Heart Failure Revision
Heart Failure Revision
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
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
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
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
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
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)