Heart failure.txt

inability of the heart to function as a pump and maintain sufficient cardiac output to meet the demands of the body

10%

both RVF and LVF together. i.e. biventricular. most common form

• ischaemic heart disease: CAD
• systemic hypertension
• cardiomyopathy: dilated so cant contract properly
• myocarditis
• mitral and aortic valve disease

• ischaemic
• hypertension
• OLD AGE
• cardiomyopathy: restrictive or hypertrophic (eg LVH)
• can be due to myocardial infiltration e.g. amyloidosis

• high output in the face of much increased needs and failure occurs when CO fails to meet these needs
• anaemia
• thyrotoxicosis
• paget's disease
• pregnancy
• AV fistulae
• wet beri beri (thiamine=B1 deficiency

• secondary to left heart failure usually
• or cor pulmonale
• pulmonary embolism
• pulmonary hypertension
• tricuspid incompetence

• PULMONARY CONGESTION
• fatigue, reduced exercise capacity
• exertional dyspnoea
• orthopnoea
• PND
• cardiac wheeze
• nocturnal cough
• pink frothy sputum
• nocturia
• cold peripheries
• weight loss
• muscle wasting

• cool skin
• BP: normal/high if hypertensive disease/low
• tachypnoea
• 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

• ankle swelling
• dyspnoea (but no orthop or PND)
• reduced exercise capacity
• chest pain as RV pressure rises or RV becomes dilated

• 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)
• hepatomegaly
• epistaxis
• left parasternal heave due to RV hypertrophy/dilatation
• increased JVP
• tricuspid regurgitation

increased JVP

• 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

• 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

• 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

<45%

• 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

• myocardial ischaemia
• max O2 consumption (VO2 max) = oxygen consumption does not rise any further despite increasing levels of exertion
• guide: cardiac transplant

arrhythmias

myocardial perfusion scanning

• determine if CAD - need for aspirin/statins/revascularisation
• RH catheter: RAP, pulm artery pressure, PACWP

• 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

• 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

• 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

• 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

• 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

• ANP: atria
• BNP: ventricles
• actions: physiological ANTAGONISTS to ATII effects - so cause vasodilation, salt and excretion

increased systemic vascular resistance so increased cardiac work and myocardial oxygen consumption

• L or R V dilation
• LVH
• pericardial effusion

• chronic passive venous congestion of liver
• secondary to right heart failure
• or congestive heart failure

• 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!

• avoid exacerbating factors: NSAIDs cause fluid retention and verapamil (negative inotrope)
• stop smoking
• eat less salt
• maintain optimal weight and nutrition
• minimise alcohol consumption

• 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)

• refractory oedema to loop diuretics
• eg metolazone

• ACE inhibitor
• start with low dose and titrate up to max tolerated dose

• dry cough then change to ATII inhibit
• hypotension with first dose
• renal impairment
• increase K+

bilateral RAS as ACEi can cause anuria

• e.g. carvedilol (extra alpha antagonist so reduce BP, good if HTN)
• bisoprolol
• 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

• diuretics: spironolactone, frusemide
• ACEi
• Beta blocker

• digoxin
• monitor K+

hydralazine and isosorbine dinitrate (vasodilators)

• reasses CAUSE
• taking DRUGS? compliance?
• at max dose?
• admit
• 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

• 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!

• CXR: ABCDE
• ECG: signs of MI
• U&E:
• cardiac enzymes
• ABG
• echo
• plasma BNP

• digoxin: Na-K ATPase inhibitor, increase Na-Ca exchange so rise in intracellular calcium
• warfarin

• 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

• revascularisation CABG: angina, ischaemic problems
• valve disease

• 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

• 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