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Heart failure

Heart failure is a clinical syndrome characterised by the symptoms and signs that occur due to a reduced cardiac output and/or increased filling pressures.

Types

  • Heart failure with reduced ejection fraction – ‘systolic heart failure’
    • Reduction in contractility of ventricles 
    • Usually divided into LVF or RVF
      • LVF is more common
      • The most common cause of RVF is LVF, but RVF can also occur independently due to pulmonary hypertension or right-sided valve disease
    • Causes below
  • Heart failure with preserved ejection fraction (HFpEF) – ‘diastolic heart failure’
    • Reduction in compliance of ventricles (i.e. stiff ventricles)
    • Usually related to old age/chronic hypertension 

Causes

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 Clinical features of heart failure

Reduced perfusionPulmonary congestion (LVF)Systemic congestion (RVF)
Symptoms•Fatigue
•Exercise intolerance  
•SOB on exertion, orthopnoea
•Paroxysmal nocturnal dyspnoea 
•White/pink frothy sputum      
•Cardiac wheeze
•Peripheral oedema
•Weight gain
•Bloating and reduced appetite 
Signs•Cyanosis
•Tachypnoea/ tachycardia
•Cool extremities
•Oliguria
•Pulmonary oedema (fine basal creps)
•Pleural effusions
•S3/ventricular gallop
•Hypotension (in advanced heart failure)
•Raised JVP
•Peripheral oedema (pedal, sacral, scrotal)
•Hepatomegaly
•Ascites

Investigations

To confirm diagnosis 

  • Serum B-type natriuretic peptide
  • Chest X-ray (ABCDE)
    • Alveolar shadowing (bat’s wings sign)
    • B-lines (interstitial oedema)
    • Cardiomegaly
    • Diversion of blood to upper lobes
    • Effusion
  • Echocardiography: diagnostic test and may help determine cause

To determine cause

  • Bloods: FBC, U&Es, TFTs, LFTs, ferritin, transferrin saturation, lipid profile, HbA1C, vasculitic/rheumatological screen, viral serologies (e.g. HIV)
  • ECG: look for ischaemia, arrhythmias, small complexes (amyloid/pericardial effusion)
  • Angiogram or functional imaging: if suspect ischaemic heart disease
  • Cardiac MRI: if poor echo windows, suspected infiltrative cause, or unclear cause

Investigations

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