Heart Failure

Question 1

Give examples of ‘low output failure’ and ‘high output failure’

Answer 1

LOW OUTPUT:
- Arrhythmia
- MI
- Myocarditis
- Sepsis
- Cardiomyopathy

HIGH OUTPUT:
- Pregnancy
- Thyroid storm
- Anaemia
- Fistula/AVM

Etc.

Question 2

GENERAL APPROACH to acute decompensated systolic failure:

Answer 2

As per cardiogenic shock:

• Optimise:
  –> Heart rate
  –> O2
  –> pH
  –> Electrolytes
• Inopressor
• –> Inodilator (dobut, levo, milrin)
• Overdrive pacing
• IABP
• ECMO VA
• Bypass

Question 3

GENERAL APPROACH to acute decompensated CCF / APO:

Answer 3

Reduce preload
Increase inotropy
Minimise myocardial O2 demand
Optimise coronary perfusion
Reduce afterload

HYPERTENSIVE (most)
- Sit upright
- O2
-CPAP
–> (preload reduction, afterload reduction, mortality benefit)
- Frusemide 1mg/kg stat
–> (preload reduction, symptomatic)
- GTN 2.5mg/hr
–> (preload reduction, coronary perfusion, afterload reduction)
If refractory, additional vasodilation:
- Sodium nitroprusside 1-4 microg/kg/min

HYPOTENSIVE (ie. cardiogenic shock- bad prognosis)
- Adrenaline
- Dobutamine

____________
- Fluid restrict <1-1.5L
- IDC
- Strict fluid balance
- Daily weigh

Question 4

Non-cardiogenic causes of APO:

Answer 4

Neurogenic APO
Re-expansion APO (PTx)
Negative-pressure APO (UAO)
HAPE

ARDS/ pneumonitis
Near-drowning
Hypervolaemia (ie. iatrogenic)
DIC

Question 5

CXR findings in APO:

Answer 5

Upper lobe diversion
Hilar ‘bat-wing’ opacity (alveolar oedema)
Kerley B lines (interstitial oedema)
Fluid in the fissures
Pleural effusion
+/- cardiomegaly (>50% PA)

Question 6

POCUS findings in APO:

Answer 6

B-lines

AKA ‘comet tails’
>3 per field of view = APO (a few is normal)

Question 7

Utility of BNP in diagnosis of heart failure:

Answer 7

Cut-offs are age specific

< 100 = HF unlikely

>500 (<50yo)
>900 (50-75yo)
>1800 (>75yo)
= HF likely

False positives:
- PE, ARDS, recent fluid resus, renal impairment, steroids

Question 8

Framingham Criteria

Answer 8