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Flashcards in Heart failure Deck (15):

What is heart failure

Inability of the heart to pump blood to all other parts of the body

Usually as a result of damage to the left ventricle Increased pressure in the left heart -fluid in the lungs causes breathlessness Increased pressure may reflect into right heart leading to congestive symptoms.

Fluid collects in the legs, enlarged liver, elevated JVP Poor blood supply to the muscles causes tiredness and wasting


Causes of heart failure

IHD ( Myocardial Infarction)
Dilated cardiomyopathy, restrictive and hypertrophic cardiomyopathies
Valvular heart disease
Pericardial disease
Congenital heart disease
Myocarditis or endocarditis


Symptoms of heart failure

Pulmonary congestion: SOBOE, orthopnoea, PND 

Poor perfusion to muscle: Fatigue, weakness

Raised CVP: Fluid retention

Oedematous GIT, malabsorption, muscle atrophy: Weight loss, cachexia

Poor perfusion to brain: Confusion, poor concentration and memory, insomnia


Signs of heart failure

S3 gallop/ third heart sound
Pulmonary basal crackles
Pulsus alternans
Elevated JVP
Ankle oedema
Tender hepatomegaly


Investigations in a patient with heart failure

CXR: cardiomegaly, bilateral pleural effusions, pulmonary congestion

ECG: likely to be abnormal, LBBB

Bloods for anaemia, thyrotoxicosis, U+E, BNP

BNP (Brain Natriuretic Peptide)



NYHA score

Used for classification of heart failure

1 - no limittation of physical activity

2 - slight limitation of physical activity, breathless on exertion (stairs)

3 -  marked limitation of physical activity, breathless walking short distances

4 - breathless at rest, impaired physical activity


Systolic heart failure

Left heart failure. 

Inadequate cardiac output leads to elevated left atrial pressures. This causes back pressure in the pulmonary veins leading to pulmonary congestion (and pulmonary oedema), back pressure can spread to right heart, causing a rise in CVP. 



Right heart failure

Secondary to chronic lung disease, PE, pulmonary hypertension, right heart valve disease - left ventricle normally unaffected

Can also be secondary to left ventricular failure (congestive heart disease) 

Elevated RA pressure leads to peripheral fluid retention 


Acute heart failure

Emergency. Develops rapidly so there is no time for compensatory changes e.g. sepsis, acute MI, valve dysfunction

Presents as acute breathlessness, orthopnoea, wheezing, anxiety and sweating. 

Treated pharmacologically - MONaD
Morphine, high flow O2, IV GTN, Diuretics


Chronic heart failure

Long term condition associated with adaptive responses in the heart (hypertrophy, dilation) 

Commonest causes MI and CAD

Results in changes in cardiac function, neurohumoural status, systemic vascular function, blood volume. 

Treatment: beta-blockers, vasodilators (GTN), spironolactone/ACEi (prevent water retention)


Pathophysiology of heart failure

Cardiac dysfuntion results in a decrese in cardiac output due to impaired systolic function (low SV). 
This results in a higher EDV, the ventricle dilates to compensate.

Reduced CO, results in a fall in blood pressure because of arterial underfilling, TPR falls. This stimulates NorA release from the sympathetic system causing vasoconstriction to maintain arterial pressure and increase heart rate to raise CO (tachycardia)

Fall in BP also decreases renal perfusion, activates RAAS to increase Na+/H20 retention (aldosterone) and vasoconstriction (Angiotensin II) to increase BP. 

Raised TPR increases ventricular afterload, which reduces SV and raises preload. Increased blood volume raised CVP. Causes pulmonary congestion and oedema. 


Why is aldosterone harmful for the heart

Exacerbates progression of heart failure by causing salt and water retention. 

This increases ventral venous pressure, and therfore increase preload promoting pulmonary congestion. Failing hearts are less responsive to changes in preload

Causes sudden cardiac death by increasing fibrosis and arrythmia

Causes ischemic events


Precipitating factors in heart failure







Poorly controlled hypertension

Lifestyle: physical activity, emotional stress, diet

Cause decompensation of cardiac function. 


Treatment of acute heart failure

Propped up position, high flow oxygen
IV morphine
High dose intravenous GTN
IV Frusemide (diuretics)
Positive inotropes


Diastolic heart failure

Heart failure with good LV systolic function but poor LV relaxation usually due to hypertrophy

Common in elderly females with hypertension

Common causes are hypertension, HCM, Aortic stenosis (LVH) and CHD

Diagnosed from signs of heart failure + abnormal relaxation of LV assessed by echo


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