HEART FAILURE

Christian Rey Cayabyab

Y3 Medical Student
University of Limerick
➤ Definition and classification
➤ Presentation
➤ Aetiology
➤ Investigations
➤ Management
➤ Prognostic factors
➤ Research
DEFINITION AND CLASSIFICATION
➤ Definition: Cardiac output is inadequate for the body’s requirements.

➤ Classification
➤ Left-sided, right-sided, biventricular
➤ Systolic failure (HFrEF), diastolic failure (HFpEF)
➤ Acute or chronic
➤ Functional - NYHA Classification I-IV
PRESENTATION
➤ A 70 yo man presents to the surgery with suspected heart failure.
➤ What are his symptoms?
➤ LVF: dyspnoea, orthopnoea, PND, poor exercise tolerance,
nocturnal cough (±frothy sputum), wheeze (cardiac asthma), cold
peripheries, pulsus alternans, weight loss
➤ RVF: peripheral oedema, ascites, nausea, anorexia, facial
engorgement, epistaxis
➤ Signs?
➤ cyanosis, ↓BP, narrow pulse pressure, displaced apex, RV heave,
signs of valve disease
➤ Differentials
➤ COPD, asthma, pneumonia, pleural effusion, PE, pneumothorax,
pulmonary fibrosis, anaemia, malignancy, etc.
AETIOLOGY
➤ Hypertension - most common cause; insiduous
➤ ↑ systemic resistance → ↑ workload for the heart → hypertrophy and fibrosis
➤ Systolic failure
➤ Valve regurgitation
➤ Ischemia/infarction
➤ EtOH, cardiotoxic drugs, e.g. chemotherapy, immunomodulators
➤ Diastolic failure
➤ Pericardial tamponade
➤ Restrictive pericarditis
➤ Hypertrophic and restrictive cardiomyopathies
➤ Chronic high output states
➤ kidney disease, anaemia, thyrotoxicosis, cirrhosis, multiple myeloma
INVESTIGATIONS
➤ ECG - old MI (Q wave), LV hypertrophy, P wave
changes (atrial enlargement in valve disease)
➤ CXR - cardiomegaly, upper lobe diversion
(cephalization), pulmonary oedema (Kerley B lines,
pleural effusion
➤ BNP/NT-pro-BNP - BNP released with increased
ventricular stretch. ?Cannot be ordered in primary care.
➤ Bloods - FBC, U&E, LFTs, TFTs, lipids, glucose
➤ Echocardiography - assess chamber volumes, wall
thickness, ventricular systolic and diastolic functions,
valvular disease
➤ Others: coronary angiography, cMRI
MANAGEMENT OF CHRONIC HF
➤ Lifestyle - no smoking, no alcohol, salt restriction (<2g/day), optimise
weight and nutrition
➤ Treat cause and exacerbating factors
➤ dysrhythmias, valve disease, anaemia, thyroid disease, HTN, infection
➤ Avoid precipitants
➤ NSAIDs (fluid retention), verapamil (negative inotrope)
➤ Flu and pneumococcal vaccine
➤ Medications
➤ Diuretics, e.g. furosemide, improve oedema and SOB
➤ ACEi*, B-blockers and mineralocorticoid receptor antagonists improve
symptoms, ↓ hospitalisations and ↑ survival
➤ ACEi also improve exercise capacity
➤ Vasodilators, use if intolerant to ACEi/ARBs, ↓ mortality
➤ Digoxin reserved for Class III/IV patients after optimal therapy; not
routinely used otherwise
➤ Choice of drugs depend on NYHA classification
CLASSIFICATION AND TREATMENT
NYHA Classification Treatment

I No symptoms ACEi/ARB + 𝛃-blocker

II No symptoms with ADLs + loop diuretic (furosemide)

+ MRA (spironolactone)
III Symptoms with ADLs ±vasodilators (isosorbide dinitrate +
hydralazine*)

+ inotropes
IV Symptoms at rest
LV assist device, transplant

➤ All Px get treated with ACEi/ARB and 𝛃-blocker including asymptomatic patients with HFrEF.
➤ MRA (spironolactone and eplerenone) is recommended for patients with HFrEF or LVEF ≤35% who remain symptomatic despite
optimal ACEi and 𝛃-blockade to reduce mortality and HF hospitalisations.
➤ AICD recommended if Px EF is <35% but class III symptoms → ↓ sudden cardiac death**
➤ Aspirin and statin if Px has ischaemic cardiomyopathy
MANAGEMENT OF ACUTE HF
DRUGS TO AVOID IN PATIENTS WITH HF
➤ NSAIDs
➤ CCBs have no benefit. Use amlodipine if absolutely necessary
➤ Trimethoprim-sulfamethoxazole - increases risk of hyperkalaemia and AKI
➤ Oral hypoglycaemics
➤ Thiazolidinediones - fluid retention
➤ Metformin - lactic acidosis
➤ PDE3, 4 and 5 inhibitors
➤ Antiarrhythmics - negative inotropes - can precipitate HF
➤ Cardiotoxic chemo agents - anthracyclines, high dose cyclophosphamide, trastuzumab and
bevacizumab
➤ Sodium containing preparations, antihistamides (LQTS in 2nd gen), theophylline, TNF-a inhibitors
CASE
➤ 51 yo M presents with cough that is exacerbated by lying down at night and improved
by propping up on 3 pillows.
➤ What questions would you ask? ➤ What investigations would you order?
➤ What are your top differentials? ➤ FBC
➤ CHF ➤ CXR
➤ GORD ➤ ECG
➤ COPD ➤ Echo
➤ Asthma ➤ PFTs
➤ Postnasal drip ➤ BNP
➤ Valve disease ➤ CT-chest
DETERMINANTS OF PROGNOSIS
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