Heart Failure Flashcards
Define heart failure
Cardiac output is inadequate for the requirement of the body
- end stage of all heart disease
What are the classifications of heart failure
Systole failure Diastolic failure Left ventricular failure Right ventricular failure Congestive cardiac failure - most common Acute heart failure Chronic heart failure Low output heart failure High output heart failure
Describe systolic heart failure + causes
Failure of adequate ventricular contraction resulting in decreased cardiac output Ejection fraction <40% Causes - ischaemic heart disease - myocardial infarction - dilated cardiomyopathy
Describe diastolic heart failure + casues
Inability of ventricular relaxation, causing increased filling pressures and decreased cardiac output
EF >50% - heart failure with preserved EJ
Causes
- ventricular hypertrophy
- restrictive and hypertrophic cardiomyopathy
- cardiac tamponade
- constrictive pericarditis
- obesity
Describe left ventricular heart failure + symptoms
Failure of the LV pump causing pulmonary congestion and oedema Symptoms - dyspnoea - decreased exercise tolerance - fatigue - orthopnoea - nocturnal cough - pink frothy sputum - wheeze - nocturia - cold peripheries - weight loss - irregular, fast heart beat - cyanosis
Describe right ventricular heart failure + causes
Inability to pump adequate blood, causing systemic venous congestion Causes - LVF (most common cause) - pulmonary stenosis - lung disease
Signs and symptoms of right ventricular heart failure
Peripheral oedema - raised JVP - hepatosplenomeagly - ankles and legs Ascites Nausea Anorexia Facial engorgement Epistaxis
Describe congestive cardiac failure (CCF)
Heart failure causes by the presence of both left and right ventricular failure
Describe acute heart failure + causes
New-onset or decompensated chronic heart failure Causes - post-MI - persistent arrhythmia - ruptured valve - ventricular aneurysm - anaemia - electrolyte disturbance - thyrotoxicosis
Describe chronic heart failure
Heart failure that starts and progresses slowly
- can commonly lead to venous congestion, but maintains arterial pressure
Describe low out-put heart failure + causes
Low cardiac output which doesn’t increase with exercise
Causes
- excessive preload (MR, fluid overload)
- pump failure (systolic/diastolic HF, decreased heart rate or negatively inottopic drugs)
- chronic excessive afterload (AS, hypertension)
Describe high out-put heart failure + causes
Normal or increased cardiac output in the face of increased needs (anaemia, pregnancy, hyperthyroidism, Paget’s, AVM, beri-beri)
- rare
Complications of high out-put heart failure
RVF features - early
LVF features - late
How is heart failure diagnosed
Clinical - history, examination and investigations
Objective evidence of cardiac dysfunction at rest
For CCF - Farmingham criteria
What is the Farmingham criteria
Diagnoses CCF based due to the presence of 2 major criteria, or 1 major and 2 minor criterion met Major criteria - S3 heart sound - acute pulmonary oedema - weight loss on treatment - paroxysmal nocturnal dyspnoea - abdominojugular reflex - neck vein distension - increased cardiac shadow on CXR - crackles in lungs Minor criteria - hepatomeagly - pleural effusion - exertional dyspnoea - tachycardia - vital capacity less than 1/3 of max - nocturnal cough
How is the severity of heart failure classified?
New York classification of HF
- class 1 - no undue dyspnoea from normal activity
- class 2 - slight limitation of ordinary activities
- class 3 - severe limitation of any activity, comfortable at rest
- class 4 - dyspnoea at rest
What are the signs of heart failure?
Hypotension Narrow pulse pressure Pulsus alternans Displaced apex - LV dilatation RV heave (pulmonary hypertension) Valve disease Grade of severity
Investigations for ?Heart failure
Bloods - FBC, U&Es, TFTs, LFTs and BNP
CXR - ABCDE
ECG - may show the cause (e.g. MI, LVH, ischaemia)
Echo
- ? cause (MI, valvular heart disease)
- LV function can be assessed
- detects ejection fraction, ventricular wall thickness and cardiac kinetics
If ECG and BNP are normal, it is likely not AF - try and find another cause
What are the signs of heart failure on CXR
A- alveolar odedma - ‘bats wing’
B - kerley B-lines
C- cardiomeagly (more than half cardiothoracic ratio)
D- diversion or dilation of blood vessels to the upper lobe
E- pleural effusion
What is the non-pharmacological management for chronic heart failure
Exercise Diet - increase healthy food - decrease salt - monitor weight Reduce alcohol - a cause of AF and heart failure Smoking cessation Flu vaccination
Pharmacological management of chronic heart failure
ABCDD
ACEI
- reduces afterload and fluid retention (slows down LV disease)
- ARB if not tolerated
Beta-blockers
- reduces afterload and heart rate to prevent arrhythmias
- decreases mortality
- benefit additional to that of ACEI in systolic HF
Calcium-channel blockers
- only is ACEI and beta-blockers are ineffective and systolic HF is not the cause
Diuretics
- loop diuretics for symptoms (increased dose as required)
- add spironolcatone if hypokalaemia
- add thiazide if refractory oedema
Digoxin
- only considered if all above is inadequate
- indicated in patients with symptomatic sinus rhythm, severely impaired LVF or with recurrent hospital admissions
Non-routine pharmacological management of chronic heart failure
Vasodilators
- hydralazine and isosorbide mononitrate
- if intolerant of ACEI and ARB
- decreases mortality and standard therapy in black patients
What are the 1st, 2nd and 3rd line medications used in chronic heart failure
Loop diuretics for symptoms at all stages
Calcium-channel blockers can be used (2nd line) if co-morbid hypertension and/or angina
1st line
- ACEI/ARB
- beta-blocker
2nd line
- spironolactone
- ARB (if not already on)
- hydralazine and isosorbide mononitrate (unless already on - black patients)
3rd line
- digoxin
What surgical interventions are used in the management of chronic heart failure
Depends on cause Revascularisation therapy - CABG or angioplasty Valve replacement LVAD Implantable automatic cardiodefibrillator - or pacemaker for arrhythmias Transplant
