms also occur due to a reduction in cardiac output like fatigue
and weakness, and these are most pronounced with exertion.
The physical examination can provide evidence of the presence and extent of cardiac filling
pressure elevation, right-sided failure, ventricular enlargement, pulmonary hypertension, and reduction
in cardiac output. Patients with mild or moderate heart failure
may appear completely normal on physical examination, with normal vital signs. However, many patients
with normal cardiac output at rest have an inability to increase the cardiac output during
exercise without excessive increase in filling pressures, resulting in exertional fatigue
and intolerance. Right-sided signs with fluid overload are often the presenting sign. In
contrast, patients with advanced heart failure may show evidence of decreased tissue perfusion
caused by a major decline in cardiac output. Four key findings that suggest greater severity
of cardiac dysfunction even at steady state include:
1- resting increase in heart rate, medically known as sinus tachycardia,
2- narrow pulse pressure, 3- sweating,
4- peripheral vasoconstriction manifest by cool, pale, and sometimes cyanotic extremities.
There are three major manifestations of volume overload in patients with heart failure: pulmonary
congestion, peripheral edema, and elevated jugular venous pressure.
●Pulmonary congestion manifests as crepitations on auscultating the lungs and is more prominent
in acute or subacute heart failure. ●Right-sided failure may be manifested as
peripheral edema with swelling of the legs, which is more prominent when the patient has
been upright. It can also manifest as fluid in the abdominal cavity referred to as ascites,
in addition to fluid accumulation in the scrotum. ●Elevated jugular venous pressure is usually
present if peripheral edema is due to heart failure.
The following tests are performed for the evaluation of heart failure:
1- Electrocardiogram — Most patients with heart failure with reduced left ventricular
ejection fraction have a significant abnormality on an electrocardiogram, the ECG. A normal
ECG makes left ventricular heart failure unlikely. In contrast, patients with heart failure with
preserved ejection fraction, HFpEF, commonly display a normal 12-lead ECG.
2- Blood tests should include: ●Natriuretic peptide [BNP or NT-proBNP]
levels. This provides evidence as to whether heart failure is present, as levels are elevated
in heart failure patients. ●Cardiac troponin T or I, to evaluate whether
the acute decompensated heart failure is due to a heart attack.
●A complete blood count, which may suggest concurrent or alternate conditions. Anemia
or infection can exacerbate pre-existing heart failure.
●Kidney function test to detect renal impairment which might be caused by and/or contribute
to heart failure exacerbation. ●Liver function tests, abnormality of which
may reflect liver congestion as a result of heart failure.
3- Chest X-Ray — Findings suggestive of heart failure include cardiomegaly, which
is an enlarged heart, with the heart to thoracic width ratio above 50 percent. Other chest
X-Ray findings would include pulmonary venous congestion, and fluid in the cavity of the
linings of the lung, known as pleural effusion.
4- Echocardiography is needed to assess the right and left ventricular systolic function,
and valve abnormalities in addition to assessment of the pulmonary pressure. It is also needed
to assess whether the left ventricular function is reduced, mid-level, or may be preserved
as in the case of diastolic dysfunction.
Treatment of heart failure depends on the cause of heart failure, and whether the heart
failure is due to reduced ejection fraction, mid-range ejection fraction or preserved ejection
fraction. Generally, the goals of therapy for heart failure are to reduce symptoms,
improve health-related quality of life and functional status, and decrease the rate of
hospitalization, and to reduce death. In addition to treating the cause of heart failure and
associated conditions, treatment of heart failure should include monitoring and preventative
care, care coordination, education and support for heart failure self-management including
lifestyle modification and daily monitoring, medication therapy, cardiac rehabilitation,
palliative care, device therapy including cardiac resynchronization therapy, implantable
cardioverter defibrillator. In advanced heart failure, mechanical circulatory support devices,
like left ventricular assist device, and cardiac transplantation, should be considered. Medication
therapy commonly used for heart failure include diuretic therapy, angiotensin converting enzyme
inhibitors or angiotensin receptor blockers, beta blockers, vasodilators and other medications.
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This is Doctor Bolad, helping you with your heart health, thanks for watching, and talk
to you soon.