Proforma B Case number

Heart Failure
Unit number
4

Presentation: Shortness of Breath Main diagnosis Heart failure Incidence: 2-4% in the general population, increasing significantly with age to between 10-20% in the over-75s. Age range: 40- 80 years, equal sex ratio ( usually occurs in OLD PEOPLE)

Pathology
There are 3 main causes of chronic heart failure: 1. Impaired ventricle contractility 2. Increased afterload 3. Impaired ventricle relaxation & filling Systolic dysfunction heart cant contract (Abnormaility of ventricular emptying) Due to: impaired contractility or excess afterload Diastolic dysfunction heart cant relax (Abnormality of ventricular filling) Due to: impaired relaxation or increased stiffness of LV wall Can also classify patients according EJECTION FRACTION Ejection fraction = percentage % of blood pumped out of left ventricle during each systole (contraction) -Heart failure with reduced EF -Heart failure with normal EF

Heart failure with reduced EF ( SYSTOLIC)

There are 2 main causes of HF with EF: 1. Impaired contractility 2. Pressure overload/ excessive afterload Pressure overload ( excess afterload) Aortic stenosis Severe Hypertension

Loss of contractility: Destruction of myocytes, due to: Coronary artery disease ( MI), ischemia Chronic volume overload, due to: Mitral regurgitation, aortic regurgitation Abnormal myocyte function, due to: Cardiomyopathy

Compensatory mechanism: Increased preload, so the body increases stroke volume to make up for the increased volume. However: ESV is still elevated Persistenly elevated LV pressure causes blood to flow back into LA from LV (-due to mitral regurgitation). Blood then flows from pulmonary veins to lungs Symptoms of pulmonary oedema (SOB), Dyspnoea, PND

Starlings Law of the Heart

The greater the stretch of ventricle in diastole, the greater the force of contraction in systole
Hence: The greater stroke volume & cardiac output Cardiac Output:
-Volume of blood ejection from ventricles in 1 minute

Stroke Volume:
Volume of blood ejection from vent in 1 systole (contraction)

CO = = SV SV x x HR HR CO Cardiac Output Output = = stroke stroke volume volume x x Heart Heart rate rate Cardiac PRELOAD= pressure at the end of vent diastole
Stretch on myocardial fibres before contraction

AFTERLOAD = resistance that must be overcome

for ventricle to eject its contents -Force at which LV ejects blood

EDV: End Diastolic Volume

Maximum volume of blood in the ventricles at the end of ventricular diastole

ESV: End Systolic Volume

Minimum volume remaining in vent after systole

Heart failure with normal EF ( DIASTOLIC)

There are 2 main causes of HF with normal EF: 1. Impaired diastolic relaxation 2. Increased stiffness of ventricular wall Impaired diastolic relaxation: CardiacTampone: compression of heart Constrictive pericarditus: inflammation of heart causes walls not to dilate fully Increased stiffness of ventricle wall: Left Ventricular hypertrophy- cant fill up Myocardial Fibrosis: thickening of walls Restrictive cardiomyopathy: walls are rigid

No need for compensatory mechanism Decreased EDV- end diastolic volume, filling of ventricle occurs at higher-than-normal-pressure (needs more pressure as there is less blood) This higher pressure cuases bloo to backflow into RA which is connected to superior & inferioir vena cava- these supply the body with blood Blood flows into vena cava & patients get symptoms of systemic oedema peripheral oedema ( ankle swelling) ascities, hepatomeagly JVP

Risk Factors
Same as Risk factors for Coronary Heart Disease: AF: Atrial Fibrilation- this one is specific to heart failure Smoking Diabetes Hypertension Hyperlipidaemia Family History Obesity

Classification of Heart Failure

NYHA Class I II III IV Symptoms No symptoms and no limitation in ordinary physical activity Mild symptoms (mild SOB/ angina) and slight limitation during ordinary activity. Marked limitation on mild activity due to symptoms, e.g. walking (20100 m). Comfortable only at rest. Symptoms at rest. Severe limitations. Mostly bedbound patients.

Symptoms/ Signs:
Left Side Fatigue SOB Orthopnoea Paroxysmal Nocturnal Dyspnoea Left Side Displaced apex beat 3rd & 4th heart sound gallop if tachycardia Murmur: Mitral regurgitation pulmonary oedema Basal Crackles ( at lung base) Right Side Fatigue SOB Anorexia Nausea Right Side JVP Peripheral Oedema: Ankle oedema Ascites Hepatomegaly

Signs:

Investigations for Heart failure BNP: Brain natriuretic peptide is a 32 amino acid polypeptide secreted by the ventricles of the heart in response to
excessive stretching of heart muscle cells (cardiomyocytes). BNP levels increase markedly in left ventricular dysfunction and the level in heart failure correlates with symptom severity. If levels are high (BNP 400 pg/ml) heart failure is likely If levels are raised (BNP 100-400 pg/ml) gray area If the levels are normal (BNP 100 pg/ml) heart failure is unlikely

Blood tests:
FBC: check for anaemia, urea & electrolytes, cardiac enzymes: troponin (acute heart failure to detect myocardial infarction), thyroid function (TFT)

Echocardiography (ECHO)
This is the gold-standard for diagnosis of heart failure. Points to look out for: Ejection fraction <55% ( percentage of blood pumped out of the ventricles each cardiac cycle) Heart size: cardiomegaly Determine cause of heart failure: check the valves are working normally, hypertrophy of ventricles

Chest x-ray (CXR)

Remember: A B C D E
A: Bats wing pulmonary oedema: bilateral
peri-hilar (hilum) shadowing- looks fluffy

B: Septal lines ( Kerley B lines) C: Cardiomegaly= cardiothoracic >50% D: Prominent upper lobe dilation /congestion
( due to accumulation of fluid)

E: Pleural effusion: loss of costo-phrenic

angle, it is filled with fluid

Treatment of ACUTE Left Ventricular failure

This is a MEDICAL EMERGENCY!!!
Sit the patient up Administer oxygen (100%) via face mask Get IV access and administer: Diamorphine 2.5-5mg with Metaclopramide 10mg IV Furosemide (diuretic) 80-100mg Put in a urinary catheter Give IV nitrates CPAP: Continuous Positive Airway Pressure

Management of CHRONIC Left Ventricular failure

ACE inhibitors Diuretics & Spironolactone Beta Blockers Nitrates Digoxin