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1
Objectives
2
Objectives
• Discuss the likely investigations that may be performed.
• Discuss the collaborative management (including
pharmacological) of the patient with cardiac failure
• Briefly discuss the action of the following pharmacological
agents used to treat heart failure:
– Diuretics
– ACE inhibitors
– Digoxin
– Beta blockers
– Positive inotropic agents
– Anticoagulants
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Definition
4
Classification
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Pulmonary
The Heart Left atrial filling
circulation AORTA From pulmonary circ
Left lung PA->2
Oxygen rich
Right lung
Left lung
PV->2 Right lung
.
VC
Venous return .
RA
LA
LV
Liver Systemic circulation
RV
Blood pressure as we
AV valve TRI measure it
Consider the word MAP
Semi Semi
Lunar Lunar
TRI TRI 6
Aetiology 1
• Abnormal volume load
• too much circulating volume
• Abnormal pressure load
• poor pump or narrow
• Myocardial dysfunction
• Dysrythmias, AMI, heart cell damage
• hypovolaemia, poor return
• Increased metabolic demands
• Infection, condition of failure in progress so increased HR
and increased WOB
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Aetiology 2
• Western countries
– Coronary artery disease
– Hypertension
• Developing countries
– Valvular disease
– Nutritional cardiac disease
• Other causes
– Cardiomyopathies
– Pericardial disease
– Arrhythmias
– High output failure – anaemia, arrhythmias
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Precipitating Causes of Insufficiency
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Pathophysiology
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Compensatory Mechanisms
Compensatory mechanism
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Compensatory Mechanisms: Sympathetic
Nervous System Response
cardiac output
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Clinical Features 1
• Subjective
– Dyspnoea
– Orthopnoea
– Paroxysmal nocturnal dyspnoea
– Reduced exercise tolerance
– Palpitations
– Fatigue and weakness
– Weight gain
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Clinical Features 2
• Objective
– Tachycardia
– Elevated JVP
– Crackles and wheezes
– Pleural effusion
– Extra heart sounds
– Altered haemodynamic measurements
– Oedema
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Elevated JVP The Heart Left atrial filling
Up here AORTA From pulmonary circ
PA->2
Oxygen rich
Increased
pressure here Left lung
PV->2 Right lung
.
VC
Venous return .
RA
LA
18
The Heart Back pressure up here
.
VC Left lung
.
Right lung
Venous return LA
• Forwards
• Poor organ perfusion
• Decreased urine output
• Decreased systemic blood pressure MAP 60mmHg
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Clinical Features 3: Complications
• Arrhythmias
• Thromboembolism
• Hepatic congestion and dysfunction
• Muscle wasting
• Respiratory muscle weakness
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Presentation of Acute Pulmonary
Oedema
• Dyspnoeic
• Tachypnoeic
• Pale
• Sweaty
• Anxious
• Confused
• Won’t lie flat
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Investigations : Initial
• Chest x-ray
• 12-lead ECG
• Urea and electrolytes
• Haematology
• CK and Troponin if suspect AMI
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Investigations: Ongoing
• Exercise test
• Coronary angiogram
• echocardiogram
• Pulmonary function tests
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Goal of Treatment
• Aim is to
– Reduce mortality
– Manage symptoms
– Enhance self-management
• Improve in functional capacity
– Quality of life
– ? Degree of improvement in quantity
(length)
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Steps to Determine Treatment 1
Establish cause
– e.g. IHD, HT, valve disease
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Steps to Determine Treatment 2
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Pulmonary
The Heart Left atrial filling
circulation AORTA From pulmonary circ
Left lung PA->2
Oxygen rich
Right lung
Left lung
PV->2 Right lung
VC
Venous return LA
LV
Liver Systemic circulation
RV
Blood pressure as we
AV valve TRI measure it
Consider the word MAP
Semi Semi
Lunar Lunar
TRI TRI 28
Steps to Determine Treatment 3
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Treatment - Asymptomatic
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Treatment – Symptomatic
• Risk factor modification
• ACE Inhibitor
• Diuretics
– Symptom relief
– Loop diuretics increase urinary sodium and chloride
excretion in ascending limb of loop of Henle
– Thiazides for mild failure – act on distal convoluted
tubule
– Loop diuretics for severe failure
– Dose adjusted to fluid state / weight
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Treatment – Symptomatic
• -blockers
– e.g. carvedilol, metoprolol, bisoprolol
– Block effects of sympathetic activity
– HR, myocardial ischaemia, arrhythmia
– myocardial perfusion
– All patients with chronic stable mild to moderate
failure
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Treatment - Symptomatic
? Digoxin
– HR + mild contractility
– Useful for controlling rate AF
– Multiple side effects – narrow
therapeutic window (nausea,
arrhythmias, confusion)
• May prevent clinical worsening
• May improve symptoms in chronic failure
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Treatment – Symptomatic
• ? Anticoagulants
–Warfarin if in AF or thrombus
formation likely
–Aspirin if history of IHD
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Treatment – Refractory Heart Failure
Intravenous inotrope
–Dobutamine
–Noradrenalin
Implantable defibrillator
Biventricular pacing
Intra-Aortic Balloon Pump
LV Assist Device
Cardiac Transplantation
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