Heart Failure

Heart Failure

  • A state in which the heart cannot provide sufficient cardiac output to satisfy the metabolic needs of the body
  • Underlining causes include: arteriosclerotic heart disease, MI, HTN, valvular heart disease, dilated cardiomyopathy, congenital heart disease, embolism, angina, arrhythmia, drugs, alcohol, pregnancy, toxins (chemotherapy), thyroid disease, anemia, idiopathic
  • Causes of Left Ventricular failure: volume overload; pressure overload; loss of muscle; restricted filling


Symptoms of Heart Failure

  • SOB, Orthopnea, Paroxysmal nocturnal dyspnea
  • Low cardiac output symptoms
  • Abdominal symptoms: Anorexia, N, Abdominal fullness, Rt hypochondrial pain


Clinical Signs & Symptoms of Heart Failure

  • High diastolic BP and occasional ↓systolic
  • JVD, RALES, Displaced and sustained apical pulse
  • 3rd heart sound-heard during rapid filling of ventricles (common in children)
  • 4th heart sound-at end of diastole
  • Pale, cold sweaty skin


Systolic and Diastolic heart failure

  • Systolic HF: failure of the pump
  • Systolic HF tests: echo, ejection fraction @ 70; BNP
  • Diastolic HR: problem with vessels filling
  • Diastolic HR test: ejection fraction will be normal


Other Causes of Heart Failure

  • High output failure
  • Large MI,
  • Aortic valve dysfunction


Right VS Left Heart Failure

Right HF

  • Most common cause is Left sided HF
  • First see signs in the periphery
  • Cor pulmonale (brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart)

Left HF

  • most common cause is R sided HF
  • The heart cannot pump enough blood to the rest of the body.
  • Begins slowly


Diagnostic Lab Tests Used for Diagnosis of Heart Failure


  • BNP (200 early sign)
  • Anemia
  • Hyperthyroid
  • Chronic renal insuff.
  • Electrolyte abnormalities
  • Pre-renal azotemia
  • Hemochromatosis



  • Old MI or recent MI
  • Arrhythmia
  • Some forms of Cardiomyopathy are tachycardia releated
  • LBBB→ may help in management



  • Size and shape of heart
  • Evidence of pulmonary venous congestion
  • Pleural Effusion



  • Function of both ventricles
  • Wall motion abnormality that may signify CAD
  • Valvular abnormality
  • Intra-Cardiac shunt


Differential Diagnosis for Heart Failure

  • Pericardial Disease, Liver Disease
  • Nephrotic Syndrome
  • Protein losing enteropathy


Treatment of Heart Failure

  • Afterload reducers – drugs that reduce BP
  • Diuretics- ↓BP and/or Blood volume
  • B-Blockers- ↓HR, SV, and BP
  • Positive inotropes- stimulate the heart by ↑contractile force development
  • Ace inhibitor or ARB
  • B-Blocker
  • Diuretic
  • Direct Vasodilators: Hydralazine, Isosorbide, nitroprusside
  • Inotropic Agents: Digoxin, Digitoxin, Amrinone, Dobutamine, Milrinone
  • Aldosterone Antagonists: Spironolactone


Drugs Used in Critical Care for Acute Heart Failure

Positive inotropic Drugs: Dobutamine, Dopamine, Milrinone, Amrinone

  • Improves myocardial contractility
  • Studies show increase mortality with oral agents
  • Must be given IV and in hospital setting
  • Used for Acute HF/Cardiogenic shock


Primacor (Milrinone)

  • Inovasodilator=causes positive inotropic effects
  • Causes peripheral Vasodilation= Afterload reduction
  • IV agent for acute to severe HF
  • MOA: inhibits phosphodiesterase (PDE)→buildup of C-AMP→ positive inotropic effect and vasodilation
  • Adverse Effects: Arrhythmias, CP, hypotension, thrombocytopenia


Afterload reducers

Nitroprusside=severe CHF or HTN Emergency

Cyanide toxicity is a major side effect (smells like almonds)



  • ↓BP, and unloads fluid


Long acting Dihydropyridines CCB


  • Used for severe HTN = relaxes and dilates blood vessels, lowering blood pressure
  • Improves breathing in people with congestive heart failure



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