Cardiac failure Domina Petric, MD

Definition of cardiac failure (CF) Cardiac output is inadequate for the body´s requirements.

1-3% of the general population, 10% among elderly patients. Prevalence 1-3% of the general population, 10% among elderly patients.

Systolic failure Inability of the ventricle to contract normally resulting in decreased cardiac output. Ejection fraction (EF) is <40%. Common causes are ischaemic heart disease, myocardial infarction, cardiomyopathy and other.

Systolic and diastolic failure usually coexist. Inability of the ventricle to relax and fill normally causing increase of filling pressures. EF is >50%. Common causes are: constrictive pericarditis cardiac tamponade restrictive cardiomyopathy arterial hypertension Systolic and diastolic failure usually coexist.

Left ventricular failure dyspnoea poor exercise tolerance fatigue orthopnoea paroxysmal nocturnal dyspnoea nocturnal cough pinky frothy sputum wheeze (cardiac asthma) nocturia cold peripheries weight loss muscle wasting

Right ventricular failure Causes Symptoms left ventricular failure pulmonary stenosis lung disease peripheral oedemas (up to thighs, sacrum, abdominal wall) ascites nausea anorexia facial engorgement pulsation in neck and face (tricuspid regurgitation) epistaxis

Congestive heart/cardiac failure (CCF) If left and right ventricular failure occur together, that is called congestive heart failure.

Acute cardiac failure New onset acute or decompensation of chronic heart failure characterized by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion.

Develops or progresses slowly. Chronic heart failure Develops or progresses slowly. Venous congestion is common. Arterial pressure is well maintained until very late.

Low output heart failure Cardiac output is decreased and fails to increase normally with exertion. Causes can be devided into three groups: pump failure excessive preload chronic excessive afterload

systolic and/or diastolic heart failure Pump failure systolic and/or diastolic heart failure bradycardia (beta blockers, heart block, post myocardial infarction) negatively inotropic drugs (most antiarrhythmic agents)

Excessive preload mitral regurgitation fluid overload (for example, NSAID causing fluid retention) Fluid overload may cause left ventricular failure in a normal heart if renal excretion is impaired or big volumes are involved (iv. infusion running too fast). More common situation is if there is simultaneous compromise of cardiac function, and in elderly.

High output heart failure This is rare. Output is normal or increased in the face of high needs. Failure occurs when cardiac output fails to meet these needs.

Causes anaemia pregnancy hyperthyroidism Paget´s disease arteriovenous malformation beri beri First there are symptoms of right ventricular failure, later on left ventricular failure develops.

Framingham criteria for CCF Diagnosis requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria.

Major criteria paroxysmal nocturnal dyspnoea crepitations S3 galop cardiomegaly (cardiothoracic ratio >50% on chest radiography) increased central venous pressure (>16 cmH20 at right atrium) weight loss >4,5 kg in 5 days in response to treatment neck vein distention acute pulmonary oedema hepatojugular reflux

Minor criteria bilateral ankle oedema dyspnoea on ordinary exertion tachycardia >120 bpm decrease in vital capacity by third from maximum recorded nocturnal cough hepatomegaly pleural effusion

wheeze (cardiac asthma) Other signs exhaustion cool peripheries cyanosis hypotension narrow pulse pressure wheeze (cardiac asthma) pulsus alternans displaced apex (left ventricle dilatation) right ventricle heave (pulmonary hypertension) murmurs of mitral or aortic valve disease

Diagnostics If ECG and B-type natriuretic peptide are normal, heart failure is unlikely. Alternative diagnosis should be considered. If either is abnormal, echocardiography is required.

Brain natriuretic peptide (BNP) Plasma BNP is closely related to left ventricle pressure. In myocardial infarction and left ventricle dysfunction, both BNP and ANP (atrial natriuretic peptide) can be released in large quantities. Secretion is also increased by tachycardia, glucocorticoids and thyroid hormones.

Brain natriuretic peptide (BNP) Vasoactive peptides (endothelin-1, angiotensin II) also influence secretion. ANP and BNP increase glomerular filtration rate and decrease renal sodium resorption. Both ANP and BNP decrease preload by relaxing smooth muscle. ANP partly blocks secretion of renin and aldosterone.

Brain natriuretic peptide (BNP) Plasma BNP reflects myocyte stretch. BNP is used to diagnose heart failure. Increased levels of BNP distinguishes heart failure from other causes of dyspnoea. BNP is highest in decompensated heart failure intermediate in left ventricular dysfunction lowest if no heart failure or LV dysfunction

Brain natriuretic peptide (BNP) BNP is higher in systolic dysfunction than in isolated diastolic dysfunction. It is highest in CCF. BNP increases in proportion to right ventricular dysfunction: primary pulmonary hypertension, cor pulmonale, pulmonary embolism and congenital heart disease. BNP levels rise more in left ventricular disorders.

Brain natriuretic peptide (BNP) The higher the BNP, the higher the cardiovascular and all-cause mortality. High levels of BNP in heart failure is also associated with sudden death.

Heart failure (HF) unlikely BNP levels <100 pg/mL Heart failure (HF) unlikely 100-400 pg/mL Clinical judgment! >400 pg/mL HF likely

NT-proBNP <300 pg/mL HF unlikely Age<50 years, >450 pg/mL HF likely Age 50-75 years, >900 pg/mL Age>75 years, >1800 pg/mL

Laboratory tests full blood count urea and electrolytes BNP, NT-proBNP

Chest X ray signs: cardiomegaly (cardiothoracic ratio >50%) prominent upper lobe veins (upper lobe diversion) peribronchial cuffing diffuse interstitial or alveolar shadowing classical perihilar bat´s wing shadowing fluid in the fissures pleural effusions septal (Kerley B) lines (interstitial oedema, engorged peripheral lymphatics)

Cardiomegaly, Radiopaedia.org >50%

Upper lobe diversion or cephalisation of pulmonary veins (Radiopaedia Upper lobe diversion or cephalisation of pulmonary veins (Radiopaedia.org) Normal

Perihilar bat´s wing shadowing Image source: ProProfs

Pleural effusion https://www.med-ed.virginia.edu

myocardial infarction ventricular hypertrophy ECG It may indicate cause: ischaemia myocardial infarction ventricular hypertrophy

It is the key investigation. Echocardiography It is the key investigation. It may indicate the cause (MI, valvular heart disease) and can confirm the presence or absence of left ventricle dysfunction.

Management of acute heart failure Oxygen if there is no pre-existing lung disease. Iv. access and ECG monitor: treat if any arrhythmias. Furosemide 40-80 mg. iv. slowly. Nitroglycerine spray 2 puffs if systolic blood pressure is more than 90 mmHg. Dose of furosemide can be repeated if the patient is worsening. Opiates!

Chronic heart failure management NYHA classification of heart failure NYHA I Heart disease present, but no undue dyspnoea from ordinary activity. NYHA II Comfortable at rest, dyspnoea on ordinary activities. NYHA III Less than ordinary activity causes dyspnoea, which is limiting. NYHA IV Dyspnoea present at rest, all activity causes discomfort. Chronic heart failure management

Management Smoking cessation! Less salt! Optimization of weight and nutrition! Treatment of cause: dysrhythmias, valve disease. Treatment of exacerbating factors: anaemia, thyroid disease, infection, hypertension. Avoiding exacerbating factors: NSAID (fluid retention) and verapamil (negative inotrope).

Diuretics Diuretics can reduce the risk of death and worsening heart failure. Loop diuretics: furosemide 40 mg divided into two doses per os (every 12 hours). Dose can be increased if necessary. Side effects: hypokalemia, renal impairment. In refractory oedema, thiazide can be added. It is very important to monitor electrolytes, especially K+ !

ACE-inhibitors ACE-i are very usefull in patients with left ventricular systolic dysfunction. If cough is a problem, an angiotensin receptor blocker may be used instead of ACE-i. Most dangerous side effect of both ARB and ACE-i is hyperkalemia.

BB decrease mortality in heart failure. Beta blockers BB decrease mortality in heart failure. BB are started with low dose that can be increased slowly (every 2 or more weeks).

Eplerenone has less side effects than spironolactone. Spironolactone 25 mg per os once a day decreases mortality rate by 30% when added to conventional therapy. Eplerenone has less side effects than spironolactone.

Digoxin It is indicated in patients with heart failure and atrial fibrillation.

Vasodilatators The combination of hydralazine and isosorbide dinitrate can be used if the patient is intolerant of ACE-i and ARBs.

Literature Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition. Medscape.com Radiopaedia.org ProProfs.com www.med-ed.virginia.edu