Cardiac failure

Question 1

define:

Answer 1

Inability of the cardiac output to meet the body’s demands despite normal venous pressures

Question 2

What are the two ways of classifying cardiac failure:

Answer 2

• Systolic versus diastolic failure
o Systolic failure: inability of the ventricle to contract normally, resulting in decreased CO. Ejection fraction <40%. (IHD, MI, cardiomyopathy)
o Diastolic failure: inability of the ventricle to relax and fill normally, causing increased filling pressures

Acute versus Chronic heart failure
o Acute: new onset acute or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema with/without signs of peripheral hypoperfusion
o Chronic: develops slowly. Venous congestion is common but arterial pressure is maintained well until late.

Question 3

What are causes of left heart failure:

Answer 3

• Ischaemic heart disease
• Hypertension
• Cardiomyopathy
• Aortic valve disease

Question 4

What are causes of right heart failure?

Answer 4

failure)
• Infarction
• Cardiomyopathy
• Pulmonary hypertension/embolus/valve disease
• Chronic lung disease
• Tricuspid regurgitation
• Constrictive pericarditis/pericardial tamponade

Question 5

What are bi-ventricular causes of heart failure:

Answer 5

• Arrhythmia
• Cardiomyopathy (dilated or restrictive)
• Myocarditis
• Drug toxicity

Question 6

What conditions lead to cardiac failure due to an increased demand?

Answer 6

o	Anaemia 
o	Beri beri
o	Pregnancy 
o	Paget's disease 
o	Hyperthyroidism
o	Arteriovenous malformation

Question 7

Epidemiology:

Answer 7

• 10% > 65 yrs old

Question 8

Symptoms of left heart failure:

Answer 8

o	Dyspnoea 
o	Orthopnoea
o	Paroxysmal nocturnal dyspnoea
o	Fatigue
o	Poor exercise tolerance 
o	Nocturnal cough (+/- pink frothy sputum)
o	Wheeze (cardiac ‘asthma’)
o	Nocturia
o	Cold peripheries 
o	Weight loss
o	Muscle wasting

Question 9

Symptoms of acute left ventricular failure:

Answer 9

o Dyspnoea
o Wheeze
o Cough
o Pink frothy sputum

Question 10

Symptoms fo right heart failure:

Answer 10

o	Swollen ankles 
o	Fatigue 
o	Increased weight (due to oedema) 
o	Reduced exercise tolerance 
o	Anorexia
o	Nausea

Question 11

Signs of left heart failure:

Answer 11

o Tachycardia
o Tachypnoea
o Displaced apex beat (LV dilatation)
o Bilateral basal crackles
o S3 gallop (caused by rapid ventricular filling)
o Pansystolic murmur (due to functional mitral regurgitation)

Question 12

Signs of acute ventricular failure:

Answer 12

o	Tachypnoea
o	Cyanosis 
o	Tachycardia 
o	Peripheral shutdown 
o	Pulsus alternans 
•	Arterial pulse waveforms showing alternating strong and weak beats 
•	Sign of left ventricular systolic impairment
o	Gallop rhythm
o	Wheeze (cardiac asthma) 
o	Fine crackles throughout lung

Question 13

Signs of right heart failure:

Answer 13

o	Raised JVP
o	Hepatomegaly 
o	Ascites 
o	Ankle/sacral pitting oedema 
o	Signs of functional tricuspid regurgitation – pulsation in neck and face
o	Facial engorgement
o	Epistaxis 
o	RV heave (pulmonary hypertension)

Question 14

Investigations:

Answer 14

• Key investigations: BNP + CXR + echo

Bloods:
o	FBC
o	U&E
o	LFTs
o	CRP
o	Glucose 
o	Lipids 
o	TFTs

In ACUTE Left Ventricular Failure
o ABG
o Troponin
o BNP

• CXR of left ventricular failure: ABCDE

• ECG
o May be normal, can indicate cause
o May show ischaemic changes (pathological q waves, t wave inversion)
o May show arrhythmia or left ventricular hypertrophy
•

Echocardiogram – KEY INVESTIGATION

Swan-Ganz Catheter
o Allows measurement of right atrial, right ventricular, pulmonary artery, pulmonary wedge and left ventricular end-diastolic pressures

Question 15

What will a CXR show?

Answer 15

CXR of left ventricular failure: ABCDE

o Alveolar oedema (shadowing – ‘bat’s wings’)
o Kerley B lines (interstitial oedema)
o Cardiomegaly
o Dilated prominent upper lobe vessels (upper lobe diversion)
o Pleural Effusion – blunt costophrenic angles

Question 16

What will an echo show?

Answer 16

Echocardiogram – KEY INVESTIGATION
o Assess ventricular contraction
o Can indicate the cause (MI, valvular heart disease) and confirm presence/absence of LV dysfunction.
o Systolic dysfunction = LV ejection fraction < 40%
o Diastolic dysfunction = decreased compliance of the myocardium leads to restrictive filling defect

Question 17

Management for cardiogenic shock:

Answer 17

• This is severe cardiac failure with low blood pressure
• Requires the use of inotropes (e.g. dobutamine)
• Managed in ITU

Question 18

Management for pulmonary oedema:

Answer 18

•	60-100% Oxygen (and consider CPAP)
•	Diamorphine (venodilator + anxiolytic)
•	GTN infusion (venodilator --> reduced preload)
•	IV furosemide (venodilator and later diuretic effect) 
•	Monitor:
	BP
	Respiratory rate 
	Oxygen saturation 
	Urine output 
	ECG 
•	TREAT THE CAUSE! (e.g. MI, arrhythmia)

Question 19

Management for chronic left ventricular failure:

Answer 19

o TREAT THE CAUSE (e.g. hypertension, valvular disease)

TREAT EXACERBATING FACTORS (e.g. anaemia)

Diuretics
 Loop diuretics e.g. furosemide
 Monitor potassium as can cause low K.

ACE Inhibitors
Inhibits RAS + cardiac remodelling

o Beta-Blockers
• Blocks the effects of a chronically activated sympathetic system

o	Aldosterone Antagonists
•	Improves survival in patients with NYHA class III/IV symptoms on standard therapy 
•	Monitor K+ (as these drugs may cause hyperkalaemia) 

Spironolactone

Angiotensin Receptor Blockers
• May be added in patients with persistent symptoms despite the use of ACE inhibitors and beta-blockers
• Monitor K+

Hydralazine and a Nitrate e.g. hydralazine + isosorbide dinitrate (VASODILATORS)

o Digoxin
• Positive inotrope

o N-3 Polyunsaturated Fatty Acids
• Provide a small beneficial advantage in terms of survival

Question 20

Complications:

Answer 20

• Respiratory failure
• Cardiogenic shock
• Death

Question 21

Prognosis:

Answer 21

• 50% with cardiac failure die within 2 years