Cardiac Failure

Question 1

Define Cardiac Failure

Answer 1

Inability of the cardiac output to meet the body’s demands despite normal venous pressures

Question 2

Explain the aetiology of Low output Cardiac Failure

Answer 2

(= Reduced CO)
Left Heart failure
      - Ischaemic heart disease
      - Hypertension 
      - Cardiomyopathy
      - Aortic valve disease
      - Mitral regurgitation
Right Heart Failure
      - Secondary to left heart failure (= congestive HF)
      - Infarction
      - Cardiomyopathy
      - Pulmonary HTN/embolus/valve disease
      - Chronic lung disease
      - Tricuspid regurgitation
      - Constrictive percarditis/pericardial tamponade
Biventricular Failure
      - Arrhythmia
      - Cardiomyopathy (dilated or restrictive)
      - Myocarditis
      - Drug toxicity

Question 3

Explain the aetiology of High output Cardiac Failure

Answer 3

(= increased demand)

• Anaemia
• Beri Beri
• Pregnancy
• Hyperthyroidism
• Arteriovenous malformation

Question 4

What is the epidemiology of Cardiac Failure?

Answer 4

10% of >65s

Question 5

What are the Presenting symptoms of Left Heart failure?

Answer 5

(Symptoms caused by pulmonary congestion)

• Dyspnoea - divided based on New York Heart Associated classification:
  1. no dyspnoea
  2. dyspnoea on ordinary activities
  3. dyspnoea on less than ordinary activities
  4. dyspnoea at rest
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Fatigue

Question 6

What are the Presenting symptoms of Acute Left Ventricular Failure?

Answer 6

• Dyspnoea
• Wheeze
• Cough
• Pink frothy sputum

Question 7

What are the presenting symptoms of Right Heart Failure?

Answer 7

• Swollen ankles
• Fatigue
• Increased weight (oedema)
• Reduced exercise tolerance
• Anorexia
• Nausea

Question 8

What are the signs of Cardiac Failure in Left Heart Failure?

Answer 8

• Tachycardia
• Tachypnoea
• Displaced apex beat
• Bilateral basal crackles
• S3 gallop (caused by rapid ventricular filling)
• Pansystolic murmur (functional mitral regurgitation)

Question 9

What are the signs of Cardiac failure in Acute Left Ventricular failure?

Answer 9

• Tachypnoea
• Cyanosis
• Tachycardia
• Peripheral shutdown
• Pulsus alternans
• Gallop rhythm
• Wheeze (cardiac asthma)
• Fine crackles throughout lung

Question 10

What is Pulsus Arternans?

Answer 10

• Arterial pulse wave forms showing alternating strong and weak beats
• Sign of left ventricular systolic impairment

Question 11

What are the signs of Cardiac failure in Right heart failure?

Answer 11

• Raised JVP
• Hepatomegaly
• Ascites
• Ankle/sacral pitting oedema
• Signs of functional tricuspid regurgitation

Question 12

Identify the appropriate investigations for cardiac failure

Answer 12

• Bloods: FBCs, U&Es, LFTs, CRP, Glucose, Lipids, TFTs
• In acute left ventricular failure: ABG, Troponic, BNP
• CXR: look for alveolar shadowing, Kerley B lines, Cardiomegaly, Upper lobe diversion, pleural effusion
• ECG: may be normal may show ischaemia, arrhythmia or left ventricular hypertrophy
• Echocardiogram: assess ventricular contraction, systolic dysfunction = left ejection fraction <40%, diastolic dysfunction = decreased compliance of the myocardium leads to restrictive filling defect
• Swan-Ganz Catheter: allows measurement of right atrial, right ventricular, pulmonary artery, pulmonary wedge and left ventricular end-diastolic pressures

Question 13

Generate a Management plan for Cardiac Failure in Acute Left Ventricular Failure

Answer 13

Treating Cardiogenic shock:

• = severe cardiac failure with low BP
• requires in the use of inotropes (e.g. dobutamine)
• managed in ITU

Treating Pulmomary Oedema:

• Sit patient up
• 60-100% oxygen (consider CPAP)
• Diamorphine (venodilator + anxiolytic)
• GTN infusion (venodilator -> reduced preload)
• IV furosemide (venodilator + later diuretic effect
• Monitor: BP, resp rate, O2 sats, Urine output, ECG
• Treat cause (e.g. MI, Arrhythmia)

Question 14

Generate a Management plan for Cardiac Failure in Chronic Left Ventricular failure

Answer 14

• Treat the cause (e.g. hypertension) and exacerbating favours (e.g. anaemia)
• ACE inhibitors: inhibit RAS and adverse cardiac remodelling = slow progression of hf + improve survival
• B-Blockers: blocks chronically activated SNS, slows HF progression + survival (additive with ACE-I)
• Loop Diuretics: with dietary salt reduction can correct fluid overload
• Aldosterone antagonists: improves survival in pts with NYHA class III/IV symptoms on standard therapy. Monitor K+ (may cause hyperkalaemia)
• Angiotensin receptor blockers: may be added in patients with persistent symptoms despite ACE-I and B-Blocker use. Monitor K+ (may cause hyperkalaemia)
• Hydralazine and a Nitrate: if persistent symptoms (particulary afro-carribeans)
• Digoxin: positive inotrope, reduces hospitalisation but does not improve survival
• N-3 Polyunsaturated fatty acids: small benefit for survival
• Cardiac resynchronisation therapy: biventricular pacing improves symptoms and survival in patients with a left ventricular ejection fraction <35%, cardiac dyssynchrony (QRS>120msec) and moderate-severe symptoms. Pts. are also candidate for ICD - may get combined

Caution: avoid drugs with adverse effect due to systolic dysfunction e.g. NSAIDs, non-dihydropyridine CCBs)

Question 15

What are the possible complications of Cardiac Failure?

Answer 15

• Respiratory failure
• Cardiogenic shock
• Death

Question 16

What is the prognosis of Cardiac Failure?

Answer 16

50% of patients die within 2 years