Heart Failure

Defined as when cardiac output is inadequate for the body’s normal requirements. End stage of all cardiac pathologies

Classifications

Systolic failure - inability of the ventricle to contract normally resulting in $\downarrow$ CO. Ejection fraction <40%

Diastolic failure - Inability of the ventricle to relax and fill normally causing $\uparrow$ filling pressure. EF >50% - preserved ejection fraction

Left ventricular failure

• Dyspnoea, poor exercise tolerance, fatigue, orthopnoea, cardiac “asthma”

Right ventricular failure

• Peripheral oedema, Ascites, nausea, anorexia
• Causes: LVF, pulmonary stenosis, cor pulmonale

Acute heart failure - new-onset acute or decompensation of chronic heart failure with pulmonary and peripheral oedema without peripheral hypoperfusion

Chronic heart failure - Develops slowly, venous congestion is common but arterial pressure is well maintained

Low-output heart failure - $\downarrow$ CO which fails to increase on exercise. Causes

• Excessive pre-load: mitral regurgitation or fluid overload
• Pump failure: systolic/diastolic heart failure, $\downarrow$ HR (eg $\beta$ blockers)
• Chronic excess afterload: Aortic Stenosis, hypertension

High-output heart failure - rare, normal or increase CO with demand

Causes/Factors

Systolic and diastolic failure pathology often coexist

Systolic:

• Coronary Artery Disease
• myocardial infarction
• Myocarditis
• dilated cardiomyopathy

Diastolic:

• ventricular hypertrophy (hypertrophic cardiomyopathy)
• Pericarditis
• Cardiac Tamponade

Symptoms

• Fatigue
• Dyspnoea
• Orthopnoea
• Paroxysmal nocturnal (breathless at night)

Signs

• High JV pressure
• Tachycardia
• Hypotension
• Cachexia (loss of skeletal muscle)

Diagnostic Tests

• Echo to assess ejection fraction, ventricle dilation and valves
• ECG
• Bloods: NT-proBNP (N-Terminal pro-Brain Natriuretic Peptide)
• CXR - ABCDE of heart failure on CXR

Management

Initial:

• Refer to cardiology and assessment with echo BNP 400-2000 $\to$ 6 week wait, 2000+ 2WW
• Drug treatment
• Lifestyle advice - annual flu vaccine, stop smoking,

Drugs:

ACEi and Beta blockers first line.

• A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated - removal of excess fluid (ARB if ACEi not tolerated)

• M – Mineralcorticoid receptor antagonist (aldosterone antagonist) when symptoms are not controlled with ACE and $\beta$-blockers (e.g., spironolactone or eplerenone)

• B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated - decreases heart rate and increases force of contraction

• L – Loop diuretics (e.g., furosemide or bumetanide) - no prognostic benefit only symptomatic

• SGLT2i (causes peeing out glucose) eg forxiga, dapagliflozin

U&Es should be monitored as ACEi, diuretics and aldosterone antagonists can all cause electrolyte disturbances. ACEi and aldosterone antagonists can cause Hyperkalaemia

Surgical:

• Heart transplant can be considered

Complications/red Flags

• Arrythmias
• Thromboembolism