HEART FAILUREBy Dr. Figgins & Dr. Gausden

HEART FAILURE IS….

Clinical syndrome resulting from inadequate cardiac output for the body’s needs.

THREE COMPONENTS…

Left heart failure

Right heart failure

Congestive cardiac failure

Low output

• Excessive pre-load

• Pump failure

Heart muscle disease

Restricted filling

Inadequate heart rate

Negatively inotropic drugs

• Excessive afterload

High output (rare)

Isolated RHF

PATHOPHYSIOLOGY

Inadequate CO stimulates compensatory mechanisms resembling response to hypovolaemia Initially beneficial, becoming maladaptive

PATHOPHYSIOLOGY

DECOMPENSATE HEART FAILURE

Arrhythmias (e.g. AF) Drug issues (e.g. non-compliance) Anaemia Infection (pneumonia, UTI) Thyroid disease

LEFT HEART FAILURE

Symptoms?

Signs?

THIRD AND FOURTH HEART SOUNDS

RIGHT HEART FAILURE

SYMPTOMS?

SIGNS?

New York heart failure classificationI = Cardiac disease but NO SYMPTOMS in ordinary physical activity

II = MILD SYMPTOMS and slight limitation during ordinary physical activity

III = Marked limitation in activity due to symptoms during LESS-THAN-ORDINARY ACTIVITY

IV = Severe limitations. Experiences symptoms at even AT REST

INVESTIGATIONS

BEDSIDE TESTS

BLOOD TESTS

IMAGING

SPECIAL TESTS

BNP

Protein secreted from ventricles of the heart

In response to overstretching of cardiomyocytes

High NEGATIVE predictive value (98%)

Used to RULE OUT heart failure, not rule in

Non-specific

HF CXR

Alveolar oedema

Kerley B lines (interstitial oedema)

Cardiomegaly

Dilated upper lobe vessels

Effusions

ECHOCARDIOGRAM 2 types

Valves

LV systolic/diastolic Fx

Aorta

LVEF

MANAGEMENT OF ACUTE HEART FAILURE

Assess ABCDE

Loop diuretics IV - furosemide

Morphine IV - slowly

Nitrates – avoid if hypotensive

Oxygen – 100% NRBM

Position upright

MANAGEMENT OF CHRONIC HEART FAILURE CONSERVATIVE Mx

CARDIAC REHABILITATION

For pts with IHD, HF or recent cardiac surgery

Available at local hospitals Education Emotional support Physical fitness

4 stages

MEDICAL MANAGEMENT OF CHRONIC HF

Recommended by NICE if reduced ejection fraction

1st line = ACE-INHIBITORS (or ARBs) + BETA-BLOCKERS

2nd line = add in ARB or spironolactone or hydralazine

3rd line = digoxin

*patients with fluid overload should receive diuretics*

AVOID CARDIO-SELECTIVE CALCIUM CHANNEL BLOCKERS

SURGICAL MANAGEMENT OF CHRONIC HF

CLINICAL SCENARIO TIME

Mr Meldrew 61 years old 3/12 Hx of malaise,

increasing SOB and ankle swelling

Now SOB walking upstairs PMHx: HTN, MI in 2008 80 pack year smoking Hx

Any other questions?

DIFFERENTIALS??

DIFFERENTIALS??CARDIAC

Valvular heart disease Coronary artery disease Left ventricular failure

RESPIRATORY

Infection Inflammation Neoplastic Degenerative

OTHER

Anaemia Anxiety

INVESTIGATIONS?

INVESTIGATIONS?

BEDSIDE

BLOODS

IMAGING

SPECIAL

*EMERGENCY*

Mr Meldrew attends A&E severely SOB

He can hardly talk

You are the FY1 in ED sent to clerk him – what do you do?

EMERGENCY OVER…

How will you manage him long term now he is stable?

EXPLANATION STATION

REFERENCES

www.merckmanuals.com Nice Guidelines. Chronic Heart failure (2010). Patrick Davey. Medicine at a Glance (2010).

Blackwell publishing http://www.medindia.net/patients/patientinfo/C

ongestive-Heart-Failure.htm The Criteria Committee of the New York Heart

Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256.