Heart Failure

• CO and BP that are inadequate for the body’s requirements
• 82% die within 6yr of getting diagnosis

Classification

• LVF and RVF may occur independently or together as congestive cardiac failure (CCF)
• Low output failure
  • Pump failure due to;
    • Heart muscle disease; IHD, cardiomyopathy
    • Restricted filling; constricitive pericarditis, tamponade, restricted cardiomyopathy (this may be the mechamism by which fluid overload causes heart failure as an expanding right heart can impinge on the LV
    • Inadequate heart rate; ?-blockers, heart block, post MI
    • Negative ionotropic drugs; most antiarrhythmic drugs
  • Excessive preload
    • Mitral regurgitation
    • Fluid overload
  • Chronic excessive afterload
    • Aortic stenosis
    • Hypertension
• High output failure – when there are increased needs that the heart fails to meet
• Causes
• Pregnancy
• Anaemia
• Thyrotoxicosis
• Pagets disease
• AV malformations
• Beri beri
• Initially associated with features of RHF and later LHF

Symptoms

• LHF;
  • Dyspnoea
  • Poor exercise tolerance
  • Fatigue
  • Orthopnoea, PND
  • Nocturnal cough, wheeze (cardiac asthma)
  • Cold peripheries
  • Weight loss, muscle wasting
• RHF
  • Peripheral oedema
  • Abdominal distension
  • Nausea, anorexia
  • Facial engorgement
  • Pulsation in the neck and face

Signs

• Patient looks ill and exhausted, cool peripheries, peripheral cyanosis
• Pulse – resting tachycardia, pulsus alternans
• Reduced systolic BP, narrow pulse pressure, raised JVP
• Praecordium – displaced apex (LV dilatation), RV heave (pulmonary hypertension)
• Ausculation S3 gallop, murmurs of the aortic or mitral area
• Chest – tachypnoea, bibasal end inspiratory crackles, wheeze, pleural effusions
• Abdomen – hapatomegaly (pulsatile), ascites

Investigations

• If ECG and BNP are normal, heart failure is unlikely
• If either is abnormal then ECHO is required
• Bloods;
  • FBC, U&Es, BNP
• CXR
  • Cardiomegaly, prominent uupper lobe veins (upper lobe diversion), peribronchial cuffing, diffuse interstitial or alveolar shadowing, perihilar ‘batwing’ shawdowing, fluid in the fissures, pleural effusions, Kerley B lines (due to interstitial oedema) and engorged peripheral lymphatics
• ECG – may indicate cause;
  • Ischaemia, MI, ventricular hypertrophy

CXR in LVF;

• A – Alveolar oedema (bat wings)
• B – Kerley B lines
• C – cardiomegaly
• D – Dilated prominent upper lobe vessels
• E – Pleural effusion

New York classification of Heart Failure

• • • I – heart disease present, but no undue dyspnoea from ordinary activities
    • II – comfortable at rest, dyspnoea on ordinary activities
    • III – less than ordinary activity causes dyspnoea which is limiting
    • IV – dyspnoea present at rest, all activity causes discomfort

Management

Acute heart failure

• Medical emergency see below

Chronic heart failure

• Treat cause or exacerbating factors
• Avoid exacerbating factors – NSAIDs (cause fluid retention), verapamil (negative ionotrope)
• Lifestyle – diet, stop smoking, limit salt, exercise
• Drugs;
  • Diuretics
    • Loop diuretuics used to relieve symptoms e.g. furosemide 40mg/24hr PO (SE – ?K+. renal failure)
    • Monitor U&Es and add spirinolactone if K+ <3.2mmol/L
    • If refractory oedema consider adding a thiazine e.g. metolazone 5-20mg/24hr
  • ACEI
    • Consider in all patients with LV systolic dysfunction
    • If cough use angiotensin receptor antagonist e.g. candesartin
  • ?-Blockers
    • E.g. carvedilol
    • Recent RCTs show they reduced mortality
    • Should be initiated after diuretics and ACEI
    • Use with caution, start low and go slow
  • Spironolactone
    • RALES trial showed it reduced mortality by 30% when added to conventional therapy
    • Initiate in patients who remain symptomatic despite optimal therapy listed above
    • It improves endothelial function and presents remodelling
  • Digoxin
    • Improves symptoms even in those who are in sinuns
    • Use if symptoms are controlled by diuretics, ACEI and ?-blocker or the patient is in AF
    • Does is 0.125-0.25mg/24hr. monitor U&Es and watch for K+ rising
  • Vasodilators
    • The combination of hydralazine and isosorbide dinitrate should be used in those intolerant of ACEI or ARB
    • It also reduces mortality in Black patient with HF

ACE-I

• Contraindications/cautions;
  • Renal failure
  • Hyperkalaemia, hyponatraemia
  • Hypovolaemia, hypotension
  • Aortic stenosis or LV outflow tract obstruction
  • Pregnancy or lactation
  • Severe COPD or cor pulmonale
  • Renal artery stenosis
• SE;
  • Hypotension – tell patient to take the first dose before going to bed
  • Dry cough
  • Taste disturbance
  • Hyperkalaemia
  • Renal impairment
  • Urticaria and angioneurotic oedema
• If patient has heart failure start ACEI under hospital supervision e.g. lisinopril 30-40mg/day
• If patient has hypertension they can be started s an outpatient e.g. lisinopril 10mg/day (elderly 2.5mg)      

Emergency management of severe pulmonary oedema

• Causes;
  • Cardiovascular – usually LVF post MI or ischaemia disease also mitral stensosi, arrhythmias and malignant hypertension
  • ARDS
  • Fluid overload
  • Neurogenic e.g. head injury

Difficult to distinguish pneumonia, COPD/asthma and pulmonary oedema – therefore start all 3 treatments at once – salbutamol nebuliser, furosemide IV, diamorphine and amoxicillin

• Sit patient upright
• 100% O2 if no pre-existing lung disease
• IV access and monitor ECG – treat any arrhythmias
• Investigations whilst continuing treatment;
  • CXR
  • ECG
  • U&E’s cardiac enzymes, ABG
  • ECHO
  • Plasma BNP if diagnosis is in question
• Diamorphine 2.5-5mg IV slowly (caution in liver failure and COPD)
• Furosemide 40-80mg IV slowly (larger doses required in renal failure)
• GTN spray 2 puff sublingual or 2 x 0.3mg tablets sublingual (don’t give is systolic <90mmHg)
  • Nitrates reduces pre and after load and are coronary artery dilators
• Necessary investigations, history, examination
• If systolic >100mmHg start nitrate infusion e.g. isosorbide dinitrate 2-10mg/hr
• If patient is worsening give further dose of furosemide 40-80mg and get help
• If systolic <100mmHg, treat as cardiogenic shock i.e. consider a Swan-Ganz catheter and inotropic support                                                                                   

• If patient fails to improve consider other diagnosis;
• Hypertensive heart failure, aortic dissection, PE, pneumonia

• Monitor progress via;
  • BP
  • Heart rate
  • Cyanosis
  • RR
  • JVP
  • Urine output
  • ABG

• Once stable and improving;
  • Weight daily, BP and pulse every 6hr. repeat CXR
  • Change to oral furosemide or bumetanide
  • If on large doses of loop diuretic then consider the addition of a thiazide
  • ACEI if LVF
  • Also consider ?-blocker and spironolactone
  • Is the patient suitable for heart transplant
  • Consider digoxin and warfarin especially if in AF

Emergency Management of Cardiogenic shock

• Caused primarily by the failure of the heart to maintain the circulation
• Has a high mortality
• Causes;
  • MI
  • Arrhythmias
  • PE
  • Tension pneumothorax
  • Cardiac tamponade
  • Myocarditis – myocardial depression (drugs, hypoxia, acidosis, sepsis)
  • Valve destruction (endocarditis)
  • Aortic dissection

Management

• If the cause if MI prompt revascularisation
• Oxygen
• Diamorphine 2.5-5mg
• Investigations and close monitoring
• Correct arrhythmias, U&E abnormalities or acid-base disturbances
• Optimise filling pressure – measure pulmonary capillary wedge pressure (PCWP)
  • If PCWP is <15mmHg give a plasma expander 100ml every 15mins IV, aim of a PCWP of 15-20mmHg
  • If PCWP >15mmHg consider ionotropic suppose e.g. dobutamine 2.5-10?g/kg/min IVI. Aim for a systolic of 80mmHg
• Consider ‘renal dose’ dopamine 2-5?g/kg/min (via central line only)
• Consider intra-aortic balloon pump if you expect the underlying condition to improve or you need time awaiting surgery
• Look for and treat any reversible cause; MI or PE – consider thrombolysis. Surgery for acute VSD, mitral or aortic incompetence

Monitor

• CVP, BP, ECG, urine output
• Swan-Ganz catherter for pulmonary wegde pressure and CO
• Arterial line to monitor pressure
• Catheterise for accurate urine output

Cardiac tamponade

• Causes;
  • Trauma
  • Lung/breast cancer
  • Pericarditis
  • MI
  • Bacteria e.g. TB
  • Rarely – raised urea, readitation, myxoedema, dissecting aorta, SLE
• Signs;
  • Falling BP, rising JVP and muffled heart sounds (Beck’s traid)
  • JVP raised on inspiration (Kussmaul’s sign)
  • Pulsus paradoxus (pulse fades on inspiration)
  • CXR
    • Globular heart
  • ECG
    • Electrical alterans
• Management
  • Pericardiocentesis
  • Whilst awaiting this give O2, monitor ECg, set up IVI. Take blood for group and save