Cardiac failure

• When switching from IV furosemide to PO diuretics, what diuretic is best to use?


  Bumetanide
• Ramipril is cardioprotective
• What is heart failure?


  Inadequate CO for the body's requirements

  Results from structural of functional cardiac disorders impairing ability of ventricles to fill with or eject blood
• What can HF be classified into?

  Systolic (HFrEF)

  • EF ≤ 40%
  • Inability of ventricle to contract normally

  Diastolic (HFpEF)

  • EF > 50%
  • Inability of ventricle to relax & fill
• What are the possible causes of systolic HF?


  IHD

  MI

  Cardiomyopathy
• What are the possible causes of diastolic HF?


  Ventricular hypertrophy

  Constrictive pericarditis

  Restrictive cardiomyopathy

  Obesity

  Tamponade
• What is acute HF?


  New-onset acute of decompensation of chronic HF by pulmonary and/or peripheral oedema
• Pathophys of acute HF


  Volume overload (due to venous congestion) → decrease venous return to heart → activation of sympathetic NS → tachycardia, increased contractility, peripheral vasoconstriction, activation of RAAS → worsens congestion → more myocardial wall stress & reduced renal perfusion → myocardium weakens → decreased CO → worsens HF symptoms
• What are the Inx for HF?


  Obs

  Full Hx & examination

  ECG

  Bloods (FBC, U&Es, LFTs, CRP, TFTs, HbA1c & glucose, troponin, BNP, ABG, D-dimer)

  CXR

  Echo
• What is shown on a CXR for HF?


  Alveolar oedema

  Kerley B lines

  Cardiomegaly

  Dilated upper lobe vessels

  Effusion (pericardial or pleural)
• What may be seen on an ECG in HF?


  Arrhythmias

  Ischaemic ST- & T wave changes
• What are the RFs of HF?


  Coronary artery disease

  MI

  HTN

  Diabetes

  Dyslipidaemia

  Older age

  Male

  Obesity

  FHx of HF

  Exposure to cardiotoxic agents

  LV dysfunction/hypertrophy

  Valvular heart disease

  Sleep apnoea

  Arrhythmias
• What are the signs & symptoms of HF (in general)?


  Fatigue

  Chest pain

  Cyanosis

  Cardiomegaly (+ displaced apex beat)

  Tachycardia

  Tachypnoea

  Murmurs

  Low BP

  Narrow pulse pressure < 25 mmHg
• What are the signs & symptoms of LHF?

  Exercise intolerance

  Dyspnoea

  Orthopnoea

  PND

  Pulmonary congestion & oedema

  Bilateral basal crackles

  Pulse alternans (alternating strong & weak beats)
• What are the signs & symptoms of RHF?


  Exercise intolerance

  Peripheral oedema

  Hepatomegaly

  Ascites

  Raised JVP
• How can HF be classified on severity?


  New York Heart Association (NYHA)

  Class I

  • no symptoms
  • no limitations of activity

  Class II

  • mild symptoms
  • slight limitation of physical activity

  Class III

  • moderate symptoms
  • marked limitation of physical activity (less than ordinary activity -> symptoms)

  Class IV

  • severe symptoms
  • unable to carry out physical activity w/o symptoms
• What are the possible complications of HF?


  Arrhythmias

  Ventricular remodelling

  Sudden cardiac death

  Thromboembolism

  Cachexia & malnutrition
• What lifestyle modifications are advised in HF?


  Increase physical activity

  Dietary restrictions (less salt & fluid management)

  Smoking cessation

  Limit alcohol intake

  Weight management
• What are the device therapies and surgical interventions that can be done in HF?


  Device

  • Implantable cardioverter defibrillators (ICDs)
  • Cardiac resynchronisation therapy (CRT)

  Surgical intervention

  • Heart transplantation
  • LVAD
• Hypocalcaemia is a side effect of loop diuretics.