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Heart failure – DR DEACPIMP
Definition
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The heart can no longer work adequately to maintain sufficient tissue perfusion for normal
metabolism
Can be split into left and right heart failure – but in reality they occur together (congestive
heart failure)
Can be split into systolic and diastolic heart failure
Risk factors
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Strong
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o
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Weak
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Hypertension
Coronary artery disease (atherosclerosis)
Previous MI
Congenital heart defects
COPD
Diabetes
Age
Male
Renal insufficiency
Cardiac hypertrophy
Family history
Obesity
Tachycardia
High salt/coffee diet
Smoking
Alcohol intake
Low SES
Differential diagnosis
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COPD
Pneumonia
PE
Cirrhosis
DVT
Pericardial disease/infection
Venous stasis
Epidemiology
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1 – 2% prevalence in western world
5-10 per 1000 incidence per year in UK
5% of emergency admissions
Men more than women
Deaths is increasing
o More people are getting CHF
o
Less people are dying of MI, so go on to get heart failure
Aetiology
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Cardiovascular causes
o Hypertension
o Previous MI
o Coronary artery disease/coronary heart disease
o Congenital heart disease
o Cardiomyopathy (dilative)
o Valvular heart disease
o Myocarditis
o Pericardial disease
Endocrine imbalance
o Diabetes
o Thyroid disease
o Acromegaly
o Phaeochromcytoma
Pulmonary
o COPD (cor pulmonale)
Toxin induced
o Heroin
o Cocaine
o Alcohol
o Amfetamine
Infiltrate disease
o Amyloidosis
o Sarcoidosis
o Haemochromatosis
Systemic vascular disease
o Lupus
o Rheumatoid arthritis
o Systematic sclerosis
Electrolyte imbalance
o Hypocalcaemia
o Hyponatremia
o Hypokalemia
o Hypophosphatemia
Infection
Drug induced
o Sulfonamides
Clinical features
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Right and left sided heart failure almost always occur together – but in terms of cause, can
split into right and left heart failure
Left heart failure
o Signs of pulmonary congestion
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o Dry cough
o Crackles
o SOB
o Tachypnoea
o Hypertension
o Paroxysmal nocturnal dyspnoea
o Orthopnoea
o Pleural effusion
Right heart failure
o Dependent oedema (legs, sacrum)
o Raised JVP
o Abdominal distention (ascites)
o Hepatomegaly
o Splenomegaly
o Anorexia/nausea
o Nocturnal diuresis
o Swelling of hands
o Hypertension
General
o Cardiomegaly
o Fatigue
o Chest pain (may go with pleural effusion/pulmonary oedema)
o Murmur (eg mitral regurgitation - systolic)
Pathophysiology
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Remodelling can occur as a result of serious injury
o MI, cardiomyopathies, hypertension, valvular heart defects
o Prevents normal contraction of the heart muscle
Mitral regurgitation
o May result from remodelling
o Inability of mitral valve to close fully, allowing blood to lead back in during systole
o Back-leak increases the volume load on the left ventricle and contributes further to
remodelling (hypertrophy, dilatation)
ANP released in response to atrial stretch
BNP released in response to ventricular stretch
Investigations
 Apex beat displacement
 Echocardiogram (may also do intra-oesophageal)
o May see dilatation (systolic heart failure)
o Hypertrophy (diastolic heart failure)
o Can measure ejection fraction (low in systolic heart failure)
 ECG
o Can measure hypertrophy by height of QRS complexes
o V2 + the higher of V4&V5 > 37mm
 CXR
o May show cardiomegaly
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o Pulmonary oedema
o Pleural effusion
BNP elevation
Cardiopulmonary exercise tolerance test
Management – UPDATE NEEDED ON DRUGS
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Low sodium diet
Fluid restriction (especially in hospital) and daily weight monitoring
Exercise
ACE inhibitors – reduces BP, so reduces afterload and the amount of work the heart needs to
dp
Beta blockers – reduces contractility and heart rate, reducing the amount of work needed
o Not to be given in acute failure
Aldosterone antagonists (potassium-sparing diuretics) – reduce BP, so reduced afterload
o Can cause hyperkalemia
o Eg spironolactone
Diuretics
o Lower BP
o Fast acting – can reduce pulmonary oedema in hours
Digoxin
o Positive ionotrope
o Inhibits Na/K pump (which increases Na and Ca exchange, so intracellular calcium is
increased - to increase contractility
o Doesn’t improve survival
Prognosis
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Poor prognosis
Depends on stage
o Lower stages have about 10% 1-year risk of mortality
o Higher stages have 40-60% 1-year risk of mortality