How do you assess if a patient has acute heart failure?
- Clinical exam
- Standard investigations (see CHF)
- Single measurement of serum natriuretic peptides (ruled out if B-type natriuretic peptide less than 100 ng/litre or N-terminal pro-B-type natriuretic peptide less than 300 ng/litre.)
- Perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities
What assessments do you do if you suspect a patient has chronic heart failure?
- Suspected heart failure and previous MI referred urgently to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.
- Measure serum natriuretic peptides if no previous MI
- ECG and further rests for aggravating factors
What can impact levels of serum natiuretic peptides?
- Obesity
- Diuretics
- ACEIs
- ß blockers
- ARBs
What can a transthoracic doppler 2D echocardiography potentially do when assessing heart failure?
- Exclude important valve disease
- Assess the systolic (and diastolic) function of the (left) ventricle
- Detect intracardiac shunts.
What is the initial pharmacological and non-pharmalogical treatment for acute heart failure? What is the aim of this?
- IV diuretics (normally loop)
- non-invasive ventilation if cardiogenic pulmonary oedema with severe dyspnoea and acidaemia
- Aim is to stabilise
What is the treatment after stabilisation of acute heart failure?
- ß blockers
- ACEIs and aldosterone antagonists
- Valve replacement (if aortic stenosis)
What is the non-surgical management of chronic heart failure?
- Lifestyle advice
- Diuretics
- CCBs - amlodipine (not others)
- Amiodarone (consult with specialist)
What surgical procedures can be offered for chronic heart failure?
- Coronary revascularisation - with angina
- Partial left ventriculectomy
What is the treatment route for patients with chronic heart failure due to left ventricular systolic dysfunction?
- First line - ACEIs (can use ARB as alternative) and ß blockers
- Second line - aldosterone antagonist, hydralazine with nitrate
- Third line - digoxin, ivabradine
- Can use ICDs
Give an overview of what heart failure is and the types.
- Congestive cardiac failure (CCF) syndrome - not one disease
- Due to low cardiac output in most cases
- Left, right, mixed
- Acute (especially LVF), chronic
- Signs and symptoms due to fluid retention
What are the main causes of L sided heart failure?
- IHD - MIs
- Cardiomypoathy
- Valvular disease
What are the main causes of R sided heart failure?
- Often secondary to R sided heart failure (often mixed)
- Cor pulmonale
- Congenital heart disease
What are the symptoms of L heart failure?
- Dyspnoea on exertion/rest
- Orthopnea
- Paroxysmal nocturnal dyspnoea
- Pulmonary oedema (sudden dyspnoea, pink frothy sputum
What are the physical exam signs of L sided heart failure?
- Tachycardia
- Fine crepitations
- Pleural effusion
- S3 (gallop rhythm = S3 + tachycardia)
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What are the CXR findings for L sided heart failure?
- Cardiomegaly
- Bat wing shadows - especially lower zones
- Interstitial fluid
What are the symptoms and signs of R sided heart failure?
Symptoms
- Oedema
Signs
- Oedema (ankle/sacral)
- JVP elevated (>4cm above sternal angle)
- Hepatomegaly
- Ascites
What are the CXR findings of R sided heart failure?
- None
What three causes of heart failure require specific therapies?
- Cor Pulmonale - Rx diuretics and oxygen only
- Valvular Disease - Surgery ideally
- Fast AF - Digoxin or DC shock
What is the acute LVF instant pathway?
- Sit up
- Oxygen
- IV furosemide
- IV diamorphine (not in COPD)
What are the stages of the New York Heart Association functional classification of Heart Failure?
- Class I - No limitation
- Class II - Slight limitation of ordinary activity
- Class III - Marked limitation of less than ordinary activity
- Class IV - Severe limitation of minimal activity or at rest
