heart failure - presentation, investigations and treatment

define heart failure

a clinical syndrome comprising of SOB, fatigue or fluid retention due to cardiac dysfunction either at rest or on exertion with accompanying neurohormonal activation

heart failure is not a final diagnosis

- what should the term be qualified by?

underlying structural abnormality and cause

• heart failure due to LVSD (left ventricular systolic dysfunction) due to IHD (ischaemic heart disease)

• heart failure due to severe aortic stenosis

symptoms of heart failure

SOB

fatigue

oedema

reduced exercise capacity

clinical signs of heart failure

oedema

tachycardia

raised JVP

chest crepitations or effusions

3rd heart sound

displaced or abnormal apex beat

obtaining evidence of cardiac dysfunction - investigations

echo

radionuclide ventriculography

MRI

left ventriculography

12 lead ECG

BNP - elevated in HF

if severe enough, any structural abnormality of the heart can lead to

heart failure

• LV systolic dysfunction

• VHD (valvular heart disease)

• pericardial constriction or effusion

• LV diastolic dysfunction - normal ejection fraction

• cardiac arrhythmias

• myocardial ischaemia/infarction

• right ventricular failure

• restrictive cardiomyopathy

causes of LV systolic dysfunction

ischaemic heart disease

dilated cardiomyopathy (DCM)

inherited

toxins

viral

infection

muscular dystrophies

hypertension

tachycardia related DCM

end stage hypertrophic CM

severe aortic valve disease or mitral regurgitation

detailed history for heart failure

MI

DM

HBP

post partum

alcohol

familial DCM (dilated cardiomyopathy)

• FH

hillwalker?

• lyme disease

• IVDA

diagnostic evaluation for heart failure after history

exclude renal failure, anaemia and thyroid dysfunction

autoantibodies

viral serology

ferritin

exclude pheochromocytoma

consider other causes

• sarcoidosis

• muscular dystrophies

ECG

ALWAYS do an echo

why is echo essential in diagnosis of heart failure

LV systolic dysfunction

valvular dysfunction

pericardial effusion/tamponade

diastolic function

LVH (left ventricular hypertrophy)

atrial/ventricular shunts/congenital heart defects

pulmonary hypertension/right heart dysfunction

normal LVEF

55-70%

mild LVEF

40-55%

moderate LVEF

30-40%

severe LVEF

clinical sign of heart failure

reduced ejection fraction

cardiac MRI benefits

more accurate than echo

additional info of tissue characteristics

NYHA grading of heart failure

- class I

no limitation to exercise

no symptoms during usual activity

NYHA grading of heart failure

- class II

mild limitation to exercise

comfortable with rest or with mild exertion

NYHA grading of heart failure

- class III

moderate limitation to exercise

comfortable only at rest

NYHA grading of heart failure

- class IV

severe limitation to exercise

any physical activity brings discomfort and symptoms occur at rest

pathophysiology of heart failure

Inadequate tissue perfusion

volume overload

chronic hypertension

myocardial infarction

valvular heart disease

coronary artery disease

congenital heart disease

dysrhythmias

aging of the myocardium

modern pharmacological treatment of heart failure

diuretics

ACEi

beta blockers

aldosterone receptor blockers

ARNI - angiotensin receptor and neprolysin inhibitor