So, of course, we’re going to do some tests
to confirm our clinical impression. We’ve
had the history, oh, this suggest heart failure,
the patient is short of breath, they have
peripheral edema. Oh, we listen to the heart
and we hear an extra sound, the S3 gallop.
Okay, we’re now pretty sure the patient
has heart failure, then we do a chest x-ray.
You can see the two examples here. The one…
on the one side is normal and the one on the
other side shows an enlarged heart. Sometimes
we will even see evidence of fluid in the
lungs. Pretty obvious on this chest x-ray,
this is called pulmonary edema. The left ventricle
has failed significantly and what we see is
fluid throughout the lungs.
And of course, this patient is very short
of breath. They might be breathing at 30 or
40 times a minute. Normal is about 12, 13,
14 times a minute and they may… you may
actually hear gurgling from this fluid that’s
collecting in the small alveolar sacs in the
lung and being transmitted into the… into
the bigger bronchial tubes. This can drop
the oxygen saturation in the blood, can lead
to fatal arrhythmias and people can die from
this. And this… this is a medical emergency
that requires urgent therapy.
And here is a chest x-ray showing a variety
of findings of a little less serious heart
failure. One can see edema in the lymphatics,
so called curly lines. One can see fluid collecting
in the pleura, you can see in the little angle
there where the heart meets the chest that
there’s a little sort of rounded area. That’s
actually fluid in the pleural space, the space
that surrounds the lungs. There’s a variety
of other findings that the radiologist will
often call you up and say, “Your patient
has heart failure.”
We often do an echocardiogram to see how bad
the heart failure is. For example, is it left
ventricular? Is it right ventricular? Is it
very advanced? Does the ejection fraction,
that is the percentage of blood squeezed out
by the heart very low? Or is it only modestly
This is an echocardiogram from a patient with
a very advanced heart failure. The left ventricle
is markedly dilated, we don’t see the film
with it, but I’m sure if we saw the film,
instead of the ventricle squeezing normally
like this, it’s doing this. Hardly squeezing
at all and you can see also, in this echo,
the left ventricle is enlarged. So, this is
a patient with longstanding heart failure.
So, let’s talk a little bit about treatment.
Clearly, treatment goals are to reduce the
edema, to reduce the excess fluid volume and
to make the patient much more comfortable
and able to have full activity. You’d also
like to increase the pumping ability of the
heart. Sometimes, if it’s, for example,
in the patient we talked about in the last
lecture, somebody with aortic stenosis, taking
away the stenotic valve and putting in a good
valve allows the ventricle to recover.
In other settings, if it’s due to severe
ischemia - lack of blood flow in the heart,
coronary bypass or angioplasty may improve
the blood flow on the heart and may, not always,
but may improve the function of the ventricle
and again, lead to resolution of symptoms.
And there’s a variety of drugs that help
increase the removal of fluid from the body.
For example, diuretics that increase renal
excretion of water and salt will reduce the
excess volume of salt and water in the body
and often lead to marked improvement in the
Patients with heart failure, particularly
new heart failure, require hospitalization.
They require a number of tests to determine
why they're on heart failure and they also
require a number of drugs that are used to
improve, if possible, the function of the
heart and to decrease the work of the heart
and to increase fluid and salt excretion.
And what you do… this step diagram is a
complicated one. I’m not anticipating that
anybody needs to learn this right away, but
it shows you as the heart failure increases,
the aggressiveness of our therapy increases.
So, in the beginning, we use ACE inhibitors
that is they vasodilate the arterioles, they
decrease the blood pressure a bit and they
decrease the work of the heart.
In a sense, what we’re trying to do is rest
the heart. Make the heart’s job, the left
ventricle’s job a little easier, but as
you go along, there’s a variety of other
interventions that are used. Both improving
blood flow, for example, with angioplasty.
We also use drugs that rest the heart a little
bit by decreasing the heart rate - beta blockers.
And then eventually, you may even progress
to devices that increase the pumping ability
of the heart while you’re getting ready
to do something more aggressive. For example,
change a heart valve or even in the most severe
stages, do a heart transplant - give the patient
a new heart.
It‘s important that patients have lifestyle
changes, particularly with the milder forms
of heart failure because what we’re trying
to do is prevent heart failure from progressing.
So, what are those lifestyle changes?
Clearly, somebody who’s obese, you’ve
got a lot of extra weight around. If you have
a big belly that has 40 or 50 pounds of extra
weight, it’s like you’re carrying a 40
or 50 pound knapsack on your back and you’re
asking the heart to do that extra work. You
can imagine, that’s a bad idea. So, dieting
and reduction of obesity is important.
Number two, cutting back on salt because the
more salt you take in, the compensatory mechanisms
of the body hold on to that salt and of course,
increase blood volume. So, restriction of
salt. It turns out that regular, particularly
in the beginning, supervised exercise or physical
activity actually improve the whole cardiovascular
system and enable patients to do more work
with the same cardiac output that they had
before. So, and of course, stopping things
like cigarette smoking which are damaging
to the blood vessels and which can cause acceleration
of atherosclerosis, just as in we talked about
in patients with a heart attack or coronary
artery disease. There’s a whole variety
of lifestyle changes and often, these are
integrated between the cardiologist and a
good cardiac rehabilitation program.
And then, there’s a number of medications.
I talked about them briefly before. Let me
describe them in just a little more detail.
We give beta blockers. Beta blockers block
the effect of adrenaline on the heart and
they decrease the heart rate. No surprise.
You got a sick tired heart, you don’t want
to keep it being... having a very... a high heart
rate, you want to decrease the heart rate.
And actually, sometimes the ventricle recovers
when we get the heart rate which had been
90 down into the 60s or 70s.
Two, we can give ACE inhibitors, that’s
the angiotensin converting enzyme inhibitors.
What these do is they block the renin-angiotensin
system, they decrease the constriction of
blood vessels on the periphery, drop the blood
pressure a bit. They also increase sodium
and water excretion so you can see - A. They
help by decreasing the work of the left ventricle
a bit and B. They help get rid of some of
the excess salt and water.
Diuretics, I already mentioned. They increase
urine flow and consequently, increase sodium
and water excretion by the heart. And of course,
you can see that there are also possibilities
of increasing the squeeze of the heart.
It turns out that increasing the squeeze of
the heart can sometimes overtax an already
tired heart, but at least one agent - digitalis,
seems to be safe. In critical situations where
the patient is in shock, that is they have
a dangerously low blood pressure, we give
intravenous drugs. For example, intravenous
adrenaline-like drugs that increase the contractility
of the heart, but you can only do that for
a short time because in a sense, you’re
whipping a tired horse. So, maybe it runs
a little faster for a short time, but they
die sooner. So, we’re very careful with
the use of drugs that markedly increase the
contraction of the heart in heart failure.
And again, here you see all the drugs listed
that can be used. You can see that the Beta
Blockers, the ACE inhibitors, the diuretics
and then the inotropic agents on the far right
are the ones we try to use as little as possible.
And again, there’s patient counseling. We
already talked about the lifestyle. Alcohol
is a depressant on the heart so we want patients
drinking as little as possible. Smoking has
to stop, we want weight control, we want regular
exercise. All of the lifestyle things, again,
repeated to work with the medicines what we’re
giving or to work with the interventions.
For example, opening up a coronary artery
or replacing a heart valve.
And further patient counseling, of course,
involves the medications. Are the patients
taking the medications? And are they taking
them regularly and as appropriately prescribed?
This is a huge problem. In the United States,
many patients fail to take their medications.
If there are surgical or catheter interventions,
what these contain and what they can do and
what the potential complications are; one
wants to reduce stress in the patient’s
life, one wants the patient to keep track
of symptoms. Are they getting better, are
they getting worse, is there weight gaining
all of a sudden because of a marked increase
in fluid retention? And of course, we would
like patients to not overdulge in fluid intake
and certainly, come for follow up visits with
the doctor or the nurse clinician in order
for us to monitor how things are going with
therapy and if we have to make further adjustments
So, in conclusion, heart failure is a growth
industry particularly in older individuals.
It’s caused by many diseases, but in particular,
by atherosclerotic heart disease that causes
damage to the left ventricle. Again, left
ventricular systolic heart failure is the
commonest. The left ventricle doesn’t squeeze
as well and the commonest cause of that, ischemic
Prevention, of course, is better than cure.
I don’t have to tell you that. And how do
we prevent that? By controlling atherosclerotic
risk factors before they put the patient in
the heart failure situation.
Of course, there’s a whole variety of diagnostic
test that we use when the patient presents
with heart failure, but remember, the clue
is in the patient’s symptoms, with confirmation
by the exam and then we do some sophisticated
tests to see what’s the cause of the heart
failure and how severe is the ventricular
damage and then we introduce a whole variety
of therapies, both drugs and even some of
the newer device therapies. For example, we
can open up blood vessels and even in extreme
cases, we can take over with little pumps
for the heart while we’re trying to get
it to respond and come back to normal.
And of course, then we’re going to have
to do lifestyle changes. There’s a new pacing
protocol with a special pacemaker that, in
some selected patients, can improve the pumping
of the heart.
All of these are fairly extreme things done
right at the end. And again, we talked about
the fact that there’s a lot of technology
here. But, the best deal is to stop the heart
failure before it starts with reduction in
risk factors or identifying it early and getting
all of those things including the lifestyle
changes implemented before the patient progresses
to a point that they need things like biventricular
pacing and heart lung machines and so forth.
Thank you for listening to this lecture. I
look forward to seeing you with the next one.