Heart Failure

Pathology

A disorder of heart structure or function that impairs its ability to fill and pump blood at a rate proportionate to the body’s requirements, resulting in pulmonary or peripheral oedema.

Aetiology

Ischaemic heart disease, Dilated cardiomyopathy, Hypertension, Valvular heart disease, Drugs (e.g. chemotherapy), Radiotherapy, Pregnancy, Amyloidosis, Sarcoidosis, Stress cardiomyopathy, Post viral, Alcohol, Hypothyroidism, Familial, Haemochromatosis, Infections (Chagas’ disease), Nutritional (Beri-Beri)

Signs

Dyspnoea, raised JVP, distended neck veins, pleural effusions, peripheral oedema, crepitations, hepatomegaly, ascites, tachycardia, 3rd heart sound, RV heave, low-volume pulse, poor peripheral perfusion, hypotension, displaced apex

Symptoms

LVF: dyspnoea, reduced exercise tolerance, fatigue, syncope, nocturnal cough

RVF: weight gain, peripheral oedema, nausea and anorexia, facial engorgement

Investigations

Bloods: FBC, U&E, LFTs, TFTs, serum nt-proBNP, uric acid, troponin

ECG: arrhythmia, LVH, prolonged QRS, evidence of old infarct

Chest X-Ray: cardiomegaly, pleural effusions, upper lobe diversion, and alveolar oedema, (Kerley B lines)

Echo: Assess ventricular function

Treatment

Acute heart failure: Fluid and salt restriction, daily weights, fluid balance chart, vasodilators and diuretics (e.g. isosorbide dinitrate and furosemide), IV Dopamine in hypotensive patients

Chronic heart failure: Cardiac rehabilitation, low-salt diet, fluid restriction, pneumonia and influenza vaccines, diuretics, beta blockers and ACE inhibitors

Device therapy: Implantable cardiac defibrillators reduce mortality when used in patients with LVEF <35%

Surgical: CABG, mitral valve surgery, LV reduction surgery, LVAD and transplantation

Prognosis

Treatment side-effects including nausea, gout, impotence, diabetes, postural hypotension, headaches, worsening heart failure, arrhythmias, and death.5-year mortality in men and women 62% and 42% respectively

New York Heart Association Classification Of Heart Failure

NYHA I: No limitation of physical activity

NYHA II: Slight limitation of physical activity Symptoms with ordinary levels of exertion, such as walking up stairs

NYHA III: Marked limitation of physical activity Symptoms with minimal level of exertion, such as dressing

NYHA IV: Symptoms at rest

Key Facts

Chest X-ray Heart Failure Findings Mnemonic

‘ABCDE’

Alveolar oedema (bat’s wings)

B Kerley lines (interstitial oedema)

Cardiomegaly

Dilated prominent upper lobe vessels

    Effusion (pleural)

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