Congestive Heart Failure (CHF)

Question 1

Definition of CHF

Answer 1

• Heart failure is a condition in which the heart is unable to generate a cardiac output sufficient to meet the demands of the body without increasing diastolic pressure.
• The term congestive heart failure is reserved for patients with breathlessness and abnormal sodium and water retention resulting in oedema.

Question 2

Aetiology of CHF

Answer 2

• Common causes include:
  
  • Coronary artery disease
  • Hypertension
  • Valvular disease
  • Myocarditis

Question 3

Signs and Symptoms of CHF

Answer 3

• Signs/symptoms include dyspnoea, neck vein distension/raised JVP, S3 gallop, cardiomegaly, hepatojugular reflux, rales, orthopnoea/paroxysmal nocturnal dyspnoea, tachycardia, chest discomfort, hepatomegaly, perihperal oedema, night cough, signs of pleural effusion, displaced apex beat and fatigue.
• Risk factors include MI, DM, HTN, dyslipidaemia, old age, male gender, left ventricular dysfunction, renal insufficiency, valvular heart disease and a family history of CHF amongst others.

Question 4

Pathophysiology of CHF

Answer 4

• Myocardial injury results in overexpression of multiple peptides.
• In the acute phase, neurohormonal activation helps maintain cardiac output and peripheral perfusion. However, sustained activation eventually results in increased wall stress, dilation and ventricular remodelling.
• This contributes to disease progression in the failing myocardium and in turn leads to systemic vasoconstriction and renal sodium and water retention, causing LVSD and thus more neurohormonal activation.
• Remodelling occurs in several conditions including MR, cardiomyopathy, hypertension and valvular heart disease.
• Remodelling’s hallmarks include hypertrophy, loss of myocytes and increased interstitial fibrosis.

Question 5

Investigation of CHF

Answer 5

• Physical examination
  
  • Tachycardia, cyanosis, elevated JVP, ankle oedema, displaced apex beat, pulmonary rales or crepitation, S3 gallop, pallor, irregularly irregular pulse, systolic murmur of aortic stenosis and mid diastolic murmur of mitral stenosis.
• Transthoracic ECHO
  
  • Systolic HF will show depressed and dilated left and/or right ventricle with low LVEF
  • Diastolic HF will show a normal LVEF but LVH and abnormal diastolic filling patterns
• ECG
  
  • Evidence of underlying CAD
  • May be conduction abnormalities
• CXR
  
  • Abnormal
• BNP/NT-pro-BNP
  
  • Elevated
• FBC
  
  • May reveal aetiology
• Serum electrolytes
  
  • Decreased sodium
  • Altered potassium
• Serum creatinine, blood urea nitrogen
  
  • Normal to elevated
• Blood glucose
  
  • Elevated in diabetes
• LFTs
  
  • Normal to elevated
• TFTs
  
  • Primary hypothyroidism
• Blood lipids
  
  • Elevated in dyslipidaemia
  • Decreased in end-stage HF

Question 6

Treatment of CHF

Answer 6

Question 7

Complications of CHF

Answer 7

• Pleural effusion
• Acute decompensation of CHF
• Chronic renal insufficiency
• Acute renal failure
• Anaemia
• Sudden cardiac death

Question 8

Prevention and Prognosis of CHF

Answer 8

• Primary prevention
  
  • Adjust/manage modifiable risk factors
• Prognosis
  
  • NYHA I annual mortality of 5-10%
  • NYHA IV annual mortality of 40-60%

Question 9

NYHA Classification

Answer 9

• I: No symptoms and no limitation in normal physical activity
• II: Mild symptoms and slight limitation during ordinary activity but comfortable at rest
• III: Marked limitation in activity due to symptoms even during less than ordinary activity and comfortable only at rest
• IV: Severe limitations experiencing symptoms at rest

Question 10

Management of acute pulmonary oedema (remember Pour SOD)

Answer 10

• Pour away (stop) their IV fluids
• Sit up
• Oxygen
• Diuretics (Furosemide)
• Aspirin
• IV opiates (act as vasodilators)
• NIV (CPAP)
• BB
• Blood transfusion
• IV GTN
• ACE-I

Question 11

Device therapy in HF

Answer 11

• ICDs
• CRT
• Mechanical circulatory support
  
  • IABP
  • Impella
  • ECMO

NB - Aim is to unload injured ventricles, wean toxic levels of vasopressors, maintain end-organ perfusion, allow cytokines to be metabolised, allow replenishment of ATP stores and to allow myocardium to recover.

Question 12

Heart transplant

Answer 12

• Main complications include:
  
  • Rejection
  • Infection
  • Allograft CAD
  • Malignancy
  • Side effects of immunosuppression

Question 13

Management of acute HF

Answer 13

• Consider CPAP if patients have severe respiratory failure not improving with diuretics - may prevent intubation