Congestive cardiac failure (CCF) Flashcards
Define cogestive cardiac failure
Congestive cardiac failure is a failure of both sides of the heart, failure being defined as an inability of the heart to act as a pump to sufficient levels to perfuse metabolic tissues adequately.
What are the common causes of congestive cardiac failure?
The main causes include:
- Ischaemic heart disease (35-40%)
- Dilated cardiomyopathy (30%)
- hypertension (20%)
Rarer causes include infection, valvular heart disease (poor ventricular filling (AV stenosis) or ventricular overload (regurgitation)), congenital heart disease (septal defect → overload), alcohol and drugs, arrhythmias (AF, tachymyopathy, CHB), pericardial disease and hyperdynamic circulation (anaemia, hyperthyroid, haemochromatosis).
Cardiac output is a function of ……
Cardiac output is a function of the pre-load (is pressure ont the ventricular wall prior to wall contraction/end of diastole), afterload (the pressure in the wall of the left ventricle during ejection/contraction - end of sytole) and myocardial contractility, which interact in a complex way as described by Starling’s law
Describe a typical history of a patient with cogestive cardiac failure
(4 stages)
New York Heart Association (NYHA) classification:
- Stage 1: Disease present, no undue dyspnoea from normal activity
- Stage 2: Dysponea present on ordinary activities
- Stage 3: :Less then ordinary activity causes dysponea, which is limiting
- Stage 4: Dysponea present at rest, any activity causes discomfort
Typical symptoms include exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea and fatigue. It may be associated with weight loss (cardiac cachexia) caused by a combination of anorexia, poor tissue perfusion and reduced exercise tolerance (wasting of disuse)
What are the typical clinical fndings for a patient with congestive heart failure?
- Jugular venous distension (raised JVP)
- Hepatomegaly/ascites
- Dependent pitting oedema
- Pleural effusions
- Cardiomegaly
- gallop rhythm
- 3rd heart sound
- Bibasal course crackles
Why can congestive heart failure cause the syndrome of ‘cardiac cachexia’?
- Life-threatening weight loss due to a combination of heatomegaly (nausea and decreased appetite) and increased metabolic demands
What is the recommened long-term management of congestive heart failure?
Confirmed diagnosis of LV dysfunction:
- Lifestyle advice
- ACEi + ß-blocker as first line
- Diuretic if symptomatic oedema
- Spironolactone/ARTA/hydralazine plus nitrate second line
- Dioxin thrid line
First line treatment for congestive cardiac failure is an ACE inhibitor and beta-blocker.
How should it be given?
Examples?
Mechanism of action?
Contracindications?
Side effects?
ACEi usually introduced first, with b-blockers added when stable
ACE inhibitors: -pril
- E.g. ramipril, captopril, lisinopril
- Low dose should be used and titrated upwards
- Work to reverse the neurohormal adaption (RAAS) in CCF (angiotensin converting enzyme inhibitor)
- Not to be used with NSAIDs (renal risk)
- Not to be used with patients with low bp - systolic below 100 (risk of severe hypotension)
- Side effects:
- Renal - monitor urea, creatinine and K+ before and during treatment
- Risk of first dose hypotension
- 10% of pts develop dry cough
Beta-blockers: -olol
- E.g. metoprolol, bisoprolol, nebivolol
- Ued to block the sympathetic activity that causes maladaptation - also has antiarrhythmic effects
- By reducing sympathetic drive symptoms initally become worse so use low dose and titrate up
- Contra-indicated in asthma - caution with COPD
Why are diuretics used for CCF?
what ones are used?
- For symptomatic relief of oedema, but also ventilate
- Thiazides (bendoflumethiazide) are used in failure or in elderly patients
- Loop diuretics (furosemide) are used especially in pulmonary oedema
What investigations should be done in a patient with suspected congestive heart failure?
- Bloods:
- FBC, LFT, U&Es, Thyroid functions tests, cardiac enzymes in acute failure
- B-type natriuretic peptide (BNP): a normal level will exclude heart failure, so a good screen for breathlessness in general practice
- CXR:
- cardiomegaly and pulmonary oedema
- ECG:
- signs of ischaemia, hypertension or arrhytmias
- Echo:
- if ECG or BNP are abnormal
- Gold standard for diagnosis
- Ejection fraction <45% diagnostic
On examination of a patient with CCF what might you find?
- Hepato- and cardio-megaly may be present
- bilateral basal crackles
- SOB
- gallop rhythm
- S3 (3rd heart sound)
- elevated JVP
- peripheral oedema
- ascites
- tachycardia.
Outline the importance of daily monitoring of weight in assessing response to diuretic treatment
It is important that patients do not lose weight too rapidly. A weight loss of around 0.5-1kg per day may be optimal, and weight loss may be an indicator of decongestion. It is important not to drop a patient’s weight too quickly as that may push them into kidney failure. Simultaneously electrolyte balance should be monitored.
