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Heart failure

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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Heart failure

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  1. By Dr. Figgins & Dr. Gausden Heart failure

  2. Clinical syndrome resulting from inadequate cardiac output for the body’s needs. Heart failure is….

  3. Left heart failure Right heart failure Congestive cardiac failure THREE COMPONENTS…

  4. 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

  5. Inadequate CO stimulates compensatory mechanisms resembling response to hypovolaemia • Initially beneficial, becoming maladaptive Pathophysiology

  6. Pathophysiology

  7. Arrhythmias (e.g. AF) Drug issues (e.g. non-compliance) Anaemia Infection (pneumonia, UTI) Thyroid disease Decompensate heart failure

  8. left Heart Failure Symptoms? Signs?

  9. third and fourth heart sounds

  10. Right Heart Failure SYMPTOMS? SIGNS?

  11. 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

  12. INVESTIGATIONS • BEDSIDE TESTS • BLOOD TESTS • IMAGING • SPECIAL TESTS

  13. 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

  14. Hfcxr • Alveolar oedema • KerleyBlines (interstitial oedema) • Cardiomegaly • Dilated upper lobe vessels • Effusions

  15. ECHOCARDIOGRAM • 2 types • Valves • LV systolic/diastolic Fx • Aorta • LVEF

  16. MANAGEMENT OF ACUTE HEART FAILURE • Assess ABCDE • Loop diuretics IV - furosemide • Morphine IV - slowly • Nitrates – avoid if hypotensive • Oxygen – 100% NRBM • Position upright

  17. MANAGEMENT OF CHRONIC HEART FAILURE • CONSERVATIVE Mx

  18. CARDIAC REHABILITATION • For pts with IHD, HF or recent cardiac surgery • Available at local hospitals • Education • Emotional support • Physical fitness • 4 stages

  19. 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

  20. SURGICAL MANAGEMENT OF CHRONIC HF

  21. 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?

  22. DIFFERENTIALS??

  23. DIFFERENTIALS?? • CARDIAC • Valvular heart disease • Coronary artery disease • Left ventricular failure • RESPIRATORY • Infection • Inflammation • Neoplastic • Degenerative • OTHER • Anaemia • Anxiety

  24. investigations?

  25. investigations? • BEDSIDE • BLOODS • IMAGING • SPECIAL

  26. *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?

  27. Emergency over… • How will you manage him long term now he is stable?

  28. Explanation station

  29. 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

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