Congestive cardiac failure

Question 1

Definition

Answer 1

Heart is unable to generate a cardiac output to sufficient to meet demands without increasing diastolic pressure

Question 2

Etiology

Answer 2

CAD
Hypertension
Valvular disease
Myocarditis
Infiltrative disease
CHD
Pericardial
Toxin-induced: heroin, alcohol, cocaine, amfetamines, lead, arsenic, cobalt, phosphorus
Infection: bacterial, fungal, viral (HIV), Borrelia burgdorferi (Lyme disease), parasite (e.g., Trypanosoma cruzi [Chagas disease])
Endocrine disorders: diabetes mellitus, thyroid disease, hypoparathyroidism with hypocalcaemia, phaeochromocytoma, acromegaly, growth hormone deficiency
Systemic collagen vascular diseases: lupus, rheumatoid arthritis, systemic sclerosis, polyarteritis nodosa, hypersensitivity vasculitis, Takayasu syndrome, polymyositis, Reiter’s syndrome
Chemotherapy-induced: for example, adriamycin, trastuzumab
Nutritional deficiencies: thiamine, protein, selenium, L-carnitine
Pregnancy: peripartum cardiomyopathy
Familial cardiomyopathy
Tachycardia-induced cardiomyopathy.

Question 3

Systolic dysfunction

Answer 3

Defined as a ↓ EF (inadequate left ventricular contractility or afterload–>compensates through hypertrophy and ventricular dilation (Frank-Starling law)–> fails, leading to ↑
myocardial work and worsening systolic function.

Question 4

History

Answer 4

Symptoms
Risk factors:
hypertension; diabetes mellitus; dyslipidaemia; tobacco use; coronary, valvular, or peripheral vascular disease; rheumatic fever; heart murmur or congenital heart disease; personal or family history of myopathy; mediastinal irradiation; and sleep-disturbed breathing
Drug history
Family history->include conduction, sudden death, cardiomyopathy, skeletal

Question 5

Physical examination

Answer 5

Examination reveals parasternal lift, an elevated and sustained left ventricular impulse, an S3/S4 gallop, JVD, and peripheral edema, hepatomegaly, Kussmauls

Question 6

Investigations

Answer 6

FBC
UEC
Glucose
TSH
BNP
Cr, Urea
Lipids
LFTs
Cardiac enzymes

CXR->cardiomegaly, VC, edema, effusions, non-cardiac
ECG->rate, rhythm, MI PE, old MI, conduction, electrical alternans
Echo->chamber dimension, systolic function, diastolic, valvular, pulmonary pressure, peri/extracardiac

Question 7

Management of chronic CCF

Answer 7

ACEi->perindopril
Beta blocker->carvedilol
Lifestyle: lose weight, sodium restriction, fluid restriction, weight monitoring, continuous health screening, exercise training
Address sleep-> elevation w/ pillows
Spirinolactone
Warfarin->particularly if AF

Consider:
Hydralazine->vasodilators
Frusemide
Digoxin
Ivabradine

Question 8

Options for refractory CCF

Answer 8

Implantable cardiac defibrillator

Cardiac transplantation

Question 9

NYHFA classification

Answer 9

Class I: Mild. No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, or dyspnoea.

Class II: Mild. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or dyspnoea.

Class III: Moderate. Marked limitation of physical activity. Comfortable at rest, but gentle activity causes fatigue, palpitations, or dyspnoea.

Class IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Question 10

Checklist before intiating BB in CHF

Answer 10

Class 2-4
On diuretics + ACE-i
No contraindications
No acute medical illness
No physical evidence of fluid retention

Question 11

Causes of severe pulmonary edema

Answer 11

LVF
ARDS
Fluid overload
Medication non-compliance
Neurogenic

Question 12

Symptoms and signs pulmonary edema

Answer 12

Dyspnea, PND, orthopnea, pink frothy sputum

Distressed, pale, sweaty, tachyP, pulsus alternance, +JVP, fine lg crackles, S3, wheeze

Question 13

Investigations in pulmonary edema

Answer 13

CXR->Cardio+, pulmonary edema: shadowing, effusions and costophrenic angles, kerly B lines
ECG->MI, dysrythmmias
UEC, cardiac enzymes
Echo
BNP
ABG
FBC, glucose, lipids, TFTs

Question 14

Management of severe pulmonary edema

Answer 14

Sit upright
ECG
Oxygen
IV access + investigations
Morphine + antiemetic
IV frusemide
Catheter?
Get help, admit to CCU

If BP >90->IV GTN
Salt, fluid restriction
Ventilation may be required->NIPV, CPAP
Monitoring BP, pulse, cyanosis, RR, JVP, UO, ABG

Once stable and improving:
Cyanosis, JVP, UP, BP, daily weights, pulse 6h
Repeat CXR
ACEi + b-blocker + spirinolactone

Question 15

Management of cardiogenic shock

Answer 15

Manage in CCU/ICU
ABC
Oxygen
IV access, catheter
Morphine
Investigations and monitoring
IVF
Nitroglycerine
Vasopressor
Ionotropes->dobutamine

Look for and treat precipitating cause

Question 16

Investigations in shock

Answer 16

1st tests to order
lactate (arterial blood gas)
pH (arterial blood gas)
partial pressure of oxygen (arterial blood gas)
base deficit (arterial blood gas)
FBC
urea and creatinine, troponins
blood glucose
serum electrolytes with calculated anion gap
C-reactive protein (CRP)
ECG

Consider:
chest x-ray
focused abdominal sonography examination in trauma (FAST) scan
echocardiography
ultrasound of thorax
ultrasound of abdomen
CT thorax, abdomen, and pelvis
central venous pressure and venous oxygen saturations
urine pregnancy test
pelvic ultrasound

Question 17

Monitoring in cardiogenic shock

Answer 17

CVP
BP
ABG
ECG
Urine output
ECG

Question 18

Counselling B-blocker

Answer 18

1. Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.
2. Indicated for your HF/HTN
3. Caution
   Shock
   BradyC, heart block
   Hyperthyroidism
   Phaeochromocytoma
   Diabetes
   Anaphylaxis
   Asthma, COPD
   Liver
4. Can be used in pregnancy and breast feeding
5. Side effects
   Hypotension, bradycardia
   Bronchospasm
   Cool peripheries
   Fatigue, dizzy
   Altered glucose and lipids
6. Rare
   hallucinations, insomnia, nightmares, depression, heart block, rash, alopecia, exacerbation of psoriasis, impotence, muscle cramp, nasal congestion, hypersensitivity reaction, thrombocytopenia, increased aminotransferase concentrations, hepatotoxicity
7. Starting medication
   a) before starting treatment, ensure that patients are haemodynamically stable and standard treatments are optimised, eg ACE inhibitor, diuretic (to relieve signs of congestion, eg fluid overload)
   b) start with a low dose and gradually increase to the highest tolerable maintenance dose, carefully monitoring BP, heart rate and clinical status with each dose increase
   if there is transient worsening of heart failure, optimise dosage of other drugs before changing carvedilol dose, eg:
   if increasing congestion, increase diuretic dose, then halve carvedilol dose if necessary
   c) if symptomatic hypotension, first stop or reduce the dose of diuretics or vasodilators as appropriate

Question 19

Counselling ACE-i perindopril

Answer 19

1. It looks like you are suffering from early stage heart failure. What I would like to do today is start you on a drug called perindopril, which is the first line treatment for your condition.
2. Perindopril belongs to the class of drugs we call ACE inhibitors, and it works by relaxing the walls of your blood vessels, so blood can flow through much easier, and also, and also helps your kidneys to reduce the amount of salt and water in your circulation. These two effects work together to reduce the workload on your heart.

3. Side effects of perindopril:
Common
o	Low blood pressure
o	Cough – common side effect, if severe then can change to angiotensin receptor blocker
o	Electrolyte changes (hyperkalaemia) - so will need to monitor with blood test regularly
o	Dizziness
o	Fatigue
o	Nausea
o	Headaches 
o	Renal impairment

Infrequent 
o	Anaphylaxis
o	Angioedema
o	Palpitations
o	Chest pain
o	Flushing
o	Fever
o	Vomiting, diarrhoea, constipation, anorexia
o	Dry mouth/sore throat
o	Muscle cramps
o	Nightmares 

4. Contraindications/Precautions:
•	Known sensitivity
•	Angioedema
•	Primary hyperaldosteronism
•	Renal impairment
•	Elderly patients – higher risk of first dose hypotension
•	Pregnancy/planned conception
•	Breastfeeding
Drugs
o	Diuretics – increases risk of first-dose hypotension
o	Spironolactone – increases risk of hyperkalaemia
o	Gentamicin
o	Lithium 

5. Prior to starting the medication we will check your renal function and re-check in a week’s time, review your use of NSAIDs, optimise other treatment and cease potassium supplements.