CARDIOLOGY

Cardiac Failure
Heart failure is defined clinically as a syndrome in which patients have symptoms and signs resulting
from and abnormality of cardiac structure and/ or function. Acute heart failure refers to rapid onset or
worsening of symptoms and /or signs of heart failure, requiring urgent evaluation and treatment.

Causes of Heart Failure

Many different conditions can lead to heart failure with possible overlap between categories. Causes
include:

 Myocardial disease
o Coronary artery disease (most common)
o Hypertension
o Cardiomyopathies eg: familial, infective, immune mediated, toxins (for example: alcohol
or cocaine), pregnancy, infiltrative (for example: sarcoidosis, amyloidosis,
haemochromatosis, connective tissue disease)
 Valvular heart disease (for example aortic stenosis)
 Pericardial disease
o Constructive pericarditis
o Pericardial effusion
 Congenital heart disease
 Arrhythmias (for eg: atrial fibrillation and other tachyarrhythmias)
 High output States:
o Anaemia
o Thyrotoxicosis
o Pheochromocytoma
o Septicaemia
o Liver failure
o Arteriovenous shunts
o Paget's disease
o Thymine (Vitamin B1) deficiency
 Volume overload
o End-stage chronic kidney disease
o Nephrotic syndrome
 Obesity
 Drugs including:
o Alcohol
o Cocaine
o Non-steroidal anti-inflammatory drugs, beta blockers, and Calcium channel blockers
(may worsen preexisting heart failure)

Clinical features of Heart Failure

Take a careful and detailed history, and perform the clinical examination and tests to confirm the
presence of heart failure.

 Symptoms
o Breathlessness - on exertion, at rest, on lying flat(orthopnoea), nocturnal cough, or
waking from sleep (paroxysmal nocturnal dyspnoea)
o Coughing (early with frothy blood-stained sputum)
o Fluid retention (ankles swelling, bloated feeling, abdominal swelling, or weight gain)
o Fatigue, decreased exercise tolerance, or increased recovery time after exercise
o Lightheadedness or history of syncope
 Signs
o Tachycardia (heart rate over 100 feet per minute) and Pulse rhythm
o A laterally displaced apex beat, heart murmurs, and third of fourth heart sounds (gallop
rhythm)
o Hypertension
o Raised jugular venous pressure
o Enlarged liver (due to engorgement)
o Respiratory signs such as tachypnoea, basal crepitation’s, wheeze and pleural effusions
o Dependent oedema (legs, sacrum) ascites
o Poor peripheral circulation

Differential diagnosis
A number of conditions can present with symptoms and signs similar to heart failure including:

 Conditions causing breathlessness such as:

o Chronic obstructive pulmonary disease
o Asthma
o Pulmonary embolism
o Lung cancer
o Anxiety
 Conditions causing peripheral oedema such as:
o Prolonged inactivity of Venus insufficiency causing dependent oedema
o Nephrotic syndrome
o Drugs (for eg: dihydropyridine, calcium-channel blocker, nonsteroidal anti-inflammatory
drugs)
o Hypoalbuminaemia (from renal or hepatic disease)
o Pelvic tumour
 Other conditions such as:
o Obesity
o Severe anaemia or Thyroid disease
o Bilateral renal artery stenosis

Investigations
 Natriuretic peptide testing:
 o In people presenting with new suspected acute heart failure, use a single measurement
of serum natriuretic peptides (B- type natriuretic peptide [BNP] or N- terminal pro-B-
type natriuretic peptide [NT-proBNP] and the following thresholds to rule out the
diagnosis of heart failure.
 BNP less than 100 ng/liter
 NT-proBNP less than 300 ng/liter
 Echo:
o In patient presenting with new suspected acute heart failure with raised natriuretic
peptide levels, perform transthoracic Doppler 2D echocardiography to establish the
presence or absence of cardiac abnormalities.
o In people presenting with new suspected acute heart failure, consider performing
transthoracic 2D echocardiography within 48 hours of admission to guide early specialist
management.
 ECG:
o To look for eg:
 Signs of heart failure eg: ventricular strain pattern
 Ischemia
 Arrhythmia
 Chest x-ray
o To look for signs of heart failure
 Upper lobe diversion (distension of Pulmonary veins)
 Kerley B septal lines (fluid in the interstitium)
 Bat's wing hilar shadowing (blurred margins of the hiler vessels)
 Fluid in interlobular fissures
 Peribranchial/perivascular cuffing and nodules
 Plural effusion
 Cardiomegaly
 Blood tests
o renal function profile
o thyroid function profile
o liver function profile
o lipid profile
o glycosylated haemoglobin (HbA1c)
o full blood count
o troponin
Management of acute heart failure
Acute heart failure can present as new onset heart failure in people without known cardiac dysfunction,
or as acute the decompensation of chronic heart failure.

 Initial pharmacological treatment:

o Opiates
 Do not routinely offer opiates to people with acute heart failure
o Diuretics
 Offer intravenous diuretic therapy to people with acute heart failure. Start
treatment using either a bolus or infusion strategy.
 For people already taking a diuretic, consider higher those of diuretic than that
on which the person was admitted unless there are serious concern with patient
adherence to diuretic therapy before admission.
 Closely monitor the person's renal function, weight and urine output during
diuretic therapy.
o Nitrates
 Do not routinely offer nitrates to people with acute heart failure.
 If intravenous nitrates are used in specific circumstances, such as for people
with concomitant myocardial ischemia, severe hypertension or regurgitant
aortic or mitral valve disease. Monitor blood pressure closely in a setting where
at least level 2 care can be provided.
 Do not offer sodium nitroprusside to people with acute heart failure.
o Inotropes/vasopressors
 Do not routinely offer inotropes or vasopressors to people with acute heart
failure
 Consider inotropes or vasopressors in people with acute heart failure with
potentially reversible cardiogenic shock. Patient with systolic BP show 90 mmHg
or drop of mean arterial pressure of more than 30 mmHg with a pulse rate
above 60 bpm and /low urine output (,0.5ml/kg/hr) are defined as being
 cardiogenic shock. Administer these treatments in cardiac care unit or high
dependency unit and alternative setting where at least level 2 care be provided.
 Initial non-pharmacological treatment
o Oxygen
 High flow oxygen is recommended in patient with a capillary oxygen saturation
< 90% or PaO2 < 60 mmHg (8.0 kPa) to correct hypoxemia.
o Noninvasive ventilation
 If a person has cardiogenic pulmonary edema with sever dyspnoea and
acidemia consider starting noninvasive ventilation without delay:
 at acute presentation or
 as an adjunct to medical therapy if the persons condition has failed to
respond.
o Invasive ventilation
 Considered invasive ventilation in people with acute heart failure that, despite
treatment, is leading to or is complicated by:
 respiratory failure or
 reduce consciousness or physical exhaustion.
o Ultra-filtration
 Do not rottenly offer ultrafiltration to people with acute heart failure
 Consider ultrafiltration for people with confirmed diuretic resistance.
 Treatment after stabilization:
o Beta blocker
 In a person presenting with acute heart failure who is already taking beta
blockers, continue the data blocker treatment unless they have heart rate less
and 50 beats per minute, second- or third-degree AV block, of shock.
 Start or restart beta blocker treatment during Hospital admission in people with
acute heart failure due to left ventricular systolic dysfunction, once their
condition has been stabilized-for example, when intravenous diuretics are no
longer needed.
 Ensure that the persons condition is stable for typically 48 hours after starting
beta blockers and before discharging from hospital.
o Ace inhibitor
 Offer an angiotensin-converting enzyme inhibitor (or angiotensin receptor
blocker if there are intolerable side effects) and during Hospital admission to
people with acute heart failure and reduced left ventricular ejection fraction. If
the ACE inhibitor (or AR blocker) is not tolerated an aldosterone antagonist
should still be offered.