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Cardiac FailureCardiac Failure
Richard PriceRichard PriceConsultant, Intensive Consultant, Intensive
Care, RAH.Care, RAH.
ObjectivesObjectives• Overview of terminologyOverview of terminology
• Pathophysiology of cardiac failurePathophysiology of cardiac failure
• Clinical features, x-rays and Clinical features, x-rays and echosechos
• Outline of acute and chronic Outline of acute and chronic treatmentstreatments
•
Cardiac failureCardiac failure
•
•A clinical syndrome with signs and A clinical syndrome with signs and symptoms of congestion and symptoms of congestion and circulatory failurecirculatory failure
EpidemiologyEpidemiology
• Prevalence Prevalence 10%10% in >65 years in >65 years
• 2% of general medical admissions 2% of general medical admissions
• In US is the most common cause of In US is the most common cause of hospitalisation in > 65 years hospitalisation in > 65 years
• Mortality Mortality 60%60% at 5 yrs post diagnosis at 5 yrs post diagnosis
• Is as ‘malignant’ as the most Is as ‘malignant’ as the most common causes of cancercommon causes of cancer
TerminologyTerminology• Acute heart failureAcute heart failure
• Chronic Heart FailureChronic Heart Failure
• Decompensated CHFDecompensated CHF
• (Right heart failure and high (Right heart failure and high output failure)output failure)
TerminologyTerminology• LV dysfunctionLV dysfunction
• Systolic dysfunction Systolic dysfunction
• (abnormal contraction)(abnormal contraction)
• Diastolic dysfunction Diastolic dysfunction
• (abnormal relaxation)(abnormal relaxation)
AetiologyAetiology• Coronary artery diseaseCoronary artery disease
• HypertensionHypertension
• Valvular heart diseaseValvular heart disease
• Cardiomyopathies eg viral, Cardiomyopathies eg viral, alcoholic, septicalcoholic, septic
Preload
Performance
Sympathetics
Normal
Failing
Preload
Performance
P1 P2
Higher pressure needed for the same performance
Afterload
Performance
Sympathetics
Normal
Failing
Afterload
Performance
Less able to cope with afterload
CO
SNS R-A-A
Na+
Vasoconstriction
Afterload Preload
OedemaOedema
• Downstream pressureDownstream pressure
• Colloid osmotic pressureColloid osmotic pressure
• Lymphatic drainageLymphatic drainage
• Capillary LeakCapillary Leak
Clinical presentationClinical presentation• Short of breath Short of breath
• HypoxaemiaHypoxaemia
• TachycardiaTachycardia
•Bilateral lung crepitationsBilateral lung crepitations
•Peripheral Oedema - takes timePeripheral Oedema - takes time
• Hypotension, Hypotension, ⇓⇓ peripheral peripheral perfusion perfusion
InvestigationsInvestigations
•ECGECG
•CXRCXR
•Basic bloodsBasic bloods
•EchocardiographyEchocardiography
Large Heart
Perihilar congestion
Fluid in the fissure
ManagementManagement• AcuteAcute
• OO22
• IV opiatesIV opiates
• IV diureticsIV diuretics
• IV nitratesIV nitrates
• CPAPCPAP
• Cardiogenic shockCardiogenic shock• InotropesInotropes• Balloon pumpingBalloon pumping• VentilationVentilation
CPAPCPAP First described in: Lancet 1936; II: 981First described in: Lancet 1936; II: 981
Meta-analysis: Lancet 2006; 357: 1155Meta-analysis: Lancet 2006; 357: 1155
3CPO study - NEJM 2008; 359: 142 3CPO study - NEJM 2008; 359: 142
no mortality difference at 7 days vs no mortality difference at 7 days vs standard carestandard care
Hypoxic despite medical therapy - CPAPHypoxic despite medical therapy - CPAP
NIV - probably no benefit over CPAPNIV - probably no benefit over CPAP
Peribronchiolar cuffing
ECG Monitoring
CVP Line
Pleural effusion
Chronic ManagementChronic Management
•DiureticsDiuretics
•ACE Inhibitors ACE Inhibitors
•ββ-blockers-blockers
•SpironolactonSpironolactone e
•Digoxin Digoxin
Chronic ManagementChronic Management
• DiureticsDiuretics
• ACE Inhibitors ACE Inhibitors
• ββ-blockers-blockers
• Spironolactone Spironolactone
• Digoxin Digoxin
Reduce symptomsReduce symptoms
Decrease mortality, Decrease mortality, improve ejection improve ejection fraction, improve fraction, improve symptomssymptoms
Decrease mortality with Decrease mortality with severe diseasesevere disease
May reduce May reduce hospitalisationhospitalisation
Cardiac resynchronisationCardiac resynchronisation
Defibrillators (ICD)Defibrillators (ICD)
Assist Devices (LVAD)Assist Devices (LVAD)
Severe ARDS
Summary Summary
A clinical syndrome due to variable pathologyA clinical syndrome due to variable pathology
Physiological response leads to further Physiological response leads to further deteriorationdeterioration
Investigations aimed at diagnosis and Investigations aimed at diagnosis and aetiologyaetiology
Treatment aims to reverse the cause and Treatment aims to reverse the cause and reduce preload and afterloadreduce preload and afterload
Common, serious and often progressiveCommon, serious and often progressive
Further reading
McMurray JJV. Systolic heart failure. New England Journal of Medicine 2010; 362: 228.