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Flashcards in Heart Failure Deck (8):
1

What is heart failure?

Heart failure is an inability of the hearts cardiac output to meet the bodies demands. It is categorised in many ways. Most heart failure is low output cardiac failure (The heart isn’t functioning properly), however in some cases high output heart failure occurs (where the heart is functioning normally, but the bodies demands are increased e.g. In pregnancy, hyperthyroidism, Paget’s Disease). These factors causing increased demand on the heart can also precipitate low output heart failure.

The heart can initially compensate for its reduced cardiac output through many mechanisms, these include sympathetic activation of the heart, renin release causing increased Water and Na uptake (due to reduced blood flow to the kidneys), and secretion of ADH, but these all lead to increased workload on the heart itself, worsening the problem. When these mechanisms are overcome, fluid collects in abnormal compartments.

Patients with Heart failure are classified into Preserved Ejection fracture (> 50%), where the heart can contract properly (Problems with relaxing in diastole, or right sided heart failure). Or Reduced Ejection fracture (<50%), where the left side of the heart cannot contract properly in systole. Someone with preserved ejection fracture will not necessarily progress to reduced ejection fracture.

Patients with heart failure can present in acute heart failure (Where preservatory mechanisms are overcome or have not yet been activated) this is normally as the result of another underlying disease process e.g. MI, infection.

Heart failure is a syndrome not a diagnosis. You need to find out the cause of heart failure

2

What are the causes of heart failure?

LHF:
Ischaemic Heart Disease e.g. Previous MI
Dilated cardiomyopathy
Hypertension
Mitral / Aortic Valve Disease
Alcohol
Atrial Fibrillation

RHF:
Chronic Lung Disease (Cor pulmonale) causing back up
PE
Left Heart Failure
Tricuspid / Pulmonary Valve Disease
ASD/VSD

3

What should you ask about in a history for cardiac failure?

Symptoms:
LHF:
Fatigue
Exertional Dyspnoea
Paroxysmal Nocturnal Dyspnoea/Orthopnoea
Nocturnal cough
Frothy Sputum - Pink tinge if any haemoptysis
Cardiac arrest/collapse – In acute heart failure

RHF:
Peripheral oedema - Affecting thighs, sacrum, ankles
Ascites
Fatigue
General Dyspnoea
Anorexia / Nausea
Leg Ulcers - Venous Congestion
Cardiac arrest/collapse – In acute heart failure

Risk factors:
Cardiovascular Risk Factors
Valvular Heart Disease/Rheumatic fever
Congenital heart disease

Specific questions to ask in a history taking:
How many pillows do they sleep with?
Work out NYHA score 
Ask about precipitating factors - Pregnancy, Hyperthyroidism, Paget’s Disease of Bone, Anaemia, Infection

Differentials for the LHF (Breathlessness):
COPD – Similar breathlessness but there will be a wheeze, large smoking history
Chronic pulmonary emboli – Similar breathlessness but will have pleuritic chest pain
Interstitial lung disease - Similar breathlessness but it is not dependant on posture like in HF
Asthma – Similar Nocturnal Cough but Asthmatics will be normal between attacks

Differentials for the RHF (Peripheral Oedema):
Renal Failure/Cirrhosis – Similar Peripheral oedema, but will have underlying risk factors and other symptoms
Bilateral DVT – Similar Peripheral oedema but there will be pain in the legs and risk factors for DVT
Obesity – Patient will be severely obese, may mistake for swelling
Bilateral lymphedema – Compromised lymphatics lead to insufficient lymph drainage

4

What are the signs specific of heart Failure?

LHF:
Hands – Raised Capillary refill time, Pulsus alternans (when the upstroke of the pulse alternates between strong and weak, only seen in severe disease)
Chest – Displaced Apex beat and apical heave (left ventricle hypertrophy), Gallop Rhythm (3rd heart sound heard), Mitral/Aortic Valve Murmur, Crackles at Lung Bases (Pulmonary oedema)
Legs -Dependent Pitting Oedema (Activation of RAAS)

RHF:
Neck – Raised JVP, positive hepatojugular reflex
Chest – Parasternal Heave (Right Ventricular Hypertrophy), Tricuspid/Pulmonary valve murmur
Abdomen – Hepatosplenomegaly, Ascites
Legs – Peripheral Pitting Oedema, check up to the sacrum

Precipitating factors:
End of the bed – Fever (infection)
Hands – Pale palmar creases (anaemia)
Neck – Thyroid Goitre
Face – Pale conjunctiva (Anaemia), Thyroid Eye Disease
Abdomen – Pregnancy

Acute Heart Failure:
End of the bed – Pale, Sweaty, Unwell, Shock
Hands – Tachycardia

5

What scoring system is used for heart failure?

New York Classification

1 - No SOB on ordinary activity, only normal levels on exercise
2 - SOB on ordinary activity
3 - SOB on light activity
4 - SOB at rest

6

What investigations will you order in suspected heart failure?

Bedside:
ECG – Most cases of heart failure will have some ECG changes e.g. Previous MI or ventricular hypertrophy (Large QRS complex’s in the appropriate leads, V1/2 right, V5/6 Left and axis deviation)
Pregnancy Test – Pregnancy can precipitate heart failure
Urinalysis - Looking for any renal failure that may be a cause of the fluid overload
Glucose – Assessing cardiovascular risk

Bloods:
FBC – Anaemia can precipitate heart failure
U&E – Looking for any renal failure that may be a cause of the fluid overload and reflects tissue perfusion
B type Natriuretic Peptide – like a d dimmer for heart failure, good negative predictor.
Lipids – Assessing cardiovascular risk
LFT’s – Congestion/back up from the heart can lead to impaired liver function and to rule out liver failure that can cause fluid overload
TFT’s – Thyroid Problems can precipitate heart failure
ABG - Prognostic value as indicates tissue perfusion
If acute heart failure look for underlying cause – FBC (Looking for infection) Troponin (Looking for MI)

Imaging:
CXR – A – Alveolar Oedema (Bats wings), B – Septal Lines (Kerley B lines), C – Cardiomegaly, D- dilated upper lobe veins, E – Pleural Effusions
Echo – Diagnostic test that can show LV function and may show underlying cause e.g. Valve Dysfunction. Used to categorise the patient into Preserved Ejection fracture (LV ejection fracture > 50%) or Reduced Ejection fracture (LV ejection fracture <50%). This will affect treatment

Special Tests:
Lung Function tests – Can show a restrictive pattern and to rule out other causes of breathlessness
Coronary Angiogram – Can be done if coronary artery disease is suspected cause of HF

7

What is the management of chronic heart failure?

Lifestyle:
Educate about chronic and progressive nature of disease
Reduce Cardiovascular Risk Factors
Optimise Weight/Nutrition
Low salt diet
Cardiac Rehab
Stop any NSAIDS (Predispose to fluid overload) and verapamil (negative inotrope)

Medication:
Preserved Ejection fracture or Right Heart Failure:
1st Line - Loop Diuretic (Furosemide) for symptomatic relief
2nd Line - Add thiazide diuretic if needed

Reduced Ejection fracture:
1st Line - Ace inhibitor (ARB if cannot tolerate) and B-Blocker
2nd Line - Aldosterone receptor antagonist (Spironolactone) or ARB
3rd Line – Hydralazine and a Nitrate
4th Line – Digoxin or a Cardiac Resynchronisation Device
Loop Diuretic - Given for symptomatic control

Surgical:
PCI/CABG – If the cause is coronary artery disease
Valve repair/replacement – If the cause is valvular heart disease
Implanted cardiac pacemaker –Offered if LVF<33% or previous VT/VF (Ventricular arrhythmias due to heart muscle fibrosis are the main cause of death)
Cardiac Resynchronisation device – In patients with heart failure and a Bundle Branch Block
Heart transplant if at end of treatment options

8

What is the management of acute heart failure?

Resuscitation:
A-E approach
Get IV Access (Make sure to only use 250ml Fluid Challenge)/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Assessment with AMPLE history and brief examination
Get help – Cardiology Registrar
Refer to ITU
Frequent Observations – Constant
Sit Patient Upright

Medication:
Morphine (analgesia)
Loop Diuretic – IV Furosemide
BP > 90 – GTN spray only followed by Long IV Acting Nitrate (e.g. Dobutamine) if BP > 100
BP < 90 treat as shock – refer to ICU, may require inotropic support e.g. Dobutamine