Heart failure

This is a failure of the heart to pump blood properly, when the left side is effected fluid is accumulated in the lungs as it cannot all be pumped through the left side properly. Often this will strain the right side also causing oedema and fluid retention throughout the body.

Most causes of heart failure are due to ischaemic heart disease (IHD) or valvular heart disease. Ischaemic heart disease tends to be in older patients with pmh: hypertension, diabetes, smoking and alcohol.

Valvular heart disease occurs in younger and older patients; in younger patients the valvular lesion is often secondry to rheumaic heart disease.

Pericardial effusion is another important cause as this can be relieved by pericardial centesis.

Symptoms

The patient is short of breath and tires easily, this is worse on exercise or mild exertion.

Pulmonary oedema will make the patient more short of breath when lying flat (orthopnoea), or wake up at night gasping for breath (paroxysmal nocturnal dyspnoea).

Signs

The patient will be short of breath and oedematous. Pulmonary oedema can be heard as crackles on the lung bases. Excess pulmonary oedema causes pleural effusion, which will usually start at the right base but be bilateral as it progresses.

Look for anaemia which can exacerbate symptoms.

It is important to look for the Jugular venous pulse in all patients with suspected heart failure. When the patient is at 30-45o the JVP should be just visible above the clavicle. If it is higher this suggests pulmonary oedema.

In pericardial effusion the jugular vein is very markedly distended and the JVP is raised. Heart sounds will also be quite.

A heart murmur may be heard if valvular incompetence is present. Low BP may occur due to failure of the left ventricle or there may be hypertension.

The pulse is often tachycardic and may be irregular if in atrial fibrillation.

Investigations

CXR will show any pulmonary oedema or pleural effusion and enlargement of the heart.

U+E: often sodium will be low due to excess fluid, it is important to look at the U+E when considering which diuretic therapy and whether to use an ACE.

Anaemia complicates and can cause heart failure and Hb should be above 9 mg/dl to avoid symptoms.

ECG can show ischaemic changes, hypertrophy, tachycardia, atrial fibrillation to confirm diagnosis and aid treatment.

Echo can definitively show any pericardial effusion as well as highlighting poor contraction and calcified valves. It can show venous congestion in the liver due to right sided failure.

Management

Treatment is based on improving the efficiency of contraction and vascular resistance and removing the excess fluid causing a great deal of the symptoms.

Inintial management sit the patient up to clear the top of the lungs and

It is important to consider fluid balance when managing heart failure (see fluid balance handout), it is usual to restrict the patient to no more than 1-1.5l fluid a day and monitor urine output.

Diuretics relieve the symptoms of excess fluid they have to be carefully titrated against the blood pressure (all diuretics drop the BP) and electrolyte balance. Frusemide is used first, it is a loop diuretic which will lower blood potassium levels. It is usually given IV to symptomatic patients, in doses of 20-80mg bd then converted to oral when the patient is less symptomatic. Spironolactone is a potassium sparring diuretic used with frusemide to keep electrolytes balanced.

Betablockers and ACE inhibitors should be given to all heart fialurepatients to control the BP and to maximize efficiency of contractility of the heart.

Blood sugar should be checked and diabetes controlled if present.

Ionotropes can be used to increase the contractility of the heart if the heart failure is severe. They are used on HDU/ICU and can maintain blood pressure for a short time. Usually not appropriate as the heart failure is irreversible and progresses to death.

Provided by T. Whitfield 2012