1. Cardiac failure
Domina Petric, MD

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

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

4. 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.

5. 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.

6. 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

7. 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

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

9. 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.

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

11. 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

12. 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)

13. 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.

14. 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.

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

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

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

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

29. 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)

30. Cardiomegaly, Radiopaedia.org
>50%

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

32. Perihilar bat´s wing shadowing
Image source: ProProfs

33. Pleural effusion

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

35. 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.

36. Management of acute heart failure
Oxygen if there is no pre-existing lung disease.
Iv. access and ECG monitor: treat if any arrhythmias.
Furosemide 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!

37. 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

38. 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).

39. 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+ !

40. 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.

41. 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).

42. 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.

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

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

45. Literature
Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition.
Medscape.com
Radiopaedia.org
ProProfs.com