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Heart Failure

Heart failure is when the heart is unable to pump sufficiently to maintain blood flow and meet the body's demands. It's also known as congestive heart failure (CHF) or congestive cardiac failure (CCF) when both sides of the heart are affected.

"Signs and Symptoms of Heart Failure" - National Heart, Lung, and Blood Institute

It's risk factors include:

  • IHD

  • Valvular Heart Disease esp. Aortic stenosis

  • HTN

  • Arrhythmias esp. AF


Its complications include:

  • Sudden cardiac death

  • CKD

  • Sexual dysfunction


Its differentials are COPD, Asthma, PE, Lung cancer.


Classification

It can be classified into pump failure or anatomy.

Pump failure:

  • Systolic HF - Impaired myocardial contraction → Reduced Ejection Fraction (< 40%)

    • Causes - IHD, MI

  • Diastolic HF - Impaired ventricular filling → Preserved Ejection Fraction (> 50%)

    • Causes - HCOM, Cardiac tamponade


Anatomy:

  • Left HF - Causes pulmonary congestion

    • Presents with SOBOE, Orthopnoea, PND, Nocturnal cough

  • Right HF - Causes venous congestion

    • Presents with Peripheral oedema, Raised JVP, Bilateral (transudative) pleural effusions, Hepatomegaly


N.B. The pulmonary congestion from Left HF can push the RV into failure as well, leading to symptoms of both Left and Right HF i.e. CHF


NYHA Classification

Presentation

Most patients present with signs of both Left and Right HF:

  • SOBOE

  • Orthopnoea - SOB when lying flat and relieved by sitting up or standing - Pts tend to use 1+ pillow at night

  • Paroxysmal Nocturnal Dyspnoea (PND) - Sudden attack of SOB during the night (as if they can’t breathe)

  • Nocturnal Cough +/- frothy pink sputum

  • Peripheral oedema


N.B. PND occurs as, when lying flat, the fluid settles across the lung surface, and when standing, the fluid settles at the base, allowing the upper lungs to be used more effectively.


Investigations

Investigations to do are:

  • Bloods - NT-proBNP

  • CXR

  • Echo - check type and degree of failure by ejection fraction

  • ECG


BNP is released by the ventricles in response to myocardial stretch. However, it has a high negative predictive value, so if it isn't raised, HF is unlikely. If raised, the patient should be referred for an Echo to assess the degree of failure (i.e. ejection fraction).


CXR Findings - ABCDE:

  • Alveolar oedema - ‘bat wing’ perihilar shadowing

  • Kerley B lines - interstitial oedema

  • Cardiomegaly - cardiothoracic ratio > 0.5

  • Dilated upper lobe vessels

  • Pleural Effusion - bilateral transudates

Chest X-Ray showing changes in Heart Failure - Mikael Häggström

Management

Lifestyle changes - Smoking cessation, Low-salt diet, Exercise


Pharmacological - The Fantastic 4:

  • RAAS inhibitor - Sacubitril/Valsartan (Entresto), ACEi, or ARB

  • B-blocker - Carvedilol 1st line

  • Aldosterone antagonist

  • SGLT2 inhibitor e.g. dapagliflozin


N.B. Loop diuretics given for symptomatic relief as well.


Patients will need to have their U&E’s monitored as the ACEi and Spironolactone can cause hyperkalaemia and renal impairment.


Those with very severe and refractory HF are at risk of developing life-threatening arrhythmias e.g. VT, VF, therefore will need an ICD implanted.



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