Heart Failure

Condition

• Heart failure 

Definitions

• Occurs when the heart is unable to maintain sufficient cardiac output to meet the demands of the body 

Main features

• increasing dyspnoea progressing to (in order):
• fatigue, especially exertion fatigue
• paroxysmal nocturnal dyspnoea 
• weight change : gain or loss 
• Dizzy spells/syncope
• Palpitations 
• Ankle oedema
• Signs
• left heart failure
• tachycardia
• low volume pulse
• tachypnoea
• laterally displaced apex heart 
• bilateral basal crackles
• Gallop rhythm 
• Pleural effusion 
• Poor peripheral perfusion 
• Right heart failure 
• elevated jugular venous pressur e
• right ventricular heave
• peripheral/ankle oedema 
• hepatomegaly 
• ascites
• Causes of heart failure
• Systolic heart failure 
• The most common cause: myocardial infarction 
• valvular heart disease, mainly aortic and mitral incompetence
• high output states (e.g. anaemia. hyperthyroidism, paget disease)
• Non-ischaemic idiopathic dilated cardiomyopathy
• Viral cardiomyopathy 
• ETOH cardiomyopathy
• Other cardiomyopathies - diabetic, familial
• persistent arrhythmias, especially atrial fibrillation 
• other systemic illness (e.g. sarcoidosis, scleroderma, myxoedema)
• Diastolic heart failure
• ischaemic heart disease
• systemic hypertension 
• aortic stenosis 
• atrial fibrillation 
• hypertrophic cardiomyopathy 
• idiopathic 
• pericardial disease

Investigation 

• Office test: ECG 
• Blood test: FBE, UEC, TFT, LFT, B type natriuretic Peptide (in uncertain cases)
• Imaging
• Chest x-ray 
• Echocardiography

Management

• Prevention is the key. Approximately 50% of patients with heart failure die within 5 years of diagnosis
• Treat or remove precipitating factors
• General non-pharmacological management
• education and support
• smoking: encourage no smoking 
• refer for a rehabilitation program with interdisciplinary care
• Encourage physical activity especially when symptoms absent or mild 
• Rest if symptoms are severe 
• Weight reduction if obese
• salt restriction: advice < 2g salt per day  
• Water restriction 
• Limit caffeine to 1-2 cups coffee/tea a day
• Limit alcohol to 1 SD a day 
• Fluid aspiration if pleural effusion or pericardial effusion if present 
• Daily weighing - check significant weight gain or loss
• Other general measures: optimise cardiovascular risk factors, monitor emotional factors including depression, regular review, vaccination (annual influenza, 5 yearly pneumococcus), 2 yearly echocardiography
• Drug therapy
• Please refer to Heart Failure Medication Titration Plan from Queensland Government. It provides excellent guidance on how to titrate ACE inhibitor, beta blocker and mineralocorticoid receptor antagonist. link
• Digoxin can also be used in controlling rapid AF 
• Device-based heart failure treatments : implantable cardiac defibrillators, biventricular pacemakers and left ventricular assist devices 

Reference

- John Murtagh's General Practice 5th edition 

- RACGP Check Program: Heart failure