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Cardiac Failure

Cardiac Failure. Richard Price Consultant, Intensive Care, RAH. Objectives. Overview of terminology Pathophysiology of cardiac failure Clinical features, x-rays and echos Outline of acute and chronic treatments. Cardiac failure.

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Cardiac Failure

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  1. Cardiac Failure • Richard Price • Consultant, Intensive Care, RAH.

  2. Objectives • Overview of terminology • Pathophysiology of cardiac failure • Clinical features, x-rays and echos • Outline of acute and chronic treatments

  3. Cardiac failure • A clinical syndrome with signs and symptoms of congestion and circulatory failure

  4. Epidemiology • Prevalence 10% in >65 years • 2% of general medical admissions • In US is the most common cause of hospitalisation in > 65 years • Mortality 60% at 5 yrs post diagnosis • Is as ‘malignant’ as the most common causes of cancer

  5. Terminology • Acute heart failure • Chronic Heart Failure • Decompensated CHF • (Right heart failure and high output failure)

  6. Terminology • LV dysfunction • Systolic dysfunction • (abnormal contraction) • Diastolic dysfunction • (abnormal relaxation)

  7. Aetiology • Coronary artery disease • Hypertension • Valvular heart disease • Cardiomyopathies eg viral, alcoholic, septic

  8. Performance Sympathetics Normal Failing Preload

  9. Performance Higher pressure needed for the same performance P1 P2 Preload

  10. Performance Sympathetics Normal Failing Afterload

  11. Performance Less able to cope with afterload Afterload

  12. CO R-A-A SNS Na+ Vasoconstriction Afterload Preload

  13. Oedema • Downstream pressure • Colloid osmotic pressure • Lymphatic drainage • Capillary Leak

  14. Clinical presentation • Short of breath • Hypoxaemia • Tachycardia • Bilateral lung crepitations • Peripheral Oedema - takes time • Hypotension, ⇓ peripheral perfusion

  15. Investigations • ECG • CXR • Basic bloods • Echocardiography

  16. Fluid in the fissure Perihilar congestion Large Heart

  17. Management • Acute • O2 • IV opiates • IV diuretics • IV nitrates • CPAP • Cardiogenic shock • Inotropes • Balloon pumping • Ventilation

  18. CPAP • First described in: Lancet 1936; II: 981 • Meta-analysis: Lancet 2006; 357: 1155 • 3CPO study - NEJM 2008; 359: 142 • no mortality difference at 7 days vs standard care • Hypoxic despite medical therapy - CPAP • NIV - probably no benefit over CPAP

  19. ECG Monitoring CVP Line Peribronchiolar cuffing

  20. Pleural effusion

  21. Chronic Management • Diuretics • ACE Inhibitors • β-blockers • Spironolactone • Digoxin

  22. Chronic Management • Diuretics • ACE Inhibitors • β-blockers • Spironolactone • Digoxin Reduce symptoms Decrease mortality, improve ejection fraction, improve symptoms Decrease mortality with severe disease May reduce hospitalisation

  23. Cardiac resynchronisation Defibrillators (ICD) Assist Devices (LVAD)

  24. Severe ARDS

  25. Summary A clinical syndrome due to variable pathology Physiological response leads to further deterioration Investigations aimed at diagnosis and aetiology Treatment aims to reverse the cause and reduce preload and afterload Common, serious and often progressive

  26. Further reading • McMurray JJV. Systolic heart failure. New England Journal of Medicine 2010; 362: 228.

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