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Cardiac failure (heart failure)

Definition
  • Cardiac Failure: A clinical syndrome where the heart is unable to pump blood at a rate commensurate with the requirements of the metabolising tissues, or can only do so with an elevated filling pressure.
Etiology/Risk Factors
  • Primary cardiac: Ischaemic heart disease, hypertension, valvular heart disease, cardiomyopathies.
  • Systemic: Thyroid disease, anaemia, high output states, chronic kidney disease.
  • Toxins/Drugs: Alcohol, chemotherapy, cocaine.
  • Others: Infections (e.g., myocarditis), arrhythmias, constrictive pericarditis.
Pathophysiology
  • Reduced cardiac output ā†’ activation of renin-angiotensin-aldosterone system & sympathetic nervous system ā†’ fluid retention & vasoconstriction ā†’ worsens cardiac workload.
Classification
  • Systolic: Impaired ejection (commonly reduced ejection fraction).
  • Diastolic: Impaired filling (normal ejection fraction but reduced compliance).
  • Based on presentation: Acute vs. Chronic.
  • Based on side of heart affected: Left, right, or biventricular failure.
Clinical Features
  • Left-Sided Failure: Dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, pulmonary oedema.
  • Right-Sided Failure: Peripheral oedema, ascites, hepatic congestion, raised jugular venous pressure (JVP).
  • General: Fatigue, palpitations, reduced exercise tolerance.
Investigations
  • ECG: May show signs of underlying cause (e.g., ischaemia, arrhythmia).
  • Chest X-ray: Cardiomegaly, pulmonary congestion.
  • Echocardiography: Assess chamber sizes, function, and valvular abnormalities.
  • Bloods: NT-proBNP, electrolytes, renal function, liver function, thyroid function.
Management
  • Lifestyle: Salt & fluid restriction, smoking cessation, weight management, exercise.
  • Pharmacotherapy: Diuretics, ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, digoxin.
  • Devices: Implantable cardioverter-defibrillator (ICD), cardiac resynchronisation therapy (CRT).
  • Severe cases: Left ventricular assist device (LVAD), heart transplantation.
Complications
  • Cardiogenic shock.
  • Arrhythmias.
  • Thromboembolism (e.g., stroke).
  • Cardiac cachexia.
Key Points
  • Cardiac failure is a complex clinical syndrome with various underlying causes and presentations.
  • Management is multifaceted and tailored to the patient’s needs and underlying aetiology.
  • Early diagnosis and intervention can improve the quality of life and prognosis.

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