Heart failure Flashcards
Define heart failure
Inability of the heart to pump blood/produce a cardiac output to meet the demand of the body without increasing diastolic pressure.
What is the The New York Heart association Heart failure classification
- Normal
- Comfortable at rest, dyspnoea on ordinary activity (Bit of a struggle, but can manage)
- Marked limitation of ordinary activity (Cannot do it)
- Dyspnoea/symptomatic at rest
How can heart failure be classified
Systolic vs diastolic
Left vs right
Congestive (Left + right due to pressure backing up into the right and so forth)
High vs low output
Acute vs chronic vs Acute on chronic (infection or MI on HF)
Preserved or reduced ejection fraction (<40%)
Aetiology of heart failure
Muscular: IHD (ACS), Cardiomyopathies, myocarditis, arrhythmias
Hypertension
Valvular disease: aortic stenosis/regurgitation, mitral regurgitation (LEFT), tricuspid regurgitation or pulmonary valve disease (RIGHT)
Pericardial disease
Arrhythmia or HOCM (hypertrophic cardiac myopathies)
Drugs e.g. cocaine, chemo
Thyrotoxicosis, Anaemia, pregnancy → High output CF (due to increased demand)
Pulmonary hypertension (cor pulmonale)
Amyloidosis
Risk factors for heart failure
MI, Left ventricular dysfunction/hypertrophy/dilation, Valvular heart disease, Atrial fibrillation
DM, dyslipidaemia
Male sex, Old age
Exposure to cardiotoxic agents, Cocaine abuse
Renal insufficiency, Thyroid disorders, Anaemia, Sleep apnoea
Elevated homocysteine, TNF-alpha, IL-6, CRP, BNP
IGF-1
Family history
Low socio-economic status, Tobacco consumption, Alcohol, Excess sodium, Excess coffee, Obesity, Tachycardia, Depression/stress, Micropalbuminuria
Symptoms of heart failure
Dyspnoea (PND, Orthopnoea, Exertional dyspnoea)
Fatigue
Peripheral oedema i.e. leg swelling
Cough (nocturnal cough, pinky froth sputum) - LHF, acute
Wheeze
Palpitations (arrhythmia)
Chest pain (nature, good for differentials)
Anorexia (the gut becomes swollen, you become nauseated -> food cannot be absorbed)
Nocturia (central re-distribution of extravascular fluid that augments the amount of circulating blood cleared from the kidneys)
Lethargy/confusion
Signs of heart failure
Cardiac
S3 gallop, S4 if severe
Displaced apex beat (cardiomegaly)
Bilateral ankle oedema
Tachycardia
Resp
PND
Bibasal crepitations
Head and neck
Neck vein distension
Hepatojugular reflux
Abdo
Hepatomegaly
Left vs Right heart failure
Left
SOB (pulmonary oedema) + basal crepitations that do not disappear on coughing
Hypoxic
Cyanosis
Fatigued
Murmur if causative
Right
Fatigue
Swelling (hepatomegaly, ascites, peripheral oedema)
Weight gain
Raised JVP + hepatojugular reflux
Murmur if causative
Diagnosis of heart failure criteria
Framingham criteria: 2 or more major OR 1 major + 2 minor
Major:
- PND
- Bibasal crepitations
- S3 gallop
- Cardiomegaly
- Increased central venous pressure
- Weight loss
- Neck vein distension
- Acute pulmonary oedema
- Hepatojugular reflux
Minor
- Bilateral ankle oedema
- Dyspnoea on ordinary exertion
- Tachycardia
- Decrease in vital capacity by 1/3
- Nocturnal cough
- Hepatomegaly
- Pleural effusion
Investigations for heart failure
ECG: evidence of underlying cardiac disease, pulsus alternans
Urinalysis
BNP: elevated >400 nanograms/L (supportive, not diagnostic)
ABG: ?resp failure
FBC: ?anaemia, lymphocytosis
Troponin: exclude ICS, risk stratify
Renal screen: tissue perfusion status
Glucose: ?DM
TFTs: ?thyroid
CXR: pulmonary oedema, cardiomegaly
Transthoracic echo:
- Systolic: Depressed + dilated LV/RV with LOW ejection fraction (<40%)
- Diastolic: LVEF normal but LVH and abnormal diastolic filling patterns
What are the causes of elevated BNP
Age over 70 years
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (ie pulmonary embolism)
Renal dysfunction (eGFR less than 60 ml/minute/1.73 m2)
Sepsis
Chronic obstructive pulmonary disease
Diabetes
Cirrhosis of the liver
What do you see on CXR in heart failure
- Abnormal, may reveal pulmonary vascular congestion
- B - Kerley B = Pulmonary oedema - “fluffy”, “bat wings” appearance
- Cardiomegaly (cardio-thoracic ratio increased)
- Dilated upper lobe vessels
- Effusion, pleural (usually right sided, often bilateral)
Management for chronic heart failure
Lifestyle: exercise, reduce salt intake (<4.5g), restrict water (<1.5L), stop alcohol/smoke, monitor weight
RF control: statin, aspirin, DM control
Vaccination: influenza + pneumococcal (one off)
- ACEi + beta blocker (one at a time)
- enalapril + carvedilol
- Preserved ejection fraction → loop diuretic - Add aldosterone antagonist
- Enalapril + carvedilol + spironolactone
- Must monitor potassium - Specialist
- Ivabradine
- Sacubitril-valsartan
- Digoxin (reduces symptoms, not mortality. Good for co-existent AF)
- Hydralazine + nitrate
- Cardia resynchronisation therapy i.e. biventricular pacemakers
Which drugs are avoided in heart failure
CI:
Thiozoladinediones
Verapamil (-ve inotrope)
NSAIDs (fluid retention)
Glucocorticoids (fluid retention)
Flecainide (-ve inotrope, arrhythmogenic)
avoid nifedipine due to risk of symptom exacerbation
Complications of heart failure
Pleural effusion
Respiratory failure
Chronic renal insufficiency
Anaemia
Acute decompensation of chronic heart failure
Acute renal failure
Sudden cardiac death
