what is the definition of heart failure?
inability of the heart to function as a pump and maintain sufficient cardiac output to meet the demands of the body
what % of over 65s have HF?
what is congestive cardiac failure?
both RVF and LVF together. i.e. biventricular. most common form
what are the causes of left ventricular systolic dysfunction?
- ischaemic heart disease: CAD
- systemic hypertension
- cardiomyopathy: dilated so cant contract properly
- mitral and aortic valve disease
what are the causes of diastolic dysfunction?
- OLD AGE
- cardiomyopathy: restrictive or hypertrophic (eg LVH)
- can be due to myocardial infiltration e.g. amyloidosis
what is high output heart failure and what are the causes?
- high output in the face of much increased needs and failure occurs when CO fails to meet these needs
- paget's disease
- AV fistulae
- wet beri beri (thiamine=B1 deficiency
what are the causes of right heart failure?
- secondary to left heart failure usually
- or cor pulmonale
- pulmonary embolism
- pulmonary hypertension
- tricuspid incompetence
what are the SYMPTOMS of left heart failure? and what are they due to?
- PULMONARY CONGESTION
- fatigue, reduced exercise capacity
- exertional dyspnoea
- cardiac wheeze
- nocturnal cough
- pink frothy sputum
- cold peripheries
- weight loss
- muscle wasting
what are the SIGNS of LHF?
- cool skin
- BP: normal/high if hypertensive disease/low
- pulse: low volume, rhythm normal/irregular due to ectopics/AF
- displaced apex beat laterally as LVH
- pulmonary oedema: fine inspiratory crackles, bibasal
- pleural effusion
- third heart sound (gallop) due to rapid filling of ventricles
- functional MR: due to dilatation of mitral annulus
what are the SYMPTOMS of RHF?
- ankle swelling
- dyspnoea (but no orthop or PND)
- reduced exercise capacity
- chest pain as RV pressure rises or RV becomes dilated
what are the SIGNS of RHF?
- peripheral oedema up to thighs, sacrum, abode wall
- abdo distension: ascites
- facial engorgement
- pulsation in neck and face, tender pulsatile liver: tricuspid regurgitation (due to dilatation of RV)
- left parasternal heave due to RV hypertrophy/dilatation
- increased JVP
- tricuspid regurgitation
what are the signs of RHF?
what are the signs of heart failure on examination?
- general: ill, exhausted
- hands: cool peripheries
- pulse: tachycardia, pulsus alternans
- BP: low SBP, wide pulse pressure
- pulse pressure: wide
- JVP: raised
- apex beat: displaced
- heave: RV heave due to pulmonary hypertension
- ausculatation: S3 gallop, murmur (mitral or aortic)
- Chest/lung: tachypnoea, bibasal end insp crackles, wheeze, pleural effusions
- Abdomen: hepatomegaly (pulsatile in TR), ascites
- Peripheral oedema: ankle and sacral
what are the investigations needed to diagnose heart failure?
- Chest x-ray: cardiothoracic ratio > 50%, ABCDE
- ECG: indicate cause eg ischaemia, MI, ventricular hypertrophy
- BNP/NT porBNP raised (normal excludes HF!) do in all dyspnoea
- Echo: confirms if there is LV systolic or diastolic dysfunction. may show cause e.g. valve/regional wall motion abnormal in IHD, CM, pericardial disease/wall thickness
- tests for: anaemia, renal function, thyroid function need to be done
what is a stress echo and what does it assess?
- dobutamine (beta1 agonist) to increase contractility and heart rate
- asses if ischaemia/viability of myocardium
- what is BNP and when is it released?
- brain natriuretic peptide
- released from ventricles in response to dilatation and STRETCH
what ejection fraction defines systolic dysfunction?
what are the CXR signs of heart failure?
- A: alveolar oedema = bat's wings shadowing
- B: kerley B lines - attributed to interstitial oedema as pulmonary venous pressure rises and engorged peripheral lymphatics
- C: cardiomegaly (cardiothoracic ratio > 50%)
- D: dilated prominent upper lobe vessels (upper lobe diversion as lower lobes congested)
- E: pleural effusions
why is exercise testing done in HF?
- myocardial ischaemia
- max O2 consumption (VO2 max) = oxygen consumption does not rise any further despite increasing levels of exertion
- guide: cardiac transplant
why is ambulatory ECG done in HF?
what does radionuclide imaging do?
myocardial perfusion scanning
why should cardiac catheterisation be done?
- determine if CAD - need for aspirin/statins/revascularisation
- RH catheter: RAP, pulm artery pressure, PACWP
what is the NYHA classification of heart failure?
- I: asymptomatic on ordinary activity
- II: comfortable at rest, dyspnoea on ordinary activities
- III: less ordinary activity causes dyspnoea which is limiting
- IV: dyspnoea at rest. all activity causes discomfort
what is the mechanism of disease process in HF?
- 1. poor ventricular function or myocardial damage e.g. post MI or dilated CM
- 2. heart failure
- 3. reduced stroke volume and reduced cardiac output
- 4. kicks of neurohumoral response
- 5. RAAS and activation of sympathetic NS
- 6. vasoconstriction, inc sympathetic tone, AT II release, ET release, reduce NO release,
- 7. Na and water retention due to increased ADH and ado
- 8. further stress on ventricle wall and dilatation due to remodelling
- 9. leads to worsening of ventricular function
which types of arrhythmias can lead to heart failure?
- AF: atrial contraction is lost
- heart block: atrial contraction is dissociated from ventricular contractions
- tachycardias: reduce ventricular filling time, increase myocardial workload and O2 demand --> ischaemia & ventricular dilatation
how are the kidneys involved in pathogenesis of heart failure?
- in heart failure get vascular redistribution of blood to areas vital for IMMEDIATE survival.
- so vasoconstriction to skin, skeletal muscle, gut and kidneys
- reduced renal perfusion - stimulate RAAS
- ATII is powerful vasoconstrictor of renal efferent and systemic arterioles where is stimulates release of NA from sympathetic nerve endings, promotes adrenal release of aldosterone
which part of the nervous system is chronically activated in heart failure and how does this affect function?
- SYMPATHETIC nervous system
- RAAS, salt and water retention, vasoconstriction…
- also chronic sympathetic stimulation results in DOWN REGULATION of cardiac B-receptors --> attenuating hearts usual response to EXERCISE
where are ANP and BNP released from and what are their actions?
- ANP: atria
- BNP: ventricles
- actions: physiological ANTAGONISTS to ATII effects - so cause vasodilation, salt and excretion
what are the effects on the heart of peripheral vasoconstriction?
increased systemic vascular resistance so increased cardiac work and myocardial oxygen consumption
what is cardiomegaly on CXR due to?
- L or R V dilation
- pericardial effusion
What is nutmeg liver? and cause?
- chronic passive venous congestion of liver
- secondary to right heart failure
- or congestive heart failure
normally pleural effusions in HF are bilateral, when would they be unilateral and which side normally?
- if unilateral: RIGHT
- why? high filling pressures so pts find uncomfortable sleeping on left so sleep on right and get a dependent oedema collecting on R
- unilateral left: malignancy!
what is the conservative management of chronic heart failure?
- avoid exacerbating factors: NSAIDs cause fluid retention and verapamil (negative inotrope)
- stop smoking
- eat less salt
- maintain optimal weight and nutrition
- minimise alcohol consumption
which drugs are used for symptom relief in heart failure?
- loop diuretics: fruseminde and bumetanide
- relieve dyspnoea and signs of salt and water retention
- give with spironolactone if low K or predisposed to arrhythmia or concurrent digoxin therapy (as low K increases risk of digoxin toxicity)
when are thiazide diuretics used as well?
- refractory oedema to loop diuretics
- eg metolazone
which drug should be started on in all patients with left ventricular systolic dysfunction?
- ACE inhibitor
- start with low dose and titrate up to max tolerated dose
name 2 side effects of ACEi
- dry cough then change to ATII inhibit
- hypotension with first dose
- renal impairment
- increase K+
when are ACEi contraindicated?
bilateral RAS as ACEi can cause anuria
what are the benefits of beta blockers in HF? and who should use them? give e.g.
- e.g. carvedilol (extra alpha antagonist so reduce BP, good if HTN)
- if STABLE i.e. euvolaemic NOT OVERLOADED. small dose titrate up
- give with ACEi
- they improve symptoms, LV function, reduce sympathetic activation
- so reduce HR --> inc time for diastole and less cardiac energy spending
what are the 3 main first lines drugs for HF?
- diuretics: spironolactone, frusemide
- Beta blocker
if first line drugs dont work, which drug should be tried for HF?
if patient is intolerant to both ACEi and ARB which drug should be used?
hydralazine and isosorbine dinitrate (vasodilators)
what is the management for intractable heart failure?
- reasses CAUSE
- taking DRUGS? compliance?
- at max dose?
- strict bed rest so need DVT prophylaxis (heparin and teds)
- metolazone and iv frusemide (not well absorbed via gut)
- daily weight and U&E (beware low K)
- may need iv inotropes
- heart transplant
what is the management of acute heart failure?
- sit up
- 100% oxygen
- iv access
- monitor ECG
- diamorphine iv: anxiolytic and venodilator and reduce breathlessness
- frusemide iv slowly
- GTN spray 2 puffs. NOT IF SBP < 90
- ventilation if worsening: CPAP
- venesect if worsening
- if sys BP < 100 treat as cardiogenic shock
- ventricular assist device: mechanical pumps that replace work of ventricles, bridge to transplant or to recovery!
what investigations need to be done in acute heart failure suspicion/pulmonary oedema?
- CXR: ABCDE
- ECG: signs of MI
- cardiac enzymes
- plasma BNP
if the patient has AF and heart failure which drugs should they be on?
- digoxin: Na-K ATPase inhibitor, increase Na-Ca exchange so rise in intracellular calcium
what are the device therapies used in HF and when for each one?
- implantable cardioverter defibrillator (ICD): reduce SCD from arrhythmia
- cardiac resynchronisation therapy (CRT): use eg LBBB dyssynchrony, EF<35%, NYHA III/IV, QRS > 15, already on optimal medical therapy
what are the surgical options for HF?
- revascularisation CABG: angina, ischaemic problems
- valve disease
what are the causes of acute heart failure?
- 1. post MI: LVSD or papillary muscle rupture
- 2. arrhythmia
- 3. acute valve regurgitation (mitral or aortic)
- 4. alcohol
- 5. decompensated chronic heart failure
- 6. myocarditis
- 7. thyroid probs
- 8. haemochromatosis
what are the complications of heart failure?
- arrhythmia: AF/ventricular
- thromboembolism: stroke, peripheral embolism, DVT, PE
- GI: hepatic congestion and dysfunction, malab
- Mskel: muscle wasting
- Resp: pulmonary congestion, respiratory muscle weakness, pulmonary hypertension