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Heart Failure (Cardiac output is inadequate for the body's…
Heart Failure
Cardiac output is inadequate for the body's requirements. Prognosis is poor with 25-50% of patients dying within 5 years of diagnosis. Affects 1-3% of the population (around 10% of the elderly population)
SYSTOLIC FAILURE
Inability of the ventricle to contract normally, resulting in reduced cardiac output
Ejection fraction is <40%
Causes include IHD, MI, cardiomyopathy
DIASTOLIC FAILURE
Inability of the ventricle to relax and fill normally, causing increased filling pressures
Ejection fraction is >50%
Causes include constrictive pericarditis, tamponade, restrictive cardiomyopathy, hypertension
Usually coexist
LEFT VENTRICULAR FAILURE
Dyspnoea, poor exercise tolerance, fatigue, orthopnoea, PND, nocturnal cough (+/- pink frothy sputum), wheeze (cardiac asthma), nocturia, cold peripheries, weight loss, muscle wasting
RIGHT VENTRICULAR FAILURE
Causes: LVF, pulmonary stenosis, lung disease
Peripheral oedema, ascites, nausea, anorexia, facial engorgement, pulsations in the neck and face (tricuspid regurgitation), epistaxis
CONGESTIVE CARDIAC FAILURE
Right and left ventricular failure occur together
ACUTE VS CHRONIC HEART FAILURE
Acute: new onset acute or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypo perfusion
Chronic: develops or progresses slowly
Management
Acute heart failure = medical emergency
Chronic heart failure
Stop smoking
Reduce salt intake
Optimise weight and nutrition
Treat the cause (e.g. dysrhythmias, valves)
Treat exacerbating factors
Avoid exacerbating factors
Drug treatment
DIURETICS - relief of symptoms and fluid retention, titrate to needs - start loop diuretic (furosemide) and add K+ sparing diuretic (spironolactone) if K+ <3.2mmol/l
CALCIUM CHANNEL BLOCKERS - amlodipine should be considered for treatment of comorbid hypertension or angina
ANTICOAGULANTS - if Hx of VTE
ASPIRIN - if coexisting atherosclerotic disease
Other agents which may be used: ACE inhibitors, beta blockers, inotropes, amiodarone etc
Consider:
Cardiac resynchronisation therapy
LV assist device
Cardiac transplantation
Framingham Criteria
Congestive Cardiac Failure diagnosis requires simultaneous presence of at least 2 major criteria or 1 major criterion plus 2 minor
MAJOR CRITERIA
PND
Crepitations
Neck vein distension
S3 gallop
Hepatojugular reflux
Cardiomegaly
Increased CVP
Weight loss >4.5kg over 5 days Rx
MINOR CRITERIA
Bilateral ankle oedema
Dyspnoea on normal exertion
Tachycardia (HR>120)
Nocturnal cough
Hepatomegaly
Pleural effusion
Decreased vital capacity by 1/3
Lifestyle
Exercise: rehabilitation, group exercise programmes
Smoking cessation
Alcohol consumption
Sexual activity
Vaccination - flu and pneumococcal
Air travel - depends on condition
Driving - must stop for 1 month after under control
Signs
Exhaustion, cool peripheries, cyanosis, low BP, narrow pulse pressure, pulses alternans, displaced apex beat (LV dilated), RV heave (pulmonary HTN), murmurs of mitral/aortic valve disease, wheeze
Investigations
ECG and BNP - if normal, HF unlikely
Echo if either ECG or BNP abnormal
FBC, U&E, BNP, CXR, ECG, Echo
Prognosis
If admission needed, 5yr mortality is 75%
CXR
A = alveolar oedema (bat wings)
B = kerley b lines (interstitial oedema)
C = cardiomegaly
D = dilated prominent upper lobe vessels
E = pleural effusion
Clinical review
Functional capacity
Fluid status
Cardiac rhythm
Cognitive status
Nutrition
Medication review
U&E, creatinine, eGFR
At least 6 monthly
New York Classification
1 = Heart disease, no undue dyspnoea from normal activity
2 = Comfortable at rest, dyspnoea on normal activity
3 = Less than ordinary activities cause dyspnoea, limiting
4 = Dyspnoea at rest, all activity causes discomfort