Congestive cardiac failure Flashcards
Definition
Heart is unable to generate a cardiac output to sufficient to meet demands without increasing diastolic pressure
Etiology
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.
Systolic dysfunction
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.
History
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
Physical examination
Examination reveals parasternal lift, an elevated and sustained left ventricular impulse, an S3/S4 gallop, JVD, and peripheral edema, hepatomegaly, Kussmauls
Investigations
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
Management of chronic CCF
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
Options for refractory CCF
Implantable cardiac defibrillator
Cardiac transplantation
NYHFA classification
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.
Checklist before intiating BB in CHF
Class 2-4 On diuretics + ACE-i No contraindications No acute medical illness No physical evidence of fluid retention
Causes of severe pulmonary edema
LVF ARDS Fluid overload Medication non-compliance Neurogenic
Symptoms and signs pulmonary edema
Dyspnea, PND, orthopnea, pink frothy sputum
Distressed, pale, sweaty, tachyP, pulsus alternance, +JVP, fine lg crackles, S3, wheeze
Investigations in pulmonary edema
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
Management of severe pulmonary edema
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
Management of cardiogenic shock
Manage in CCU/ICU ABC Oxygen IV access, catheter Morphine Investigations and monitoring IVF Nitroglycerine Vasopressor Ionotropes->dobutamine
Look for and treat precipitating cause
Investigations in shock
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
Monitoring in cardiogenic shock
CVP BP ABG ECG Urine output ECG
Counselling B-blocker
- Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.
- Indicated for your HF/HTN
- Caution
Shock
BradyC, heart block
Hyperthyroidism
Phaeochromocytoma
Diabetes
Anaphylaxis
Asthma, COPD
Liver - Can be used in pregnancy and breast feeding
- Side effects
Hypotension, bradycardia
Bronchospasm
Cool peripheries
Fatigue, dizzy
Altered glucose and lipids - Rare
hallucinations, insomnia, nightmares, depression, heart block, rash, alopecia, exacerbation of psoriasis, impotence, muscle cramp, nasal congestion, hypersensitivity reaction, thrombocytopenia, increased aminotransferase concentrations, hepatotoxicity - 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
Counselling ACE-i perindopril
- 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.
- 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
- 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.
