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Transcript
By Dr. Figgins & Dr. Gausden HEART FAILURE HEART FAILURE IS…. Clinical syndrome resulting from inadequate cardiac output for the body’s needs. THREE COMPONENTS… Left heart failure Right heart failure Congestive cardiac failure Low output • Excessive pre-load • Pump failure Heart muscle disease Restricted filling Inadequate heart rate Negatively inotropic drugs • Excessive afterload High output (rare) Isolated RHF PATHOPHYSIOLOGY Inadequate CO stimulates compensatory mechanisms resembling response to hypovolaemia Initially beneficial, becoming maladaptive PATHOPHYSIOLOGY DECOMPENSATE HEART FAILURE Arrhythmias (e.g. AF) Drug issues (e.g. non-compliance) Anaemia Infection (pneumonia, UTI) Thyroid disease LEFT HEART FAILURE Symptoms? Signs? THIRD AND FOURTH HEART SOUNDS RIGHT HEART FAILURE SYMPTOMS? SIGNS? New York heart failure classification I = Cardiac disease but NO SYMPTOMS in ordinary physical activity II = MILD SYMPTOMS and slight limitation during ordinary physical activity III = Marked limitation in activity due to symptoms during LESS-THAN-ORDINARY ACTIVITY IV = Severe limitations. Experiences symptoms at even AT REST INVESTIGATIONS BEDSIDE TESTS BLOOD TESTS IMAGING SPECIAL TESTS BNP Protein secreted from ventricles of the heart In response to overstretching of cardiomyocytes High NEGATIVE predictive value (98%) Used to RULE OUT heart failure, not rule in Non-specific HF CXR Alveolar oedema Kerley B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels Effusions ECHOCARDIOGRAM 2 types Valves LV systolic/diastolic Fx Aorta LVEF MANAGEMENT OF ACUTE HEART FAILURE Assess Loop ABCDE diuretics IV - furosemide Morphine IV - slowly Nitrates – avoid if hypotensive Oxygen – 100% NRBM Position upright MANAGEMENT OF CHRONIC HEART FAILURE CONSERVATIVE Mx CARDIAC REHABILITATION For pts with IHD, HF or recent cardiac surgery Available at local hospitals Education Emotional support Physical fitness 4 stages MEDICAL MANAGEMENT OF CHRONIC HF Recommended by NICE if reduced ejection fraction 1st line = ACE-INHIBITORS (or ARBs) + BETA-BLOCKERS 2nd line = add in ARB or spironolactone or hydralazine 3rd line = digoxin *patients with fluid overload should receive diuretics* AVOID CARDIO-SELECTIVE CALCIUM CHANNEL BLOCKERS SURGICAL MANAGEMENT OF CHRONIC HF CLINICAL SCENARIO TIME Mr Meldrew 61 years old 3/12 Hx of malaise, increasing SOB and ankle swelling Now SOB walking upstairs PMHx: HTN, MI in 2008 80 pack year smoking Hx Any other questions? DIFFERENTIALS?? DIFFERENTIALS?? CARDIAC Valvular heart disease Coronary artery disease Left ventricular failure RESPIRATORY Infection Inflammation Neoplastic Degenerative OTHER Anaemia Anxiety INVESTIGATIONS? INVESTIGATIONS? BEDSIDE BLOODS IMAGING SPECIAL *EMERGENCY* Mr Meldrew attends A&E severely SOB He can hardly talk You are the FY1 in ED sent to clerk him – what do you do? EMERGENCY OVER… How will you manage him long term now he is stable? EXPLANATION STATION REFERENCES www.merckmanuals.com Nice Guidelines. Chronic Heart failure (2010). Patrick Davey. Medicine at a Glance (2010). Blackwell publishing http://www.medindia.net/patients/patientinfo/Co ngestive-Heart-Failure.htm The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256.