LVF

Question 1

LVF What is it? How does it Cause Congestion?

Answer 1

• It is one of the types of heart failure which affects the left ventricle. It is unable to contract strongly enough to force the blood into the aorta
• Failure of the left ventricles leads to poor ventricular contractions and therefore blood is backed into the lungs
• AAR this increases pulmonary vein hydrostatic pressure causing fluid to enter the alveoli (oedema) which reduces the gas exchange
• This can back up through the right side of the heart and eventually cause systemic venous congestion

Question 2

Chronic vs Acute Heart Failure

Answer 2

Chronic heart failure is a long term condition which can develop from multiple causes eg age and co-morbidities. Acute heart failure can arise from another syndrome eg ACs or develop from a pre -existing heart failure diagnosis. Acute heart failure represents a decompensating patient.

Question 3

Causes of AHF

Answer 3

• MI
• Hypertension
• ACS
• Disease of the mitral valve
• Bradyarrhythmia’s/tachyarrhythmias eg AF, VT
• Infection
• Drugs and toxic substances
• PE
• Chest trauma

Question 4

What happens to the Heart in LVF

Answer 4

• LVF effects the hearts ability to effectively pump blood from the left ventricle is affected. as a result, the ejection fraction of the left ventricle can fall from 60-40%. Meaning the heart must work harder to pump the same volume of blood
• The ventricle wall structure can be altered due to complications causing hypertrophy (thickening of the walls), inflammation of the walls

Question 5

Complications from LVF

Answer 5

• Pulmonary Oedema
• Heart valve complications - increased pressures in the heart disrupting blood flow
• Kidney damage - kidneys receive less blood which may lead to kidney failure
• Liver damage - fluid backing up from the heart can put pressure on the liver

Question 6

Signs and Symptoms of Normal LVF

Answer 6

• Dysponea
• Worsening cough
• Worsening breathlessness at night
• Fine crackles/expiratory wheeze
• White/pink frothy sputum
• Peripheral oedema
• Abdominal Ascites
• Capnography - elevated CO2 retention, can sometimes see a tombstone shape that indicates the LVF is severe and they could be going into/in cardiogenic shock
• Fatigue - caused by medications like beta blockers, diuretics, calcium channel blockers, ACE inhibitors)

Question 7

How is LVF Different to Other Heart Failures; Right, Biventricular, Chronic, Acute, Congestive

Answer 7

• Right - fluid backing up into the venous system (swelling to feet, ankles, legs, abdomen, increased urine, nausea, weight gain, loss of appetite)
• Biventricular - affects both sides, has symptoms of both right and left failure
• Congestive - happens when the heart can’t pump blood well enough for a normal supply, blood and fluid collects in the lungs and legs over time
• Chronic - heart failure that develops over time
• Acute - heart failure that occurs suddenly eg from an MI, drug/alcohol use, clots, inflammation of the heart

Question 8

Primary Survey of AHF

Answer 8

A - may be audibly bubbly/wheezy, could be coughing and producing sputum, cyanosis

B - tachypnoea

C - may be pale/clammy

D - fatigue, confusion altered GCS in later stages

Question 9

Red Flag Symptoms of LVF

Answer 9

• Orthopnoea - increased breathlessness on lying down. The pt may have slept in a chair for the preceding nights
• Paroxysmal Nocturnal Dyspnoea (PND) - waking up SOB at night, relieved by sitting up
• New dyspnoea - with PMH of MI/hypertension/angina
• New Peripheral Oedema - accompanied by dyspnoea
• Coughing up Pink, frothy sputum

Question 10

3 Different Presentations of AHF

Answer 10

1. 50% of patients show signs of congestion without hypoperfusion
2. 45% of patients show signs of congestion with signs of hypoperfusion
3. 5% of patients wont show any signs of congestion but may show signs of cardiogenic shock

Question 11

Symptoms of Congestion Presentation

Answer 11

• Fine basal crackles
• Dull percussion
• Raised JVP
• S3 or S4 heart sounds
• Murmur

Question 12

Symptoms of Hypoperfusion Presentation

Answer 12

• Hypoxia
• Tachypnoea and accessory muscle use
• Tachycardia
• Cyanosis
• Cold, pale and sweaty peripheries
• Oliguria
• Confusion/agitation
• Syncope/near syncope
• Narrow pulse pressure (25%/40 between di/sys)

Question 13

General Pre-Hospital Management of LVF

Answer 13

• Pre-hospital diagnosis is very difficult
• Recognise the need for time-critical transfer
• Manage patients in fully upright position at all times (important)
• Oxygen therapy
• Do an ECG recording any abnormalities

Question 14

The 3 Outcomes/Severity Management

Answer 14

1. If no peripheral or pulmonary oedema with no increased WOB then consider referral to other services
2. If pulmonary oedema and respiratory distress consider GTN, Frusemide, CPAP if available and consider oxygen therapy
3. If showing signs of cardiogenic shock/hypotension/hypoperfusion transfer to local ed urgently - note most common cause is STEMI. Consider oxygen therapy

Question 15

Treatments Based on Cause in LVF

Answer 15

• MI - medication controlled
• Valve problem - usually fixed by surgery
• Conductivity problems - pacemaker
• Lifestyle improvements - excersise, decreasing alcohol consumption

Question 16

List of Differentials in LVF

Answer 16

• Pericardial Effusion
• MI *
• Pneumonia/Chest Infection *
• Exacerbation of COPD
• PE *
• Asthma