Now, it’s important to remember that heart
failure relates to atherosclerosis, in the
majority of cases who present to the cardiologist
with heart failure. No surprise. Remember
we talked about the last time, I spoke to
you about the typical patient? That’s the
commonest patient that comes to the cardiologist,
the patient with atherosclerotic heart disease.
When that disease is advanced, particularly
if the patient has had previous myocardial
infarcts or heart attacks, the ventricular
function is compromised and the patient shows
up with heart failure.
So, what are the risk factors for heart failure?
They are the risk factors for atherosclerotic
heart disease. They are hypercholesterolemia,
hypertension, cigarette smoking, diabetes,
all the things we talked about before that
can lead to atherosclerosis. And you can see
that the commonest ones, you know, are... problem
leading to heart failure is ischemic heart
disease, but there’s a number of other factors
that are involved as well, but ischemic heart
disease, the number one cause of death in
the world, number one cause of heart failure.
There are a number of rarer causes of heart
failure. I’m not going to go into this in
any detail, but for example, in the United
States, one of the commonest causes of cardiomyopathy
is excessive alcohol intake. Alcohol is a
poison for the myocardium. Taking in small
amounts, it’s good. Increases the HDL level,
can be very pleasant in a social setting,
but excessive alcohol can lead to cardiomyopathy
and of course, a lot of other problems, liver
failure from cirrhosis, etcetera, etcetera.
There are other things that can cause heart
failure. We’ve talked about this before.
Cardiomyopathy from a chronic viral infection,
certain drugs can do it. One of the favorite
drugs for chemotherapy for breast cancer also
damages the heart and some drugs… other
drugs can do the same thing. And of course,
arrhythmias with long standing fast heart
rate that’s uncontrolled can also lead to
cardiac fatigue. These things are much rarer.
Remember, ischemic heart disease is number
one public enemy.
And here you just see all of the symptoms
that patients will have with heart failure.
They will be dyspneic, that is they’ll be
short of breath. You will find maybe their
lips are blue because they’re not pumping
enough oxygenated blood around. There may
be heart murmurs as we had in the patient
in the last lecture with aortic stenosis.
Sometimes on physical exam, you will hear
a loud extra heart sound that says the ventricle’s
really hurting. The patient’s breathing
fast. You may hear actually sounds from fluid
in the lungs and so forth.
There’s a whole variety of physical findings
that the doctor finds that confirms the diagnosis
of heart failure. Remember from the last lecture,
the most important thing are the symptoms,
they give you the clue. 90% of the answer
of the diagnosis is in the history, you then
move to the physical exam. Oh yes, I’m hearing
things, I’m seeing things that suggest that
the reason the patient is tired, the reason
the patient is short of breath, the reason
the patient has swelling in their legs is
because of heart failure.
Right ventricular heart failure alone can
cause a different set of symptoms and signs.
Of course, the edema, the extra fluid is in
the legs and you will remember that you may
have problems in the abdomen because the increased
venous pressure backing up is not only in
the legs, but it’s also in the abdomen,
the liver swells, there’s also swelling
in the… fluid in the abdomen, patients may
find their waist size gaining, they become
very, very tired and often, you can even feel
on physical exam this bulging abdomen that’s
full of fluid.
Remember again, right heart failure? Much
less common than left heart failure. Commonest
cause of left heart failure - ischemic heart
disease that is previous heart attacks. So,
here’s a few diagrams that just show you
what the cardiologist sees when they see a
patient usually with very clear and significant
heart failure. And you can see their pupils
may be dilated from the adrenaline that’s
circulating, the skin may be gray or pale or
even blue, cyanotic and a whole bunch of things.
They may be short of breath, breathing fast,
they may be uncomfortable lying back and feel
more comfortable breathing sitting up. There
may actually be sounds in the lungs from fluid
in the lungs, crackles or so called rales.
They may have a cough from the excess fluid
that’s in their system. There is often increased
pressure in the veins and you can actually
see that in the neck. I’m going to show
you a picture of that and the blood pressure
maybe decreased because the cardiac output
is down. And also, the patient may even have
some discomfort in the abdomen, swelling and
nausea and so forth. And of course, you may
see bulging of the abdomen as I mentioned
and edema that is swelling in the legs.
All of these are not seen necessarily in one
patient, but in individuals, you may see a
number of these findings. And of course, patient's
anxiety level is increased, of course, because
they’re short of breath. One of the worst
things that can happen to you is to be suffocated.
It activates anxiety in a huge way. And again,
you may see the fact that the patient has
decreased oxygen saturation. Often we can
test that with a little finger thing or
an ear thing to see that the oxygen level
in the blood is going down. The patients in
advanced heart failure may be confused, particularly
in elderly patients. There may be, as I’m
going to show you a picture in a moment, the
jugular vein is distended because of high
filling pressures in the right atrium transmitted
back to the jugular vein. There can… if
the patient's had a heart attack, there may
be chest discomfort in association with this.
Of course, the patient is markedly fatigued
and you may hear the heart sounds that I mentioned
before. This extra heart sound, the heart
may be increased in rate and again, you may
feel swelling of the liver or the spleen from
the venous congestion that goes back there.
And of course, there’s decreased cardiac
output if you measure that often with an echo
and the pulse may be therefore weak. The patient
is often cool… cool, the skin
may be sweaty.
So, here’s a picture, that’s a lovely
picture of a distended internal jugular vein.
You can see it rising up from just above the
clavicle, the bone that’s right here on
the front of the chest and you can see rising
up almost to the level of the jaw. So, this
is a patient with quite advanced heart failure.
In this case, it’s a finding of right ventricular
failure, but the commonest cause of right
ventricular failure is often left ventricular
failure that increases pressure in the lungs,
increases the work of the right ventricle
which eventually fails. So, this could be
a patient with left ventricular and right
ventricular failure or it could be somebody
with isolated right ventricular failure.
And here, we see an example of peripheral
edema, you can see you push into the soft
tissue of the leg and you’ll notice that
the impression stays when you take your finger
away. So, this is a patient with advanced
peripheral edema. It also looks to me like
the skin doesn’t have its normal tone,
its normal color. It looks gray and mottled
and often this is because of decreased cardiac
So, of course, we’re going to do some tests
to confirm our clinical impression. We’ve