heart failure
Types
Heart
failure with
preserved ejection
fraction
DIASTOLIC
heart failure
with reduced ejection
fraction EF <50%
SYSTOLIC
Acute
decompensatio
n heart failure
high output heart failure
acute heart failure
right heart fialure
aetiology
Coronary heart disease
ciggarette smoking
Hypertension
obesity
Diabetes
Valvular heart disease
evaluation
Ischae
mic
cardio
myopat
hy,
dilated,
valvulo
pathy,
hyperte
nsion. dilated cardiomyopathy idiopathic, myocarditis,
ischaemic heart disease,
infultrative disease
EF >50% Ischaemic cardiomyopathy, Htn, valvulopathy, (not dilated),
anything that stops the heart relaxing, like HOCM, infultrative
diseases like amyloidosis and sarcoidosis, restrictive pericarditis.
Pulmonary oedema,
peripheral oedema,
type one respiratory
failure
causes: AMI, acute valvular regurgiation, myocarditis, arrythmia.
normal pumping heart
cannot meet the damands
of the tissues
anaemia, thyrotoxicosis, pregnancy
causes: RCA disease inferior MI, amyloidosis, increased
afterload: pulmonary hypertension, primary or secondary due to
LV failure, pulmonary valve stenosis, PE.
non-compliance with fluid balance, dont take diuretics and eat
salt
AF can worsen it
Infections, like pneumonia
PE
Anaemia
History
examination
Is this heart failure, ddx inc COPD
and other causes of fluid overload.
How bad is the heat failure
What is the cause of the heart failure
Whats making this worse
peripheral oedema, pulsatile liver, GIT
symptoms, nausea, indigestion.
right heart failure
dysopnea, orthopnea, PND, end organ
perfusion symptoms like fatigue, renal symptoms like nocturia
inthe early stages and then oliguria. cerebral symptoms like
confusion memory impairment or anxiety. angina is common
from ischaemic heart disease. palpitations.
Left heart failure
NYHA heat criteria. 4 classes. 1 no limitation, 2 slight limitation, 3
symptoms on minimil exertion, and class 4 SOB at rest (high 4
year mortality of 64%)
start with general inspection SOB, BMI, swelling, change in colour jaundice, cyanosis or
pallor, pulse resting sinus tachycardia, weak rapid and thready,
AF common in failure. narrow pulse pressure.
JVP: elevated , kausmalls sign JVP goes high when breathing in
due to right ventrcular failure.
Apex beat: displaced to the lateral side.
murmurs: valvulopathy causing heart failure. S3 gallop rhythm in
reduced ejection fraction heart failure after S2 heaps of blood left
in ventricle and causes the 3rd sound. during diastole.
Lungs: crepitations, coarse creps. pleural effusion: stony dull to
percussion can be caused by right heart failure.
Abdomen: tircuspid regurgitation causing liver to be tender adn
pulsatile and can cuase the JVP to increase (hepato jugular reflux)
oedema: in legs, scrotum, ascites, sacral.
peripheral: vasoconstriction, pallor and diaphoresis.
investigations
signs of ischaemia, sinus tachy or AFECG
FBE WCC decomp heart failure, UnE:
hyponatraemia, renal failure acute recomp and assess organ
dysfunction, also need baseline electrolytes, LFTs for RHF,
lactate: indicator of end organ ischaemia, BNP: B type
naturietic peptide from increased wall tension in the artia.
bloods
: differentiate between respa nd cardiac cause. size of
the heart is more than 50% of the chest. interstitial oedema
kerly b lines, peribrnchial cuffing, hazy contour of vessels,
,fluid in the horisotal fissure. air bronchograms, cotton wall
appearance. upper lobe diversion.
CXR
identify the cause and severity of heart fialure.
distinguish between systolic and diastolic. 50-70% EF is
normal. <40 % EF if heart fialure.
ECHO
ultrasound of the vena cava, cardiopulmonary exercise
testing, cardiac biopsy, cardiac MRI.
treatment
symptomatic management
morbidity and mortality
correct systemic facotrs: diabetes, thyrid, anaemia and
arrythmias
lifestyle factors: exercise
Durg review
treat the underlying cause
refractory treatment: LVAD
Smoking cessation, alcohol restriction, salt restriction, weight
loss, daily weights and fluid balance
sodium and water retention, negative
ionotrppy and direct cardiac toxicity.
NSAIDS, anti arrythmics because neg ionotropes, calcium
channel blockers because of neg ionotropic (amlodipine),
chemotherapic agents.
: increased haemodynalic load, aim to decrease
the pre and afterload in heart failure. B blockers, ARBS, ACE
inhibitrs,. and diuretics.
hypertension
: need revascularisationreno vascular stenosis
: MI = dyskenetic wall, and or
ischaemic dysfunction hybernating myocardium. can
revascularise with stents or CABG. pacemakers.
ischaemic heart disease
: repair.valvular disease
diuretics loop is best but thiazides can be used, positive
ionoprope (digoxin) beta blockers, ACEi and ARBs.
digoxin has no survival benefit only symptomatic, diuretics, B
blockers dont start when acute decomp, ace and arbs block
RAAS for fluid overload, hydralisine and nitrates (vasodilators),
spironolactone.
decrease fluid , then ACEi or ARB,
then B blocker, then when optimised can use the other stuff.
reduces hospitalisation.
acute decompensation
decrease the stimulation of the SNS on the
heart. catecholamine are toxic to the heart. the old school
ones were not as good. beta blockers secletion is important.
carbenelol, mesoprolol, lebetolol, metoprolol (slow release)
are the cardioselective ones. survival benefit is increased
when used wih ACEi. contraindicated in asthma, bradycardia
an hypotension and AV block, resting limb ischaemia.
beta blockers
ARBs: useful for those with ACEi cough. end with SARTAN
hydralazine and nitrates: increase vasodilation decrease pre
adn afterload. optimum starling forces on the heart.
digoxin: doesnt reduce mortality, controls symptoms, positive
ionotrope, controls symptoms, reduced hospitalisation, used
as rate control in AF, if they have low BP thenits a good
option.
statins: stops the atherosclerotic process. worsen dementia.
also myalgia side effects.
leads to positive ionopropic effect. and non- dihydro
piridines (non- vasoselective) negative ionopropic. verapimil
and diltiazam might not make better.
vasoselective calcium channel blockers: di hydro
piridine
amlodipine
felodipine
isradipine
nicardipine
nifedipine
nimodipine
nitrendipine
Diuretic
s,
vasodil
ators,p
ositive
ionopro
phic
drugs.
basic
princip
les:
IF ivabridine, SA node blockertachycardiac at rest
