Congestive Heart Failure

Question 1

Compare L + R failure

Answer 1

Left:

• dyspnoea
• poor exercise tolerance,
• fatigue
• orthopnea, PND
• nocturnal cough ± pink frothy sputum
• wheeze (cardiac asthma),
• nocturia
• cold peripheries
• weight loss
• muscle wasting.

Right:
Causes = LVF, pulm. stenosis, lung disease
- peripheral oedema (up to thighs, sacrum, abdo wall)
- ascites
- nausea, anorexia
- facial engorgement,
- pulsation in neck + face (tricuspid regurg)
- epistaxis

Question 2

What is the difference in acute vs chronic

Answer 2

• Acute = new onset or decompensation of chronic HF - characterised by pulm or peripheral oedema +/- signs of peripheral hypoperfusion
• Chronic = slow, venous congestion common. Arterial pressure maintained until late stage

Question 3

What is low output heart failure

Answer 3

Cardiac output = low + fails to increase w. exertion
CAUSE =
- Pump failure –> low heart rate, -vely inotropic drugs
- Excessive preload –>mitral regurg or fluid overload (NSAID causing fluid retention, renal excretion impaired, ++ vol added quickly)
- Chronic excessive afterload –> aortic stenosis, HTN

Question 4

What is high output HF

Answer 4

• Rare
• Anaemia, pregnancy, hyperparathyroidism, Paget’s, ateriovenous malformation

–> Initially feature of RVF, later LVF evident

Question 5

How common is congestive heart failure

Answer 5

1-2% adults have HF

- 10% >70years

Question 6

Who does it affect

Answer 6

• elderly

- In younger age groups, M>F (CHD)

Question 7

What causes it

Answer 7

Valvular heart disease
- aortic stenosis –> LVH (chronic excessive overload)

2o to myocardial disease

• CHD, MI, AF
• HTN
• Drugs - BB, Ca antagonists, anti-arrhythmias, cytotoxics
• Toxins - alcohol, cocaine
• Endocrine - DM, hypo/ hyperthyroidism, Cushing’s
• Nutritional - def thiamine, obesity
• Infiltrative - sarcoidosis, amyloidosis, haemochromatosis
• Infective - HIV

Question 8

How does it present

Answer 8

• Breathlessness
• Fatigue (limit exercise tolerance)
• Ankle swelling
• Dyspnoea
• Fluid retention
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Nocturnal cough or wheeze (pink frothy sputum)
• Nocturia
• cold peripheries
• weight loss and muscle wasting

Question 9

What are the signs on examinations

Answer 9

• Tachycardia
• Tachyponea
• Pleural effusion
• Raised JVP
• Peripheral oedema
• Hepatomegaly (tender)
• Neck vein distention
• Pulmonary oedema
• May have cardiac abnormalities- Third heart sound, cardiac murmurs, echocardiogram abnormalities

May show galloping heart beat due to third noise

Question 10

What are some differential diagnoses

Answer 10

• Acute resp distress synd
• Acute trauma
• Asthma
• Cardiogenic shock
• COPD
• Drug overuse
• MI
• Pneumonia
• Pulmonary fibrosis
• Respiratory failure
• Sepsis

Question 11

What investigations would you do

Answer 11

• Doppler echocardiography
• Echocardiography
• ECG
• CXR – Kerly B lines, fluid in fissures, alveolar ‘bat wings’, cardiomegaly, pleural effusions, prominent upper lobe veins, peribronchial cuffing

ECG and B-type natriuretic peptide (BNP), if normal, heart failure is unlikely; if either abnormal, ECHO required.

FBC, U&E,

Endomyocardial biopsy rarely needed.

Question 12

What is the treatment for CHF + it’s side effects

Answer 12

DIURETICS e.g. furosemide

• Relieve symptoms
• SE: Low K+, renal impairment, arrhythmias
• consider giving K+ sparing diuretic alongside

ACEi

• Consider in all LV systolic dysfunction
• SE: Increased K+, cough –> ARB (candesartan) substitute

B-Blockers

• Decreases mortality + additional to those w. ACEi
• e.g. carvedilol

Spironolactone

• Additional therapy used if still symptomatic
• K+ sparing

Digoxin

• Help symptoms even in sinus rhythm
• AF pt or systolic dysfunction inc ACEi + B-blocker
• May cause hyperkalaemia

Metolazone + IV furosemide
Opiates + IV nitrates - may relieve symptoms
Palliative - treat comborb, good nutrition, involve GP. O2 + opiates may help pain + SOB