Heart failure Flashcards
What is heart failure?
Also known as congestive heart failure (CHF) or congestive cardiac failure (CCF).
Refers to the failure of the heart to generate sufficient cardiac output to meet the metabolic demands of the body.
Examples of how heart failure can be classified?
Can be classified in several ways.
Acute vs. chronic
Ejection fraction
What is acute vs. chronic heart failure classification?
Acute
- new presentation or deterioration/decompensation in someone with existing heart failure.
Chronic
- slow progress of heart failure, takes many years to develop.
What is ejection fraction?
Refers to the percentage of blood in the left ventricle that is pumped out with eachventricular contraction.
An ejection fractionabove 50%is considered normal.
What is heart failure with reduced ejection fraction?
Ejection fraction≤40%
What is heart with mildly reduced ejection fraction?
Ejection fraction41-49%
What is heart failure with preserved ejection fraction?
Pt has clinical features of heart failure but their ejection fraction is ≥50%.
What classification system is used for heart failure symptom severity?
New York Heart Association (NYHA)
What are the classifications under the New York Heart Association (NYHA)?
Class I
- no limitation in physical activity
- no symptoms
Class II
- slight limitation of physical activity, and comfort at rest (no symptoms at rest).
- Ordinary physical activity causes fatigue, palpitation and/or dyspnoea.
Class III
- marked limitation in physical activity, but comfort at rest.
- Minimal physical activity causes fatigue (less than ordinary).
Class IV
- inability to carry on any physical activity without discomfort, with symptoms occurring at rest.
- If any activity takes place, discomfort increases.
Causes of heart failure?
- Ischaemic heart disease
- Valvular heart disease (commonlyaortic stenosis)
- Hypertension
- Arrhythmias (commonlyAF)
- Cardiomyopathy
- Congenital heart disease
- Obesity
- Drugs (alcohol, cocaine, NSAIDs, BB, CCB)
How does left heart/ventricular failure (LHF) present?
Fatigue
SOB
Orthopnoea (SOB lying flat)
Paroxysmal nocturnal dyspnoea
Nocturnal cough (+/- pink frothy sputum)
Tachypnoea
Bibasal fine crackles on auscultation of the lungs
Cyanosis
Prolonged capillary refill time
Hypotension
Less common signs:
- pulsus alternans
- S3 gallop rhythm
How does right heart/ventricular failure (RHF) present?
Fatigue
Ankle oedema
Weight gain
Abdominal swelling and discomfort
Anorexia and nausea
Raised JVP
Pitting peripheral oedema (ankle to thighs to sacrum)
Tender smooth hepatomegaly
Ascites
Transudative pleural effusions (typically bilaterally)
How is heart failure diagnosed/investigated?
Clinical assessment
1st line: NT-pro-BNP level
>2000ng/L = refer urgently to specialist and echocardiography within 2 wks
400-2000ng/L = refer urgently to specialist and echocardiography within 6 wks
<400ng/L = diagnosis of HF is less likely
ECG
Transthoracic echocardiogram (TTE)
- ventricular ejection fraction
Other IVx:
- Bloods (U&Es, LFTs, TFTs, glucose, lipid profile)
- CXR
Alveolar oedema
Kerley B lines (caused by interstitial oedema)
Cardiomegaly (cardiothoracic ratio >0.5)
Upper lobe blood diversion
Pleural effusions (typically bilateral transudates)
How is heart failure managed?
Conservative:
- wt loss (if BMI >30)
- smoking cessation
- reduce salt intake
- reduce alcohol
- supervised exercise-based group rehabilitation programme for people with HF
- offer annual influenza vaccine
- offer one-off pneumococcal vaccine
- DVLA
- travel advice (carry meds, write down med hx and current drug tx)
Medical:
- Loop diuretics (e.g. furosemide or bumetanide; helps for oedema)
- consider antiplatelet drug and statins
- 1st line =ACEi/ARB (hydralazine) and BB
If symptoms persist and NYHA class 3 or 4, consider:
-Aldosterone antagonists (spironolactone or eplerenone)
- Hydralazine and a nitrate for Afro-Caribbean patients.
- Ivabradine if in sinus rhythm and impaired EF.
- Digoxin = useful in those with AF. This worsens mortality but improves morbidity.
- SGLT2 inhibitors (dapagliflozin or empagliflozin; given if symptomatic chronic HF and other meds are optomised)
BASH medications demonstrate mortality benefit in patients with reduced ejection fraction HF = ACE-I, BB, Spironolactone and Hydralazine.
Surgical/interventional management of heart failure?
Cardiac resynchronisation therapy -pacemakers (if ejection fraction <35%)
Implantable cardioverter defibrillators (continually monitor the heart and apply adefibrillator shocktocardiovertthe patient back into sinus rhythm if they identify a shockablearrhythmia, used if pt previously had a ventricular tachycardia/fibrillation)
Heart transplant
