1. Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive Care, RAH.

2. Objectives Overview of terminology Overview of terminology Pathophysiology of cardiac failure Pathophysiology of cardiac failure Clinical features, x-rays and echos Clinical features, x-rays and echos Outline of acute and chronic treatments Outline of acute and chronic treatments

3. Cardiac failure A clinical syndrome with signs and symptoms of congestion and circulatory failure A clinical syndrome with signs and symptoms of congestion and circulatory failure

4. Epidemiology Prevalence 10% in >65 years Prevalence 10% in >65 years 2% of general medical admissions 2% of general medical admissions In US is the most common cause of hospitalisation in > 65 years In US is the most common cause of hospitalisation in > 65 years Mortality 60% at 5 yrs post diagnosis Mortality 60% at 5 yrs post diagnosis Is as ‘malignant’ as the most common causes of cancer Is as ‘malignant’ as the most common causes of cancer

5. Terminology Acute heart failure Acute heart failure Chronic Heart Failure Chronic Heart Failure Decompensated CHF Decompensated CHF (Right heart failure and high output failure) (Right heart failure and high output failure)

6. Terminology LV dysfunction LV dysfunction Systolic dysfunction Systolic dysfunction (abnormal contraction) (abnormal contraction) Diastolic dysfunction Diastolic dysfunction (abnormal relaxation) (abnormal relaxation)

7. Aetiology Coronary artery disease Coronary artery disease Hypertension Hypertension Valvular heart disease Valvular heart disease Cardiomyopathies eg viral, alcoholic, septic Cardiomyopathies eg viral, alcoholic, septic

8. Preload Performance Sympathetics Normal Failing

9. Preload Performance P1 P2 Higher pressure needed for the same performance

10. Afterload Performance Sympathetics Normal Failing

11. Afterload Performance Less able to cope with afterload

12. CO SNS R-A-A Na + Vasoconstriction AfterloadPreload

13. Oedema Downstream pressure Downstream pressure Colloid osmotic pressure Colloid osmotic pressure Lymphatic drainage Lymphatic drainage Capillary Leak Capillary Leak

14. Clinical presentation Short of breath Short of breath Hypoxaemia Hypoxaemia Tachycardia Tachycardia Bilateral lung crepitations Bilateral lung crepitations Peripheral Oedema - takes time Peripheral Oedema - takes time Hypotension,  peripheral perfusion Hypotension,  peripheral perfusion

15. Investigations ECG ECG CXR CXR Basic bloods Basic bloods Echocardiography Echocardiography

16. Large Heart Perihilar congestion Fluid in the fissure

18. Management Acute Acute O 2 O 2 IV opiates IV opiates IV diuretics IV diuretics IV nitrates IV nitrates CPAP CPAP Cardiogenic shock Cardiogenic shock Inotropes Inotropes Balloon pumping Balloon pumping Ventilation Ventilation

19. CPAP  First described in: Lancet 1936; II: 981  Meta-analysis: Lancet 2006; 357: 1155  3CPO study - NEJM 2008; 359: 142  no mortality difference at 7 days vs standard care  Hypoxic despite medical therapy - CPAP  NIV - probably no benefit over CPAP

22. Peribronchiolar cuffing ECG Monitoring CVP Line

23. Pleural effusion

24. Chronic Management Diuretics Diuretics ACE Inhibitors ACE Inhibitors  -blockers  -blockers Spironolactone Spironolactone Digoxin Digoxin

25. Chronic Management DiureticsDiuretics ACE InhibitorsACE Inhibitors  -blockers  -blockers SpironolactoneSpironolactone DigoxinDigoxin Reduce symptoms Decrease mortality, improve ejection fraction, improve symptoms Decrease mortality with severe disease May reduce hospitalisation

26. Cardiac resynchronisation Defibrillators (ICD) Assist Devices (LVAD)

27. Severe ARDS

28. Summary A clinical syndrome due to variable pathology Physiological response leads to further deterioration Investigations aimed at diagnosis and aetiology Treatment aims to reverse the cause and reduce preload and afterload Common, serious and often progressive

29. Further reading McMurray JJV. Systolic heart failure. New England Journal of Medicine 2010; 362: 228.