Heart failure

  • BMJ: Clinical review heart failure (Jul'10): http://www.bmj.com/cgi/content/full/341/jul14_2/c3657
    • Prevalence {1.6-4.6|0.9-2.2}/1000 ({m|f}, 45-75yrs), {1|2}% in men after {75|80}yrs
    • Clin: dyspnoea, fatigue, exercise intolerance, fluid retention
    • Def: HF=dcrd CO, tissue hypoperfusion, congestion
    • Diagnosis:
      • Exertional dyspnoea (most common sy, sens 87%; DD: COPD, pneumonia - may coexist)
      • Fatigue (common; due to tissue hypoperfusion)
      • Presence of RF for cardiovasc dis (old age, male sex, prev cardiovasc dis, DM, dyslipidaemia, Htn, LVH)
      • Prev MI (=single best predictor of CHF: when present prob CHF icrd x21!)
      • Neck vein distension (high specif, low sens, Framingham criterion)
      • 3rd HS (S3 gallop) (Specificity 99%) (aj: http://www.youtube.com/watch?v=Ge12P7u0aQo)
      • Cariomegaly/dilatation/hypertrophy by {CXR|ECG|Echo} (Specif 85%)
        • (aj: ECG criteria eg http://www.gp-training.net/protocol/cardiovascular/ecg_reporting.htm)
          • limb leads (low sensit, hi specif)
            • R(I)+S(III)>25mm
            • R(avL)>11mm
            • R(avF)>20mm
            • S(avR)>14mm
          • precordial leads (hi sensit, lo specif)
            • R5/6>26mm
            • R5/6+S1>35mm
            • R(max)+S(max)>45mm
          • Sokolow-Lyon (1949): S1+R5/6>=35mm
          • Cornell criteria (1987): S3+R(aVL)>{28|20}mm in {m|f}
          • Framingham criteria (1990): R(avL)>11mm, R4-6>25mm, S1-3>25mm, S1/2+R5/6>35mm, R1+S3>25mm
      • Hepatojugular reflux 
      • Lung creptitations (low sens, high specif 81%)
        • aj: http://forums.studentdoctor.net/showthread.php?t=350651
        • Wheeze = high pitched musical sounds (bronchospasm, mucosal edema, excessive secretions)
        • Rhonchi = low pitched sonorous sound, may have gurgling quality, originating in larger airways when there is excessive secretions or abnormal airway collapsibility; they frequently clear after cough
        • Crackles/Crepitations/Rales: {coarse|fine} {>|<}10 ms:
          • Fine crackles = soft high pitched sounds, crisp in nature, formed by explosive opening of small airways (terminal bronchioles to alveoli), commonly seen in acute pulmonary oedema and Interstial lung disease (they do not clear but become worse after coughing)
          • Coarse crepitations = loud low pitched sounds caused by air bubbling through fluid in Pneumonia, Obstructive lung disease and chronic pulmonary oedema.
      • Ankle oedema (esp. in men)
      • Tachycardia (HR>120bpm)
      • Hepatomegaly (low sens, hi specif 97%)
      • Night cough
      • Pleural effusion (<1/3 of max. vital capacity)
      • Thyroid enlargement (may point to thyroid disease)
    • Fluid overload
      • dyspnoea, icrd wt (>2kg in 3d), raised JVP, crepitations, hepatomegaly, peripheral oedema
    • Exercise tolerance (NYHA classfication and evidence based treatments)
      • NYHA I: no limitations of physical activity (Tx if lo LVEF: ACEI, consider BB; none if preserved LVEF)
      • NYHA II: slight limitation of physical activity (fatigue/palpitations/dyspnoea) (Tx if lo LVEF: ACEI, BB (Carvedilol/Bisoprolol/Nebivolol/Metoprolol), Candesartan: specialist if with ACEI; Tx if preserved LVEF: Candesartan)
      • NYHA III: marked limitation of physical activity (fatigue/palpitations/dyspnoea)  (Tx if lo LVEF: ACEI, BB, Candesartan: specialist if with ACEI, Spironolactone (avoid: ACEI+ARB+Spiro), Digoxin; Tx if preserved LVEF: Candesartan)
      • NYHA IV: symptoms at rest (Tx if lo LVEF: ACEI, Carvedilol/Bisoprolol, Candesartan: specialist if with ACEI, Spironolactone, Digoxin; Tx if preserved LVEF: Candesartan)
    • LVEF:
      • up to 50% of pt may have nml LVEF (>50%): in those little evidence of treatment effects
    • Investigations:
      • Echo (gold standard; distinguishes betw HF with lo EF vs preserved EF; assesses associated valvular disease)
      • {BNP | NT-pro BNP} (eg where diagnosis is uncertain--eg coexisting respir disease: if lo/nml: rules out CCF; better than ECG)
      • CXR (cardiomegaly, pulmonary venous congestion: if present very specific; also to evaluate respir causes of SOB)
      • ECG (if nml: rules out CCF; BNP more accurate)
      • Spirometry (can diagnose respir conditions, but may coexist)
      • FBC (anaemia as cause of CHF)
      • TFT ({hyper|hypo}thyroidism as cause of CHF)
      • Crea (renal failure as cause of fluid overload; Crea needed for drug dosing)
      • Gluc/HbA1c/Lipids (RF for cardiovasc dis)
      • LFT (if icrd, may influence drug choice)
      • U&E (important to monitor during treatment)
      • (aj: assessment of IHD if associated angina)
    • Differential diagnosis
      • SOB
        • CHF
        • Renal failure
        • Depression, anxiety, hyperventilation
        • Anaemia
        • Obesity
        • COPD
        • PE
        • AF
      • Oedema
        • CHF
        • Renal failure
        • Depression (oedema as a result of inactivity)
        • Drugs (CCB, NSAIDs)
        • Benign ankle oedema (aj:?)
        • Obesity
        • Hypoalbuminaemia
        • PE
        • AF
    • Treatment
      • ACEI (aj: examples below, incr dose q2wk, unless {SBP<100|clin'ly hypotensive|terminal comorb}; SE: cough, icr Crea [consider stop if icr>50%], hyperkalaemia)
        • Ramipril (start 2.5, target 5bd/10od)
        • Perindopril (start 2, target 4)
        • Lisinopril (start 2.5-5, target 35)
      • Diuretics (eg if dyspnoea, ankle/pulmonary oedema: to be given before start of BB; no proven mort. benefit; can be stepped down once stabilised; aj: examples below)
        • Bumetanide (loop diuretic)
        • Furosemide (loop diuretic)
        • Bendroflumethiazide (may combine with loop diuretic)
        • Metolazone
        • Spironolactone (may combine with loop diuretic)
      • BB (aim for minimal fluid retention before start; aj: examples below, double dose q2wk; SE: bradycardia, AV block, bronchospasm)
        • Carvedilol (start 3.125, target 25-50 bd)
        • Bisoprolol (start 1.25, target 10)
      • Candesartan (dcrs hospital admission in CHF with preserved LVEF; but not Irbesartan)
      • Spironolactone: Aldosterone antagonists (for NYHA III/IV; SE: hyperkalaemia, worsening renal function, esp if combined with ACEI and intercurrent illn eg D&V, therefore stop during those)
        • Spironolactone (caution >25mg) 
      • Digoxin (if SOB despite above treatment; even if in SR: dcrs mort and hospital admission)
      • Other drugs
        • Hydralazine (if intolerant to ACEI & ARB; esp for African-Americans)
        • ISDN (if intolerant to ACEI & ARB; esp for African-Americans)
        • Statins (dcrs ischaemic events)
        • ? Antiplatelet agents (evidence unclear)
      • Device based treatments (if lo LVEF and once standard medical treatment has been optimized)
        • primary ICD (implantable cardiac defibrillator)
        • Biventricular PPM
    • Patient education
      • weigh themselves same time each day (eg if icr >2kg in 1-3days: icr loop diuretic and see GP)
      • lo salt diet
      • drug use (eg stop ACEI/Spiro if D&V)
    • Prognosis
      • mort {11|30}% at {1|2}yrs if systolic dysfunction (but improves with eg BB)
  • ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (2008): http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-HF-FT.pdf
    • HF = symptoms (SOB[OE], fatigue, ankle swelling) 
      + signs (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised JVP, periph oedema, hepatomegaly)
      + objective evidence (cardiomegaly, S3, cardiac murmurs, abnml echo, icrd BNP)
    • Clinical features, symptoms and signs
      • periph. oedema/congestion: SOB, tiredness, fatigue, anorexia (periph oedema, raised JVP, pulm oed, hepatomegaly, ascites, fluid overload, cachexia)
      • pulm oedema: severe SOB at rest (crackles/rales over lungs, effusion, tachycardia, tachypnoea)
      • cardiogenic shock (lo output syndrome): confusion, weakness, cold periphery (poor peripheral perfusion, SBP<90, an/oliguria)
      • high BP (hypertensive heart failure): SOB (usu. icrd BP, LVH, preserved EF)
      • right heart failure: SOB, fatigue (raised JVP, periph oed, hepatomegaly, gut congestion)
    • Common causes of heart failure due to myocardial disease
      • Coronary heart dis
      • Cardiomyopathies
      • Drugs: BB, CCB, Antiarrhythmics, cytotoxics
      • Toxins: Alcohol, medication, cocain, trace elements (mercury, cobalt, arsenic)
      • Endocrine: DM, thyroid disease, Cushing's, adrenal insuff, GH excess, phaeochromocytoma
      • Nutritional: deficiency of thiamine/selenium/carnitine; obesity, cachexia
      • Infiltrative: sarcoidosis, amyloidosis, haemochromatosis, connective tissue dis
      • Others: Chagas' dis, HIV, peripartum CMP, ESRF
    • Clinical history
      • Symptoms: SOB (orthopn, PND), fatigue (tiredness, exhaustion), angina, palpitations, syncope
      • Cardiovasc events: coronary heart dis (MI, PCI, CABG), stroke, PVD, valvular dis
      • Risk profile: FH, smoking, HLP, HTN, DM
      • Response to current/prev therapy
  • SIGN guideline Management of chronic heart failure (Feb'07): http://www.sign.ac.uk/pdf/sign95.pdf
    • Symptoms (+Sensitivity, Specificity) in diagnosing chronic heart failure
      • Dyspnoea (66%, 52%)
      • Orthopnoea (21%, 81%)
      • PND (33%, 76%)
      • Hx of oedema (23%, 80%)
    • Diagnostic signs (+Sensitivity, Specificity) in diagnosing chronic heart failure


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