By Dr. Figgins & Dr. Gausden

 Clinical syndrome resulting from inadequate cardiac output for the body’s needs.

 Left heart failure  Right heart failure  Congestive cardiac failure

Low output Excessive pre-load Pump failure  Heart muscle disease  Restricted filling  Inadequate heart rate  Negatively inotropic drugs Excessive afterload High output (rare) Isolated RHF

 Inadequate CO stimulates compensatory mechanisms resembling response to hypovolaemia  Initially beneficial, becoming maladaptive

 Arrhythmias (e.g. AF)  Drug issues (e.g. non-compliance)  Anaemia  Infection (pneumonia, UTI)  Thyroid disease

Symptoms? Signs?

SYMPTOMS? SIGNS?

New York heart failure classification I = Cardiac disease but NO SYMPTOMS in ordinary physical activity II = MILD SYMPTOMS and slight limitation during ordinary physical activity III = Marked limitation in activity due to symptoms during LESS-THAN-ORDINARY ACTIVITY IV = Severe limitations. Experiences symptoms at even AT REST

 BEDSIDE TESTS  BLOOD TESTS  IMAGING  SPECIAL TESTS

 Protein secreted from ventricles of the heart  In response to overstretching of cardiomyocytes  High NEGATIVE predictive value (98%)  Used to RULE OUT heart failure, not rule in  Non-specific

 A lveolar oedema  Kerley B lines (interstitial oedema)  C ardiomegaly  D ilated upper lobe vessels  E ffusions

 2 types  Valves  LV systolic/diastolic Fx  Aorta  LVEF

 Assess ABCDE  Loop diuretics IV - furosemide  Morphine IV - slowly  Nitrates – avoid if hypotensive  Oxygen – 100% NRBM  Position upright

 CONSERVATIVE Mx

 For pts with IHD, HF or recent cardiac surgery  Available at local hospitals  Education  Emotional support  Physical fitness  4 stages

 Recommended by NICE if reduced ejection fraction  1 st line = ACE-INHIBITORS (or ARBs) + BETA-BLOCKERS  2 nd line = add in ARB or spironolactone or hydralazine  3 rd line = digoxin  *patients with fluid overload should receive diuretics*  AVOID CARDIO-SELECTIVE CALCIUM CHANNEL BLOCKERS

 Mr Meldrew  61 years old  3/12 Hx of malaise, increasing SOB and ankle swelling  Now SOB walking upstairs  PMHx: HTN, MI in 2008  80 pack year smoking Hx  Any other questions?

CARDIAC  Valvular heart disease  Coronary artery disease  Left ventricular failure RESPIRATORY  Infection  Inflammation  Neoplastic  Degenerative OTHER  Anaemia  Anxiety

 BEDSIDE  BLOODS  IMAGING  SPECIAL

 Mr Meldrew attends A&E severely SOB  He can hardly talk  You are the FY1 in ED sent to clerk him – what do you do?

 How will you manage him long term now he is stable?

  Nice Guidelines. Chronic Heart failure (2010).  Patrick Davey. Medicine at a Glance (2010). Blackwell publishing  ngestive-Heart-Failure.htm ngestive-Heart-Failure.htm  The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994: