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By Dr. Figgins & Dr. Gausden. Heart failure. Clinical syndrome resulting from inadequate cardiac output for the body’s needs . Heart failure is…. Left heart failure Right heart failure Congestive cardiac failure. THREE COMPONENTS…. Low output Excessive pre-load Pump failure
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By Dr. Figgins & Dr. Gausden Heart failure
Clinical syndrome resulting from inadequate cardiac output for the body’s needs. Heart failure is….
Left heart failure Right heart failure Congestive cardiac failure THREE COMPONENTS…
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
Inadequate CO stimulates compensatory mechanisms resembling response to hypovolaemia • Initially beneficial, becoming maladaptive Pathophysiology
Arrhythmias (e.g. AF) Drug issues (e.g. non-compliance) Anaemia Infection (pneumonia, UTI) Thyroid disease Decompensate heart failure
left Heart Failure Symptoms? Signs?
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
Hfcxr • Alveolar oedema • KerleyBlines (interstitial oedema) • Cardiomegaly • Dilated upper lobe vessels • Effusions
ECHOCARDIOGRAM • 2 types • Valves • LV systolic/diastolic Fx • Aorta • LVEF
MANAGEMENT OF ACUTE HEART FAILURE • Assess ABCDE • Loop 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
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?? • CARDIAC • Valvular heart disease • Coronary artery disease • Left ventricular failure • RESPIRATORY • Infection • Inflammation • Neoplastic • Degenerative • OTHER • Anaemia • Anxiety
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?
www.merckmanuals.com • Nice Guidelines. Chronic Heart failure (2010). • Patrick Davey. Medicine at a Glance (2010). Blackwell publishing • http://www.medindia.net/patients/patientinfo/Congestive-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. References