Congestive Heart Failure

Classification:
Heart failure with impaired ejection fraction (HFIEF) (systolic)
o
more common
Heart failure with preserved ejection fraction (HFPEF) (diastolic)
o
Less common, HTN related
Aetiology of heart failure: TOP 5
IHD
HTN
Valvular heart disease
Dilated cardiomyopathy (Alcohol)
Other (Cardiomyopathies, DM, arrhythmias, autoimmune, DM)
Precipitants of decompensation
Ischaemic event
Arrhythmia
Infection
Anaemia
Fluid overload/medication compliance
Clinical features
Dyspnoea

How far can you walk before you need to rest?

How far were you able to walk before?
How long does it take you to get your breath back?
Are you every short of breath at rest?

Diagnosis of Congestive Heart Failure

NYHA Classification of CHF severity
Class I
No symptoms or limitation on normal physical exertion
Class II
Mild limitation/symptoms at normal physical exertion
Class III
Severe limitation/symptoms at normal physical exertion
Class IV
Symptoms at rest
Diagnosis requires both:
1. Symptoms consistent with CHF
a. SOB, Fatigue, Ankle swelling, Orthopnoea, PND
2. Objective evidence of cardiac dysfunction at rest
a. Investigations, Echo best
Investigations/Diagnostic process
Patient presents with symptoms consistent with CHF
Initial CV disease
Ix

Vital signs: PR, SBP, DBP, pulse pressure

ECG: assesses for cause of CHF > IHD, also precipitants > arrhythmias
CXR: objective evidence of radiological CHF
Alveolar/Pulmonary oedema (bat wing sign)
B: Kerley B lines (interstitial oedema)
Cardiomegaly
D: Upper lobe diversion
E: Pleural effusion
BNP: differentiates between respiratory and cardiac causes of dyspnoea
>100pg/mL present in CHF
sensitive and specific for LV dysfunction causing congestion

If these initial investigations are negative, then CHF diagnosis is unlikely, if positive:
Echocardiography

Function
>regional wall motion abnormalities
>chamber size
>valve disease
>cardiomyopathies
Ejection fraction < 45% = systolic dysfunction
Diastolic dysfunction: relaxation of cardiac muscle, chamber size, stroke volume

If abnormal, CHF diagnosed. Further investigations for aetiology/precipitants/prognosis

Precipitants

Aetiology/Prognos
is

FBE: anaemia, infection

UECs: renal failure
Troponin
TFT: thyrotoxicosis precipitating CHF
Stress echo: for IHD, Valvular disease, cardiomyopathy (exercise or dobutamine
used)
Cardiopulmonary exercise testing
Measures your cardiopulmonary reserve
Functional assessment
Also used in IHD, Arrhythmia, HTN
6 minute walk test
Functional assessment of severity
Measure SaO2 and PR
Also used in pre-surgical assessment

Management of Congestive Heart Failure

Acute management of APO
LMNOP
Lasix
To get rid of excess fluid
Morphine
To lower anxiety and reduce cardiopulmonary demand
Nitrates
Reduce pulmonary venous pressure + increase coronary perfusion
C/I: HoTN
Oxygen
High flow oxygen > CPAP > Intubation
Position
Sitting up
Also: blood pressure control
If HoTN: then dobutamine can be given as a positive ionotrope, or noradrenaline
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Position upright with oxygen

Diuretics
Morphine
Nitrates GTN spray
CXR
More diuretics if needed
More diuretics if needed
If BP high IV GTM
More diuretics if needed + CPAP
If still unstable call ICU + intubate

Chronic management of CHF

ACE-I (ARB)
Mortality benefit
(1)
Titrate to maximum dose tolerated
>> renal function, cough, HoTN
ACE-I better than ARBs, as bradykinin is protective of the heart
Beta-blocker
(1)

Spironolacto
ne
(3)
Loop
diuretics
(2)
Digoxin
(4)

NEVER use in APO

Mortality benefit (long term protective)
Titrate to maximum tolerated dose
>> PR, HoTN, Asthma
Examples: long acting metoprolol, carvidelol
Must be in SINUS RHYTHM
If C/I:
Use ivabradine (not as good because it only acts on sinus node, not SNS contractility)
Do NOT use centrally acting CCBs: diltiazem/verapamil b/c negative ionotropes
Aldosterone antagonist: prevents long-term fibrosis of the heart
Must be cautious with co-administration of ACE-i:
>> Hyperkalaemia if renal impairment
Also: men get gynacomastia
ALTERNATIVE: epleronone
Morbidity/symptomatic benefit, NO mortality benefit
Patients to adjust dose according to their in daily weight
Positive ionotrope, negative chronotrope
Morbidity benefit, no mortality benefit
Used in CHF + AF w/ rapid ventricular rate for rate control
Used in CHF + sinus rhythm not contolled by ACE-I, BB, Spironolactone and a loop
diuretic
Digoxin is renally excreted, normal half-life >24hrs, >5 days til steady state
concentration. Patients with renal impairment are at risk of digoxin toxicity, digoxin
concentrations must be monitored when therapy is inititated and after. Anything
causing decreased renal perfusion can cause digoxin toxicity

Interventional management
Revascularisati Bypass surgery or stenting
on
CRT
Chronic resynchronising therapy
Indications: LBBB and HFIEF
(APO)
Reasoning: LBBB decreases the EF of the heart by ~5% due to a less co-ordinated
action/the septum compromising the effort by moving spastically.
Pacing: RV pacing + LV pacing achieved by going through the coronary sinus and left
ventricular vein into the left ventricle to achieve narrow QRS complex
Must have:
Sinus rhythm, LBBB, optimum Rx CHF for 6months + unacceptable result
ICD
Implantable cardiac defibrillator
Indications
(VF/VT)
>>Secondary: PHx VT/VF if L.E. > 1 year
>>Primary: Low EF despite best Rx to prevent sudden cardiac death, L.E. > 5years
It looks like a regular pacemaker except there are two thick coils along the wires.

Transplant

Younger patients with severe HF and L.E. < 6 months

QoL or prognostic value
Failure of above interventions and pharma therapy
C/I: age, malignancy, Pulm HTN, PE, Renal failure, PVD
Ongoing: immunosuppression, recurrence of IHD
Different kinds of pacemakers:
One ventricular lead + atrial lead
One ventricular lead (high septal)
Biventricular (RV endo, LV epi)
+ ICD

Standard pacing
AF, Complete heart block
LBBB
As above plus two coils along pacing leads

Medications to be avoided
NSAIDs: fluid retention, vasoconstriction, renal function (esp. if ACE-I/Loop)
TCAs: prolonged QT + hypotension
CCBs (verapamil/diltiazem): negative ionotropes
Anti-arrhythmics (fleicanide/dronedarone):
Steroids
Glitazones; sodium retention
Lifestyle + Patient management
Fluid balance
medication compliance
patient education
Fluid/salt/diet control
Daily weight and diuretic adjustment (+1kg = +1 diuretic pill)
If fail see GP

Heart failure with preserved ejection fraction

Aetiology
HTN + metabolic syndrome, smoking
Aortic stenosis
Hypetrophic cardiomyopathy
IHD (small infarcts > cardiac remodelling)
Mx principles
Treat other conditions
Treat HTN
Strict euvolaemia

Summary for OSCE

What is it?
HOPC:
CF
Dyspnoea (SOBOE, SOBAR)
Orthopnoea
PND
Nocturnal cough
Ankle swelling
Anorexia/weight loss (congestion)
Fatigue
Why now?
CVS SxRx: CDOPS (and dizziness) FAPI
IHD: CHPx, dizziness, sweating, nausea, SOB
Arrhythmia: CHPx, palpitations, syncope, dizziness
Infection: sputum, fevers, shakes, rigors
Anaemia: pale, fatigue, GI blood loss, palpitations, dizziness
Fluid overload: ankle swelling worse? Medication/Fluid/Salt compliance
How did it happen?
Aetiology
IHD
Valvular heart disease
HTN
Cardiomyopathy (dilated)
Other (HOCM, infiltrative, pericarditis etc.)
PHx:

CHF
Current medications/Compliance
Fluid/salt restrictions/home weight monitoring
PHx APO
IHD (angina, AMI), valve disease, HTN (+ metabolic syndrome), arrhythmias, other.
Anaemia, thyrotoxicosis, renal fx,,

Meds

Current CHF medication/Aetiological medication and status

New medications?
NSAIDs/TCAs/CCBs

Allergies

FHx:

Heart disease, heart attacks

SHx:

Exercise/Weight loss/smoking/alcohol

Signs

bi-basal inspiratory course crackles

Weight loss, cold peripheries, muscle wasting
Raised JVP
Pitting oedema/sacral oedema/facial engorgement
Hepatomegaly/ascites

Auscultation
Management of CHF chronic
Management of APO