Clinical Features of Heart Failure

Right-Sided Heart Failure

• Right heart failure is equivalent to diastolic failure
• Clinical features include:
  • Peripheral oedema
  • Hepatosplenomegaly
  • Pleural effusion
  • Ascites

Left-Sided Heart Failure

• Clinical features include:
  • Pulmonary congestion and oedema
  • Cough
  • Dyspnoea/orthopnoea/PND

Pharmacological Management of Heart Failure

• ACE inhibitors and beta blockers are used to manage heart failure
• Diuretics like Furosemide are used to decrease fluid load in patients with HF
• Anticoagulant and anti-arrhythmia medication are used in patients with HF with arrhythmias

Non-Pharmacological Management of Heart Failure

• Moderate physical activity is recommended
• Weight reduction through physical activity and healthy eating is recommended to reduce BMI
• Reduction of salt intake is essential to prevent fluid retention
• Careful monitoring of fluid intake is necessary to prevent fluid overload
• Daily weight monitoring is recommended, with any sudden increase in weight reported and documented

Complications of Heart Failure

• Renal failure
• Hypokalaemia/hyperkalaemia
• Hyponatraemia
• Impaired liver function
• Thromboembolism
• Atrial and ventricular arrhythmias
• Sudden death

Pathophysiology of Heart Failure

• Heart failure can be acute or chronic
• Often associated with systolic and diastolic congestion and with myocardial weakness
• Acute HF involves a sudden decrease in the amount of blood pumped out from both ventricles, reducing oxygen supply to the tissues
• Chronic HF involves a gradual progression of the disease, with early stages possibly having no symptoms of HF

Investigations for Heart Failure

• ECG
• Chest x-ray
• Echocardiogram/Transesophageal echocardiogram
• Cardiac enzymes
• Brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test

Echocardiogram

• Non-invasive procedure using ultrasound waves
• Provides a semi-quantitative assessment of left ventricular systolic and diastolic function
• Valvular disorders can be accurately delineated and pulmonary artery systolic pressure can be estimated

Types of Heart Failure

• Left heart failure (congestive heart failure) = systolic failure
• Right heart failure = diastolic failure

Heart Failure

• Right heart failure = diastolic failure
• Clinical features of Right-sided heart failure:
  • Peripheral oedema
  • Hepatosplenomegaly
  • Pleural Effusion
  • Ascites
• Clinical features of Left-sided heart failure:
  • Pulmonary congestion and oedema
  • Cough
  • Dyspnoea/orthopnoea/PND

Pharmacological Management of Heart Failure

• Ace inhibitors and beta blockers commenced at a low dose and titrated until target dose is achieved or tolerated dose is reached
• Diuretic like Furosemide, used to decrease fluid load in patients with HF
• Anticoagulant and anti-arrhythmia medication used in patients with HF with arrhythmias (e.g. AF)

Non-Pharmacological Management of Heart Failure

• Moderate physical activity as the condition allows
• Weight reduction through physical activity and healthy eating to reduce BMI
• Reduction of salt intake is essential as excessive intake can cause fluid retention and lead to an exacerbation of cardiac problems
• Careful monitoring of fluid intake prevents fluid overload
• Patients may be placed on fluid restriction as directed on their care plan
• Daily weight monitoring with any sudden increase in weight is reported and documented

Complications of Heart Failure

• Renal failure
• Hypokalaemia/hyperkalaemia
• Hyponatraemia
• Impaired liver function
• Thromboembolism
• Atrial and ventricular arrhythmias
• Sudden death

Atherosclerosis and Hypertension

• Vascular bed: blood vessels can dilate, constrict, pulsate and form a closed delivery system for the blood, which begins and ends at the heart
• Abnormal heart sounds from ventricular dysfunction
• Pericardial friction rub may occur from inflammation
• Dullness in lung percussion and inspiratory crackles from pulmonary congestion may occur
• Angiotensin II released and contributes to pathogenesis
• Vasoconstriction
• Fluid retention
• Catecholamine release and coronary artery spasm
• Myocyte growth and fibroblast formation of collagen, resulting in myocardial 'remodelling'

Evaluation for Myocardial Infarction

• Chest x-ray
• Cardiac enzymes
• ECG
• Angiography
• Echocardiography

ECG Changes

• [Image]

Complications of Myocardial Infarction

• Arrhythmias
• Death
• Recurrent MI
• Stroke
• Heart failure

Myocardial Infarction Management

• Oxygen and aspirin, sublingual glyceryl nitrate and IV morphine
• Admission to coronary care unit
• May give ACE-inhibitors or beta blockers
• Coronary artery bypass graft
• Thrombolytics or percutaneous angioplasty (PTCA) and stenting
• Aim is to increase coronary perfusion and decrease myocardial workload and demand for oxygen
• Decrease work of heart by decrease BP, HR, Contractility and end diastolic volume
• Decrease blood clot formation
• Address dyslipidaemia

Management of ACS -- Acute Coronary Syndromes

• Initial assessment of ACS should involve a 12-lead ECG with clinical interpretation within 10 mins of first presentation
• Care is guided by a suspected ACS assessment protocol
• Cardiac-specific troponin concentration is measured on presentation and at defined periods thereafter
• If appropriate, dual antiplatelet therapy with aspirin (100-150mg/daily) and either clopidogrel or ticagrelor for 12 months irrespective of whether coronary revascularisation was performed
• Highest tolerated dose of statin should be initiated and continued indefinitely
• Lifestyle education, cardiac rehab programs and chest pain action plans = long-term management strategy

Heart Failure Syndrome

• Characterised by an underlying structural abnormality or cardiac dysfunction that impairs the ability of left ventricle (LV) to fill with or eject blood, particularly during physical activity
• Symptoms of Congestive Heart Failure -- dyspnoea and fatigue can occur at rest or during physical activity
• Pathophysiology of Heart Failure -- both ventricles can fail independently
• Can be acute or chronic
• Often associated with systolic and diastolic congestion and with myocardial weakness
• Acute HF, sudden decrease in the amount of blood pumped out from both ventricles, reducing oxygen supply to the tissues
• Chronic HF, progression of the disease is gradual and early stages may have no symptoms of HF
• Right side of Heart fails = Right-sided heart failure (RSHF), causes peripheral congestion
• Left side of Heart fails = Left-sided heart failure (LSHF), causes pulmonary congestion