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Chronic heart failure (Aetiology (Metabolic Anaemia Padget's disease…
Chronic heart failure
Aetiology
Metabolic
Anaemia
Padget's disease
Idiopathic
Cor pulmonale (COPD, PH, PE etc.)
Infection/inflammation
Pericarditis/tamponade
Chagas disease
Genetic
Cardiomyopathy
ASD/VSD
Vascular
IHD
Valve disease (AS, MR)
HTN
Arrhythmias
Endocrine
Thyrotoxicosis
Drugs
Negative inotropes e.g. some CCBs, B-blockers
Diagnosis
Examination
Cardio/resp
Cold peripheries, high JVP
high RR, high HR, murmurs?
Basal creps, peripheral oedema
Resp
Cold peripheries, high JVP
high RR, high HR
Basal creps, peripheral oedema
Abdo
High JVP, ascites
RUQ discomfort (hepatomegaly)
Investigations
Bedside
Obs - RR, HR, HTN, etc.
ECG - may show ischemia,
hypertrophy, strain patterns etc.
Bloods
FBC (anemia), U+E (renal), LFT (liver),
TFTs (thyroid), glucose, lipids, BNP (raised)
Imaging
CXR - hypertrophy, perihilar shadows,
upper lobw diversion, kerly B lines, effusions
ECHO - assess function and cause
Special tests
Cardiac catheterisation
Nuclear imaging/PET
MRI/CT
Stress ECHO
History
PC - SOB, cough, wheeze, fatigue
PMH - prev cardiac disease, endocrine etc.
DH - negative inotropes, illicit drugs, allergies
FH - any cardiac disease
SH - smoking, alcohol, diet
Diagnostic criteria
(Framingham)
2+ major or
1 major 2 minor
Major
Symptoms - PND, weight loss after tx
Signs - Creps, S3 gallop, inc JVP
Investigations - CXR cardiomegaly
Minor
Symptoms - bilat ankle oedema, dyspnoea exert, nocturnal cough
Signs - HR>120, effusion, hepatomegaly
IMaging - ECHO reduced VC
Classification
(New York)
Stage 3
SOB less than ordinary activity
Stage 4
SOB at rest
Stage 2
SOB ordinary activity
Stage 1
Mild/no SOB on ordinary activity
Pathophysiology
Initial change
Cardiac lesion results in reduced CO
low CO and reduced peripheral perf
Changes to heart
Ventricular dilatation
Reduced EF with each beat, so inc vol blood left in ventricle
Increased diastolic pressure causes myocardium to stretch
Initial inc contraction (Starling), eventually cannot compensate with more stretch (flat bit Starling)
Backpressure, oedema and dilatation of the ventricle
Increased work of the heart
Ventricular remodelling
Hypertrophy, death of myocytes, fibrosis
Other organs
Peripheral vessel damage
Kidneys
Compensation
Initially help but
bad long term
Naturetic peptides
ANP (atris), BNP (ventricles), C-type peptide (vasculature)
Diuretic, naturetic, hypotensive actions, reduce afterload
Also reduces preload, inc work on heart
RAAS activation
Low CO and SNS activation reduces renal perf
RAAS activated, Na and H2O retained
Venous pressure inc, increasing preload (Starling)
Arteriole constriction inc afterload, work on heart
SNS activation
Reduced LV/RV function compensated by inc HR, contractility and venous constriction, increasing preload (Starling)
Arterial constriction increases afterload, inc work on heart
Types of HF
Low/high output
Low - low CO, failed inc on exertion
Anatomical
Pericardial - effusion, tamponade
Myocardial - CAD, MI, HTN, etc.
Endocardial - valves, ASD/VSDs
Systolic/diastolic
Diastolic - fail to fill (normal EF)
Systolic - fail to contract (low EF)
L/R heart
LHF most common
Often together as CCF
Epidemiology
Common
10% of >65y
Major public health problem
(drug budget, hospital admissions)
Management
Medical
ARBs
Indication: alternative to ACEi
E.g. losartan, candesartan
MOA: bocks AngII, reduces RAAS
SEs: hyper-K+
CI: bilateral RAS
ACEi
Indication: 1L systolic failure
E.g. ramipril, lisinopril
MOA: reduces RAAS activation and
fluid retention, reducing afterload
SEs: cough, hypotension, renal dysf
CI: bilateral RAS
Diuretics
Thiazides
E.g. bendroflumethiazide
Aldo antagonists
Indication: add on for overload
E.g. spironolactone, eplenerone
MOA: weak diuresis, K+ sparing
SE: renal dysf, hyper-K+, gynaecomastia
Loop
Indication: fluid overload
E.g. furosemide
MOA: Na and water loss, reducing
preload and afterload
SEs: hypo-K+, renal dysf
B-blockers
Indication: add on after ACEi+diuretic
E.g. carvedilol (cardioselective)
MOA: inhib SNS drive, reduces afterload
Digoxin
Indication: add on (rarely used)
Vasodilators
Indication: alternative to ACEi/ARB
E.g. hydralazine, isosorbide dinitrate
MOA: dilate vasculature, reduces afterload
Surgical
Implantable devices
ICD
Indication: LV<30%, HF and VT/VF
MOA: pacemaker plus intrinsic
defib to restart heart
Cardiac resynch therapy
Indication: LV systolic, mod-severe symptoms or wide QRS
MOA: pacemaker plus biventricular leads to synch
Heart surgery
Revascularisation
Indication: CAD
MOA: angioplasty +/- stent, CABG
Transplant
Indication: young patients
SEs: death, infection,
rejection, atherosclerosis
Conservative
Smoking cessation
Education
Diet (low salt, low alcohol,
fluid restrict 1.5L/d)
Avoid exacerbators
(e.g. drugs)
Driving
(if symptomatic,
can't drive HGV etc.)
Vaccinations
(influenza, pneumococcal)
Definition
Pathophysiological syndrome where the heart
is unable to maintain adequate circulation to
meet requirements of normal metabolism
Clinical syndrome caused by abnormality of
the heart resulting in haemodynamic, renal,
and neurohumoral responses
Clinical
presentation
LHF
Cough
Pink frothy sputum
Wheeze
Dyspnoea
(Worse on exertion, orthopnoea,
paroxysymal nocturnal dyspnoea)
Fatigue
Weight loss
RHF
Dyspnoea
Worse on exertion
Fatigue
Weight loss
Abdo pain
*Prognosis
Mortality 10%/yr
25-50% by 5y*