Cardiac failure

Question 1

What is the difference between systolic + diastolic heart failure

Answer 1

Systolic failure

• inability of ventricle to contract normally, resulting in decreased cardiac output (CO)
• Dec CO + EF <40%
• Causes: IHD, MI, cardiomyopathy
• Heart muscle is weak/damaged and can’t contract properly, so EF is reduced.

Diastolic failures/ HFpEH

• inability of ventricle to relax and fill normally, causing increased filling pressures
• not enough blood filled in ventricles during diastole h/e no issue with contraction and ejection
• EF >54/looks normal. Also referred to as HF with preserved EF (HFpEF)
• Causes: ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy
• Heart is pumping hard enough but ventricles are not filling with enough blood.

Systolic and diastolic failure can co-exist

Question 2

Three causes/types of HF

Answer 2

(1. ) Ischaemic heart failure
- systolic dysfunction and reduced cardiac output causing an imbalance between myocardial oxygen demand and supply

(2. ) Valvular heart failure
- HF due to damaged or disease valves

(3. ) Hypertensive heart failure
- HF caused by chronically raised BP

Question 3

LSHF + RSHF - causes + syx + signs

Answer 3

LSHF (HTN, Aortic stenosis, hypertrophic CM, restrictive CM)

• Dyspnoea
• Orthopnoea
• PND
• Pink sputum cough
• Exercise intolerance
• Bibasal crackles

RSHF (Cor pulmonale, AV septal defect, LSHF)

• LSHF or lung disease syx
• Raised JVP
• Hepatosplenomegaly
• Ascites
• Peripheral Oedema

Question 4

WHat is New York classification

Answer 4

New York classification assess severity

I. Heart disease present, but no undue dyspnoea from ordinary activity

II. Comfortable at rest; dyspnoea during ordinary activities

III. Less than ordinary activity causes dyspnoea, which is limiting

IV. Dyspnoea present at rest; all activity causes discomfort

Question 5

Ix + Dx of HF

Answer 5

Dx = syx of failure + evidence of cardiac dysfunction

(1. ) Bloods: BNP, FBC, UE, LFT, troponin, lipids, HBA1c, TFT
- >400 BNP = referral for specialist assessment + ECHO
- >2000 BNP = refer urgently for specialist assessment + ECHO

(2. ) 12-lead ECG
- Normal ECG makes HF unlikely.
- Look for evidence of ischaemia, MI or ventricular hypertrophy
- AF (due to enlarged atria)
- Left-axis deviation (due to LVH)
- P-wave abnormalities

(3. ) CXR: ABCDE:
- Alveolar oedema - (perihilar/bat-wing opacification)
- Kerley B lines: small, horizontal, peripheral straight lines represents interstitial oedema
- Cardiomegaly - Cardiothoracic ratio >50%
- Dilated upper lobe vessels
- Pleural Effusion - costophrenic blunting

(4. ) ECHO (TTE 1st line imaging)
- Confirms LV dysfunction + identifies any valvular disease

Question 6

Mx of HF + acute mx

Answer 6

Conservative

• Lifestyle: diet: Na and water restriction, exercise, smoking cessation, reduce alcohol
• Flu + pneumococcal vaccines
• Management of comorbidities

Medical Mx ‘ABAL’

• ACEi (improves mortality)
• Bb (improves mortality)
• Aldosterone antagonists (2nd line)
• Loop diuretics (improves syx)

Initiated by Specialists

• Ivabradine
• Sacubitril-valsartan
• Digoxin
• Hydralazine
• Cardiac resynchronisation therapy

Acute Mx
Causes: Iatrogenic, Sepsis, MI, arrythmia
- Sit pt up
- Oxygen if <94%
- IV loop diuretics
- Monitor fluid balance + aim for negative balance