Defenition
failure of the heart to generate sufficient cardiac output to meet metabolic demands of the body
The four ways in which heart failure is classified
- Low-output HF vs High output HF
- Systolic vs Diastolic HF
- Acute vs Chronic HF
- New York Heart Association Classification of HF
How is Low-output HF vs High-output HF defined
Low-output HF
* cardiac output is reduced due to primary problem with the heart, so it cannot meed bodies needs
High-output HF
* heart that has normal cardiac output, but there is an increase in the bodies metabolic demands that the heart cannot meet
Low-output much more common
Causes of high-output HF - 6
AAPPTT mnemonic
Anaemia
Arteriovenous malformation
Paget’s disease
Pregnancy
Thyrotoxicosis
Thiamine deficiency (wet Beri-Beri)
Systolic vs Diastolic Heart failure definition
AKA reduced ejection fraction and preserved EF
Systolic dysfunction - ventricles can fill, but cannot contract sufficiently - reduced ejection fraction
Diastolic dysfunction - ventricles cannot relax and fill normally - preserved ejection fraction
Causes of systolic heart failure /HFrEF - 3
- IHD
- dilated cardiomyopathy
- mycarditis
Causes of diastolic heart failure / HFpEF - 3
- chronic HTN (bcos LV hypertrophy)
- hypertrophoc cardiomyopathy
- cardiac tamponade
New York Heart Association (NYHA) Classification of HF - 4
Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea.
Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea.
Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.
Clinical features of left HF - 8
Causes pulmonary congestion (backup into lungs) and systemic hypoperfusion
- SOB on exertion
- Noctural dyspnoea
- Orthopnoea
- Pink frothy sputum
- fine crackles on lung auscultation
- cyanosis
- long cap refil
- hypotension
Clinical features of right HF - 6
Causes venous congestion and pulmonary hypoperfusion from reduced right heart output
- Ankle swelling and abdo swelling
- Anorexia and nausea
- raised JVp
- pitting oedema
- hepatomegaly
- transudative pleural effusion
Differentials of Heart failure - 4
COPD
ARDS
Renal failure
Liver failure
Investigations
- NT-pro-BNP Level (1st line)
- 12 lead ECG
- Bloods - U and E, LFTs, TFTs, lipid profile, glucose
- CXR
- Echo (looks at ejection fraction)
What are the ranges for BNP when measuring for HF
- below 400 - HF not likely
- 400-2000 - refer in less than 6 weeks
- over 2000 - refer for 2 weeks
What are the EF percentages from an echo that differentiate between HFrEF and HFpEF?
- if EF less than 40% - HFrEF (systolic dysfunction)
- if EF is more than 40% - HFpEF (diastolic dysfunction)
- EF 50%-70% with a normal BNP - normal
What are CXR findings of heart failure - ABCDEF
A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
B: Kerley B lines (caused by interstitial oedema)
C: Cardiomegaly (cardiothoracic ratio >0.5)
D: upper lobe blood diversion
E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure
Conservative management of heart failure - 5
- weight loss
- smoking cess
- salt and fluid restriction
- excercise based group rehab
- annual flu and pneumococcal vaccine
1st line medical Management of Heart failure - 6
1st line for all - Loop Diuretics e.g. fuorosemide
For HFpEF:
* manage co-morbidities
* cardiac rehab programme
For HFrEF
* ACEi and Beta blocker
* Consider ARB if intolerant to ACEi
* Consider hydralazine if intolerant to ACEi and ARB
Medications used if symtoms persist after initial medical management of heart failure - 5
- Aldosterone antagonists = spironolactone or eplerenone.
- Hydralazine and a nitrate for Afro-Caribbean patients.
Others:
- Ivabradine if in sinus rhythm and impaired EF.
- Digoxin = useful in those with AF
- SGLT2 inhibitors - dapgliflozin
What does the BASH mnemonic stand for
Medications that demonstrate mortality benefits in HFrEF:
Beta blockers
AceI
Sprionolactone
Hydralazine
Surgical management of HF
Cardiac resynchronisation therapy
ICDS (implantable cardioverter defibrillator) are indicated if following criteria fulfilled:
QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III
QRS interval 120-149ms without LBBB, NYHA class I-III
QRS interval 120-149ms with LBBB, NYHA class I
