Congestive Cardiac Failure (CCF)
Definition:
Heart Failure (HF) is a situation where the heart is incapable of maintaining a cardiac output adequate to accommodate venous return and the metabolic requirements of the body.
Causes:
There are 4 main causes:
1. IHD (Ischaemic Heart Disease)
2. HTN (Hypertension)
3. AS (Aortic Stenosis)
4. Dilated cardiomyopathy
Pathophysiology:
Clinical features of CCF:
Acute LVF:
- Symptoms (sudden-onset SOB / orthopnoea / frothy sputum)
- Examination signs (sitting up / pulsus alternans / S3 (third heart sound) / basal crepitations)
CCF severity categorisation:
- Symptoms (exertional dyspnoea / orthopnoea / PND / fatigue)
- New York Heart Association (NYHA):
Class I = asymptomatic
Class II = Sx on moderate exertion
Class III = Sx on light exertion
Class IV = Sx @ rest
Causes of decompensation:
"FAILURE"
Forgot medication
Arrhythmia / anaemia
Ischemia / infarction / infection
Lifestyle (excess salt in diet)
Upregulation of CO (pregnancy, hyperthyroidism)
Renal failure
Embolism (pulmonary - PE)
Investigation of CCF:
Baseline investigations:
The purpose of these are to confirm the diagnosis, to consider the aetiology and to assess severity.
- Bloods: aetiology (FBC / GGT / TFTs / glucose/ lipids). Also perform U&Es before/during ACE-I therapy.
- ECG: IHD / LVH / arrhythmias.
- CXR: enlarged heart (increased CTR) / pulmonary oedema signs (upper lobe diversion / Kerley B lines / perihilar “Bat’s wing” haziness / alveolar shadowing).
- Echocardiography: valvular lesions / LV dysfunction / ejection fraction (treat if < 40 %) / diastolic dysfunction (Doppler echo).
- +/- radionucleotide ventriculography: severity of dysfunction.
Special investigations:
- if ? IHD: ETT (Exercise Tolerence Test) / coronary angiography
- if ? arrhythmias: 24-Holter ECG monitor ('24-hour tape')
- if ? myocarditis: ventricular biopsy
Monitor treatment in hospital:
- daily weights
- daily U+Es
Management of CCF:
Conservative:
- treat underlying cause: aggressive Mx of CVS RFs
- lifestyle: fluid restrict / salt restrict / limit EtOH (alcohol) / increase physical exercise
- stop aggravating treatments: NSAIDs / b-blockers
Medical (vs. maladaptive neuroendocrine response):
- For symptomatic relief: loop diurectics (all patients)
- For systolic dysfunction: ACE-I * (all patients with symptoms (or LVEF < 40 % without symptoms)
(LVEF < 40 %):
- b-blockers (only if haemodynamically stable)
- spironolactone (if dyspnoea at rest)
- digoxin (if symptoms still present with other treatments)
* alternatives include: AT II-inhibitors (if cough with ACE-I) or hydralazine + ISMN (Isosorbide Mononitrate - if ACE-I are CI due to renal dysfunction)
Evidence:
- diuretics (no trial evidence of effect on mortality - would be unethical)
- ACE-I (do decrease mortality)
- b-blockers (decrease mortality in selected Pts)
- digoxin (no change on mortality if in sinus rhythm - all other ionotropes increase mortality)
Complications (prophylaxis / treatment):
- thromboembolism: Warfarin
- AF: digoxin / b-blockers
- VF / VT: amiodarone / b-blockers / ICD (Implantable Cardioverter-Defibrillator)
Surgical:
- valvular surgery
- heart transplant (if NYHA class IV and referactory to other medical / surgical treatments)
Management of pulmonary oedema:
'LMNOP'
Lasix (furosemide)
Morphine (IV - decreases anxiety, vasodilatation). With anti-emetic (metoclopramide)
Nitrate (sublingual GTN - venodilator)
Oxygen (100% O2 @ 15 L/min)
Position (sit up)
