heart failure - clinical features, investigation + management

what type of heart failure could present suddenly?

acute heart failure (AHF)

what type of heart failure could present more insidiously?

chronic heart failure (CHF)

what are the two types of left ventricular ejection fraction heart failures?

- heart failure with reduced ejection fraction (HFREF)

- heart failure with preserved ejection fraction (HFPEF)

what is heart failure with reduced ejection fraction classified by?

ejection fraction

what usually causes HFREF? (3)

- ischaemic heart disease

- valvular heart disease

- hypertension

what is heart failure with preserved ejection fraction classified by?

symptoms and signs of heart failure with ejection fraction >50%

what else can be signs of HFPEF? (4)

- decreased left ventricular compliance

- increase in thickness of left ventricular wall

- increase in left atrial size

- abnormal left ventricular relaxation but normal left ventricular volume

what is HFPEF also known as?

diastolic heart failure/dysfunction

what are patients in the midzone with 40-50% ejection fraction classified as?

heart failure with mid-range ejection fraction (HFmrEF)

what are the signs of heart failure? (11)

- hypotension

- tachycardia

- elevated jugular venous pressure (JVP)

- displaced apex beat

- basal crepitation or cardiac wheeze

- pleural effusion

- third heart sound (S3)

- loud S2

- ascites

- oedema

- hepatomegaly

- cardiomegaly

what is a specific sign for right-sided heart failure?

firm, smooth, tender and pulsatile liver edge

what does a basal crepitation sound like?

popping and crackling sound

how can you confirm pleural effusion? (3)

- no crackling

- dull resonance

- flat percussion

what do you look for in investigating JVP?

if it is raised - greater than 3cm

what are the symptoms of heart failure? (9)

- dyspnoea (difficulty breathing)

- orthopnoea (difficulty breathing lying down)

- paroxysmal nocturnal dyspnoea (PND) (woken from sleep as cannot breathe)

- reduced exercise tolerance

- night-time and/or morning cough

- palpitations

- chest pain

- lethargy, fatigue

- loss of appetite/feels full/bloated

what are the classes of heart failure according to the new york heart association (NYHA) classification?

class I, II, III + IV

what is class I of heart failure?

asymptomatic:

- no limitation of ordinary physical activity due to breathlessness, fatigue or palpitations

- but evidence of left ventricular systolic dysfunction

what is class II of heart failure?

mild:

- slight limitation on physical activity

- comfortable at rest but activities like climbing up stairs results in symptoms

what is class III of heart failure?

moderate:

- marked limitation on physical activity

- mild exertion like walking on level ground can provoke symptoms

what is class IV of heart failure?

severe:

- symptoms are present at rest

- increase with any physical activity

what should diagnosis of heart failure be based on? (4)

- detailed history

- clinical findings

- natriuretic peptide levels

- echocardiography/chest MRI

what are the 3 requirements to diagnose HF-REF?

- symptoms typical of heart failure

- signs typical of heart failure

- reduced LV ejection fraction

what are the 4 requirements to diagnose HF-PEF?

- symptoms typical of heart failure

- signs typical of heart failure

- normal only mildly reduced LV ejection fraction and LV not dilated

- relevant structural heart disease (LV hypertrophy/ left atrial enlargement) and/or diastolic dysfunction

why do we measure for atrial and brain natriuretic peptides? (2)

- they are released in response to volume expansion/pressure overload

- they counter-regulate the RAAS by vasodilation and increased urinary Na+ excretion

where is ANP released from?

atria

where is BNP released from?

ventricles

what is the test tool for natriuretic peptides called?

NT-proBNP

what NT-proBNP levels is HF unlikely?

≤400ng/L

what do you do if the NT-proBNP is 400-2000ng/L?

6 week wait assessment + echo

what do you do if the NT-proBNP is ≥2000ng/L

2 week wait assessment + echo

what can be explored by an echocardiogram/chest MRI?

ejection fraction (%)

what is the ejection fraction?

- stroke volume/end diastolic volume x 100

- the fraction of blood pumped out of the ventricle in one beat

what is a normal range for ejection fraction?

50-70%

what is the generally accepted EF for heart failure?

≤55%

what is management of heart failure based on? (4)

- relieving symptoms

- delaying disease progression

- improving quality and length of life

- trying to find the factors aggravating the HF to be treated

what is the general lifestyle advice on management of heart failure? (7)

- education - effective counselling of patients and family emphasising lifestyle + medical changes that could prevent hospitalisation

- dietary modification - less salt, fluid restriction

- quit smoking

- physical activity + rehabilitation - low endurance exercise

- vaccinations against pneumococcal disease + influenza

- sexual activity - do not take sildenafil as could induce profound hypotension

- driving - only disqualifies form driving large lorries and buses

what does monitoring of heart failure include? (3)

- functional capacity (exercise tolerance test + echocardiography)

- fluid status (body weight)

- cardiac rhythm (ECG)

how long does a patient diagnosed with heart failure usually stay when admitted to hospital?

5-10 days

what complex devices can be used for heart failure?

- implantable cardioverter-defibrillator (ICD)

- cardiac resynchronisation therapy (CRT-D/CRT-P)

what does an ICD do?

shocks the heart back into sinus rhythm whenever it detects fibrillation

what is a CRT-D?

cardiac resynchronisation therapy defibrillator - CRT + ICD

what is a CRT-P?

cardiac resynchronisation therapy pacemaker

what do CRTs do?

send small electrical impulses to get the left and right ventricles pumping at the same time

what is the difference between CRT-Ds and CRT-Ps?

CRT-Ds can also detect and resolve faster heart rates

what is the difference between ICDs and CRTs?

- ICDs have one or two leads, first on the right ventricle, then on the right atrium

- CRTs have 3 leads, the third being places on the left ventricle

what are the 3 criteria for CRT?

1) LBBB on ECG

2) LVEF < 30%

3) NYHA class III

signs of L sided heart failure?

- pulmonary oedema

- SOB

- orthopnoea

- PND

- frothy white and pink sputum

- pulsus alternans

what is pulsus alternans?

alternating strong and weak pulses

signs of R sided heart failure?

- ascites

- peripheral oedema

- raised JVP

- cardiomegaly

- hepatosplenomegaly

what would be seen on ECG due to cor pulmonale?

P pulmonale

what is P pulmonale?

tall peaked P-wave - from right atrial enlargement

signs of HF on chest x-ray?

- alveolar oedema (bat-wings)

- kerley B-lines

- cardiomegaly

- dilated upper lobe vessels

- pleural effusion

how do you manage type 1 pulmonary failure caused by heart failure?

IV furosemide and high flow oxygen