heart failure

Written by Jun Yu Chen

Last Reviewed: June 2019

Review Due: June 2020

 

DEFINITION

‘an abnormality in cardiac structure or function, leading to an inability of the heart to deliver oxygen at the rate required by metabolising tissues’

 

AETIOLOGY

Ischaemic Heart Disease

Hypertension

Valvular Heart Disease

Adult Congenital Heart Disease

Diabetes Mellitus

Arrhythmias

Dilated Cardiomyopathies

Alcohol Excess

SIGNS AND SYMPTOMS

Signs

Pulmonary Oedema (crackles)

Peripheral Pitting Oedema

Elevated Jugular Venous Pressure

Third Heart Sound

Cardiomegaly (displaced apex beat or enlarged cardiac silhouette on CXR)

Pleural Effusion (on CXR)

Symptoms

Dyspnoea

Paroxysmal Nocturnal Dyspnoea

Orthopnoea

Fatigue

Ankle Swelling

Cough

Weight Loss

Exercise Intolerance

 

classification

PATHOPHYSIOLOGY

Cardiac output = heart rate x stroke volume

 

Heart failure leads to a reduction in stroke volume and cardiac output due to an abnormal cardiac structure or function. This triggers compensatory responses to increase the workings of the heart. 

 

  1. Haemodynamic. A reduced cardiac output increases blood in the ventricle leading to myocardial stretch via Starling’s law.

  2. Neurohormonal. The sympathetic nervous system increases heart rate and force of contraction and the renin-angiotensin-aldosterone system increases blood pressure.

  3. Structural. Adverse ventricular remodelling leads to myocardial dilatation, cardiomyocyte hypertrophy and fibrosis.

 

Most commonly heart failure is systolic. This means that the heart is unable to effectively eject blood from the ventricles leading to a reduced cardiac output.

 

The most common reason for this is the ventricle muscles becoming weakened and thin due to dilation of the ventricles. 

 

Each side of the heart can fail in isolation but usually the left will fail first, which then leads to right heart failure. The symptoms are related to the side of the heart that is failing. 

 

With left sided heart failure, blood will back up into the pulmonary vessels causing pulmonary oedema. With right sided heart failure, blood backs up into the liver and abdomen causing ascites and peripheral oedema. 

 

Investigations

Cardiac Biomarkers

Natriuretic peptides 

Released from the heart following myocardial strain 

BNP or NT-proBNP (terminal fraction of BNP)

NT-proBNP is more stable in plasma and a better marker

Chest X-Ray

There are several features of heart failure that may (or may not) be elicited on a plain chest radiograph.

A - Alveolar Oedema (bat's wings sign)

B - Kerley B Lines

C - Cardiomegaly

D - Dilated Upper Lobe Vessels

E - Pleural Effusion

Echocardiogram

An echocardiogram (transthoracic or transoesophageal) establishes the diagnosis of heart failure and provides a dynamic picture of the heart's structure and function. It can be useful in assessing chamber volumes, myocardial thickness and valve function. It is also necessary to classify heart failure by ejection fraction (reduced or preserved).

 

TREATMENT

risk factor modification

Smoking cessation

Identify and treat hypertension, diabetes and dyslipidaemia

Diet modification

Encourage exercise

acute 

Acute decompensation of heart failure is a common presentation to A&E

An A-E approach should be used to initially assess the patient

If the patient is breathless - sit them up and provide oxygen therapy 

Appropriate investigations should be arranged - CXR, ABG troponin

If there is evidence of pulmonary oedema - consider furosemide

GTN may also help improve symptoms 

adapted from the European Society Of Cardiology Guidelines 

Chronic

Chronic heart failure is managed in stepped levels of pharmacological treatment

adapted from the European Society Of Cardiology Guidelines 

Additionally there are various lifestyle changes that patients can make to help improve their condition 

Reduce Salt Intake

Fluid Balance/Weight Monitoring

Diet

Alcohol Avoidance

Smoking Cessation

Low-Moderate Intensity Exercise

 
 

EPIDEMIOLOGY

Incidence – 20% lifetime risk 

Prevalence – 1 – 2 % of the adult population

 

It is thought that the prevalence of asymptomatic systolic heart failure and diastolic heart failure might be higher.

REFERENCES

  1. 1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J [Internet]. 2016 Jul 14 [cited 2019 Apr 10];37(27):2129–200. Available from: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehw128

  2. 2. Struthers A, Blue L, Calvert J, Choy AM, Church J. SIGN 147 Management of chronic heart failure [Internet]. 2016 [cited 2019 Apr 10]. Available from: www.nice.org.uk/

 
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