Download Heart failure

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.
