Transcript Heart Failure Presentation

Heart Failure
Dr Nidhi Bhargava
Cardiac Failure
 Clinical
syndrome that can result from any
structural or functional cardiac disorder
that impairs the ability of the ventricle to fill
or eject blood.(AHA/ACC HF guidelines
2001)
 Economic
burden- 1.2-2% of all healthcare
costs and 60-75% of these costs relate to
hospital burden
 NYHA
 All
classes 1-1V
class HF mortality- 50% in 5 years
 NYHA
Class 1V- 1 year survival -50%

NYHA (New York Heart Association Classification)

Class 1 Cardiac disease but no limitation in ordinary physical
activity, e.g. no SOB when walking, climbing stairs etc.

Class 2 Mild symptoms ( mild SOB and or angina) and slight
limitation during ordinary activity

Class 3 Marked limitation in activity due to symptoms, even during
less than ordinary activity , e.g. walking short distances (20-100 m)
Comfortable only at rest.

Class 4 Severe Limitations. Experiences symptoms even at rest.
Mostly bedbound patients
 Causes
of death
40%
Sudden
50% pump failure
30-40%
are in NYHA class 111- 1V
Rehospitalisation rates
 2%
at 2 days
 20% at 1 month
 50% at 6 months
Causes
1.
2.
3.
4.
5.
6.
7.
8.
Myocardial Dysfunction (IHD, DCM)
Volume overload (AR, MR)
Obstruction (AS, MS, HOCM)
Diastolic Dysfunction (Constriction)
Mechanical Problems (LV aneurysm)
Rhythm Disturbance (AF)
High Output (anaemia, shunts, thyrotoxicosis)
IHD and HT-most common disease processes often in
combination causing myocardial damage
Pathophysiology
 Large
MI
CO
BP
Compensatory Mechanisms
Neuroendocrine activation

Renin angiotensin
Aldosterone
Pathophysiology
Neuroendocrine Activation- Increased HR and
contractility
Aldosterone System-Na retention and hence
water retention
Renin angiotensin system- vasoconstriction
Pathophysiology

An increase in LVED volume

Starling’s law- increased LVED volume and hence increased stroke
volume

Hence increased stress on the left ventricular wall- further thinning of
the infarcted wall and expansion of infarcted region

The normal wall can compensate for the rest of infarcted areacompensatory mechanism otherwise LV dilatation and LVSD-worse
than original infarct
Signs and Symptoms of Heart failure

ESC guidelines
 Essential
features-SOB, ankle swelling, objective
evidence of cardiac dysfunction at rest using echo
 Non
essential features- Response to treatment
directed at HF (if diagnosis in doubt)
Symptoms
1.
Exertional Dyspnoea
2.
Orthopnoea
3.
PND
4.
Ankle swelling
5.
Anorexia and wt loss
6.
Cold peripheries
7.
Tiredness
Signs

Tachycardia

Hypotension

Raised JVP

3rd heart sound

PSM of MR

Basal crackles

Ankle oedema
Investigations

ECG- If normal chances of LVSD are very low (<5%)- LBBB, Q waves, non specific
ST/T waves changes

CXR- cardiomegaly, Pulmonary oedema

BNP- elevated in both systolic and diastolic dysfunction, results affected by
obesity, diuretics and ACEi,  blockers, spironolactone-all decerase the levels .
LVH, ischaemia and tachycardia , PE , eGFR < 60, COPD, sepsis will increase the
levels

Echo-confirmatory test- systolic dysfunction/any valvular disease/ischaemic
aetiology or regional wall motion abnormality/diastolic dysfunction

Nuclear imaging

Stress echocardiography

Cardiac catheterisation

Lung function tests
Treatment

Acute HF
 Sit
up, high dose O2, i/v diamorphine, i/v GTN ,
intubation
 Treat
intercurrent infection
 Systolic
BP<80 –poor prognosis
 Ionotropes
to increase BP and help orgn perfusion
Treatment

Chronic HF
 Non
pharmacological- restrict salt and fluid
intake, encourage exercise, decrease or abstain
from alcohol
 Flu
vaccination
 Tight
 Loop
BP control
diuretcis-frusemide 40-80mgs or bumetanide
1-2mgs
Non Coronary Interventions

Pacing- broad QRS+ LBBB

Defibrillators-ventricular arrhythmias

Valvular surgery-Mitral valve repair

Heart Transplant- otherwise fit individuals

Left ventricular assist devices- as a bridge to
transplantation
Treatment

ACEi – improve prognosis and symptoms, optimise dose, slow
titration every 2 weeks with UEs monitoring

ARBs- role not confirmed (to be used if unable to tolerate ACEi)

Hydralazines and nitrates- improve diagnosis and prognosis
(consensus study), first line or 2nd line (NYHA 111-1V), Africo carribean
population

 blockers- Improve prognosis and symptoms. Assess HR and BP at
each titration , use those licensed for HF (even in pts with COPD)

Spironolactone- NYHA 111-1V, monitor K levels and eGFR

Ivabradine- in pts with NYHA class 2-4 stable CHF with systolic
dysfunction, in sinus rhythm, HR ≥ 75/min and given in combination
with other HF treatment or when beta blocker is contraindicated,
LVEF ≤ 35% aftre stabilisation with other treatement for at least 4
Treatment

Rehabilatation- supervised group exercisesrehab programme

Psychological and educational support-role of
community heart failure nurses
CRT (cardiac resynchronisation
therapy)

Moderate to severe LVSD

NYHA 111-1V

No revascularisation or surgery strategy

Stable and optimal medical regime

QRS ≥ 130ms

EF≤ 35%

LVED dimension ≥ 55mm
Case 1

73 years old female

Recent onset of orthopnoea

PMH-HT diagnosed 3 years ago

Medication-atenolol

o/e- b/l basal crepts

? Suspected diagnosis

Tests needed to confirm diagnosis

Treatment
Case 2

71 years old male

P/C- breathlessness and fatigue , gradually worsening

PMH- Type 1 DM, angina

o/e- irregular pulse (possibly AF), low volume

? Heart failure

Tests for confirmation
Case 3

68 years old female

P/C- exertional breathlessness, ankle swelling, cough

PMH- Type 2 DM

o/e- ankle oedema, high BP and 2cms hepatomegaly

? Heart failure

Tests

Treatment
Case 4

80 years old female

P/C- fatigue , weight loss, feels stomach always bloated

PMH-chronic bronchitis

o/e- raised JVP, PSM in the lower sternal edge, 3rd HS, ascites

? Heart failure

Tests
Case 5

62 years old male

P/C- breathlessness and orthopnoea

PMH-COPD

o/e- b/l basal crepitations and tachycardia

? Exacerbation of COPD or possible heart failure

Tests
Case 6

65 years old female of Africo-Caribbean ethinicity

P/C- 3/52 of exertional breathlessness

PMH- Hypertension and obesity

o/e- b/l basal crepitations, laterally displaced apical impulse

? Heart failure

Tests

Treatment

After 6 months pt presents again with worsening breathlessness

Treatment

Pt returns after 4 months with breathlessness at rest
Case 7

57 years old male smoker

P/C- 3/52 cough

PMH- LVSD

Current medication-Bisoprolol 10mgs and Ramipril 7.5mgs

o/e- chest clear , no signs of fluid overload

CXR normal, renal function normal

Review the previous diagnosis of heart failure

Repeat BNP
Case 8

64 years olf female

P/C- 2/7 breathlessness

PMH- HT, STEMI 8/7 treated with PCI

Medications- aspirin 75mgs, clopidogrel 75mgs, atenolol 25mgs,
Ramipril 3.75mgs

o/e- b/l crepts in lower 1/3 of lungs, raised JVP, 3rd HS , normal Ues

Suspected HF secondary to MI

Treatment
Case 8 continued…

Echo- moderately severe systolic dysfunction

Aldosterone antagonist licensed for HF following MI

Eplerenone 25mgs – monitor UE and K levels

Change atenolol to Bisoprolol 1.25mgs

Titrate Bisoprolol once signs of congestion cleared