Congestive Heart Failure

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Congestive Heart Failure

• Stephen Gottlieb, MD
• Professor of Medicine
• Director, Cardiomyopathy and Pulmonary
  Hypertension
• University of Maryland

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What is Congestive Heart Failure?

• ? Ejection Fraction
• ? NYHA (New York Heart Association Class)
• ? Cardiac Index
• ? Pulmonary Capillary Wedge Pressure
• Cardiopulmonary exercise test (CPEX)
• BNP
• ? None of the above

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Congestive Heart Failure is a Clinical Diagnosis!

• Called heart failure, chronic heart failure, CHF,
  HF
• It is not equivalent to cardiomyopathy
• Often defined as inability to maintain adequate
  cardiac output (CO) at normal filling pressures,
  either at rest, with exercise or both - resulting
  in symptoms and / or signs.
• All of the previous factors help the clinician
  decide if the patient has CHF

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Causes of Heart Failure

• Ischemic heart disease
• Myocardial infarction
• Ischemic heart disease
• Non-ischemic cardiomyopathy
• Alcohol
• Hypertension
• Thyroid disease
• Amyloid
• HIV
• Myocarditis
• Idiopathic
• Diastolic dysfunction
• Normal ejection fraction heart failure

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Symptoms

• Shortness of breath (dyspnea)
• Fatigue, Weakness
• Orthopnea (dyspnea lying flat)
• Paroxysmal nocturnal dyspnea (episodes of waking
  from sleep by dyspnea)
• Cough, chest discomfort

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Signs

• Pulmonary
• Rales, CXR abnormalities (may disappear with
  chronicity)
• Fluid overload
• Edema, hepatomegaly, ascites, increased jugular
  venous distention

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Diagnosis

• Clinical
• Does the patient have typical symptoms?
• Shortness of breath with exertion
• Orthopnea, PND
• Fluid overload
• Known cardiac disease
• Is it cardiac or pulmonary
• If cardiac, what is the cause?

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Dilated CardiomyopathyDiverse etiologies,
Common pathology
?
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Ejection Fraction

• What is it?
• The of blood coming out of the heart with each
  beat
• Advantages
• Objective
• Tells if there has been myocardial damage
• Prognostic
• Disadvantages
• Doesnt reflect physiology
• Doesnt tell you about physical limitations of
  patient

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No Systolic (Diastolic?) Dysfunction

• Normal cardiac function
• Elderly
• Hypertension
• Infiltrative (Restrictive Cardiomyopathy)
• Amyloid
• Hemachromatosis
• Hypertrophic (HCM)
• With Obstruction HOCM

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NYHA (New York Heart Association Class)

• What is it?
• A subjective indication of physical status
• I - no limitations
• II dyspnea on moderate exertion
• III dyspnea on minimal exertion
• IV dyspnea at rest
• Stages
• A - Risk for CHF B LF dysfunction without
  symptoms C- Symptoms of CHF D Advanced CHF
• Advantages
• Assesses physical limitation
• Disadvantages
• Subjective
• Affected by depression, deconditioning,
  psychological status

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Predictors of Depression (BDI)
From Gottlieb et al, HF-ACTION data, 2008
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Hemodynamics
Cardiac Index (CI)Pulmonary capillary wedge
pressure (PCWP)

• What is it?
• A catheter measures cardiac function
• Advantages
• Objective, shows cardiac function
• Disadvantages
• Poorly related to symptoms
• A one time measurement
• PCWP reflects fluid status

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Cardiopulmonary Exercise Test (CPEX)

• What is it?
• Can measure work-load, peak oxygen consumption
• Advantages
• Objectively measures functional status
• Disadvantages
• Affected by deconditioning
• Affected by lung disease

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BNP

• What is it?
• Blood test of peptide released by heart when
  distended

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We Know BNP Levels Higher in Patients with
Cardiogenic Dyspnea
N139 N14 N97
Maisel, A. et al. JACC, 2001 37
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We Know BNP and NT-proBNP is Prognostic in CHF
Below Median
Above Median
From Richards et al. J Am Coll Cardiol 20064752
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BNP

• Advantages
• Objective
• Reflects cardiac pressure
• Disadvantages
• Can change with fluid status
• Affected by Obesity, Intensive Care, Renal
  Disease, Chronicity of CHF, Pulmonary disease, Age

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Conclusion
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Conclusions

• Heart failure is common, the cause of many
  hospitalizations (the most for Medicare) and
  disability
• There are many different types of heart failure
  with many causes
• It can be very difficult to determine if someone
  has heart failure
• Our tests all tell different information

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