Heart Failure:

Mostly caused by IHD, cardiomyopathy, HTN. Other causes include valvular heart disease, pericardial
disease, congenital, arrhythmias, ETOH/drugs.

Divided into right/left/congestive, chronic/acute. Best divided into pump failure/preload/afterload.

Acute heart failure is cardiogenic dyspnea with pulmonary congestion. Aka Acute Pulmonary Edema.
Often caused by extensive MI ± rupture, acute valvular regurgitation (eg. Mitral papillary/chordal
rupture or aortic valve endocarditis), PE, and tamponade.

Pathophysiology: Ventricular dilation (decreased ventricular function leaves more blood in

ventricles), myocyte hypertrophy (increased work in ventricles), BNP/ANP secretion (counteracts
RAA, induces diuresis and vasodilation), salt and water retention (reduced kidney perfusion activates
RAA system), peripheral vasoconstriction, sympathetic stimulation. If heart remains stable it is
compensated HF. Loss of the beneficial compensatory mechanisms = decompensated HF.

Acute:

General PC: Fatigue, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, anorexia,
nausea.

Symptoms:
- LVF o Muscle wasting
o Dyspnoea - RVF
o Poor exercise tolerance o Peripheral oedema
o Fatigue o Abdominal distension
o Orthopnoea o Nausea
o Paroxysmal nocturnal dyspnoea o Anorexia
o Nocturnal cough (pink frothy sputum) o Facial engorgement
o Wheeze o Pulsation in neck and face
o Nocturia o Epistaxis
o Cold peripheries
o Weight loss

Signs
- LVF
o General inspection
Tachypnoea (due to raised pulmonary pressures)
Central cyanosis (due to pulmonary oedema)
Cheyne-stokes breathing (oscillation between apnoea and tachypnoea)
Peripheral cyanosis (low cardiac output)
Hypotension
Cachexia
o Pulse Sinus tachycardia
o Apex beat displaced with dilatation of the LV
o Auscultation LV S3, functional mitral regurgitation
o Lung fields crackles from pulmonary oedema
- RVF
o General signs
Ankle/abdominal swelling
Peripheral cyanosis
o Pulse – low volume
o JVP – elevated, Kussmaul’s sign (JVP that rises with inspiration)
o Apex beat – right ventricular heave
o Auscultation – right ventricular S3, pansystolic murmur of tricuspid regurg
o Abdo – tender hepatomegaly
o Oedema – pitting ankle and sacral oedema, ascites or pleural effusions

Ex: Cardiomegaly with mitral regurgitation, gallop rhythm, crackles at lung bases, JVP, hepatic
enlargement, dependant pitting edema, ascites, pleural transudates.

Ix: FBC, LFT, U&Es, cTn, CK, TFT, CXR (ABCDE alveolar or interstitial shadowing , Kerley B lines,
peribronchial cuffing/cardiomegaly, prominent upper lobe veins and diversion, bat’s wing
shadowing, fluid in fissures, pleural effusion,), ECG, BNP/NTproBNP, *echocardiogram*, stress
echocardiography, radionuclide angiography (RNA), single photon emission computed tomography
(SPECT) cardiac MRI, PET, cardiac catheterization, cardiac biopsy, Holter monitor, VO 2 testing.

Tx: Supportive. Relieve Sx, prevent and control disease progression, improve QoL. Risk factor
reduction (Risk Factors: SHIFT MAID smoking, HTN, noninsulin DM, family Hx, triglycerides, male,
age, inactivity, diet), education. Treat causes: dysrhythmias, valvular heart disease etc.

Treatment of exacerbating factors. Treatment of HTN, (use of ACE – enlarpril/ARBs – irbesartan +

beta blocker, sodium restriction + diuretics [Loop – furosemide Thiazide – metolazone K sparing–
spironolactone]) Treatment of diabetes, dyslipidemia, + oxygen, revascularization/surgery.

Digoxin + anticoagulation. Ca channel blockers are sometimes used.

Beware use of NSAID's and verapamil in renal failure/AF respectively.