Congestive Heart Failure

Exam Cram

• Congestive Heart Failure: heart fails to pump the blood around the body, resulting in fluid overload (from increased back pressure)

• Two types of heart failure: preserved and reduced ejection fraction

• Ejection fraction is the % of blood ejected from the left ventricle on each contraction

• Furosemide removes the resultant fluid overload

Outline

Assessment

Acutely decompensated CHF

History:

• Acute history of:

  • Short of breath, reduced exercise tolerance, leg swelling

• Background: known CHF

  • Poor compliance with fluid restriction

  • Furosemide dose change

  • Recent decompensating infective symptoms: 0-7d fevers, lethargy, dysuria, sputum, diarrhoea

Examination:

• Bi-basal coarse crackles

• Bilateral peripheral pitting oedema

• Tachypnoea, hypoxic

Investigations

• Raised BNP, ECG: signs of LVH, unremarkable troponin

• AKI: raised Cr

• ECHO: reduced ejection fraction

• Baseline FBC, urea and electrolytes, LFTs

• Consider Septic screen: blood & urine cultures, viral PCR +- CRP

New diagnosis of CHF (chronic presentation)

History

• Weeks to month

• Leg swelling, worsening exercise tolerance, shortness of breath

• Episodes of chest pain

Examination

• Peripheral oedema: pretibial oedema

• Perhaps auscultate

Investigations

• BNP- enlarged

Diagnosis

Diagnostic criteria: 

• Heart Failure with reduced ejection fraction (HFrEF): ECHO- ejection fraction < 35% (European Guidelines)

• Heart Failure with preserved ejection fraction (HFpEF):  clinical signs of heart failure with ejection fraction > 35%

  • • • • • • Sob, reduced exercise tolerance

            • Leg swelling, bibasal crackles

            • Raised BNP, CXR showing cardiomegaly and pulmonary fluid overload

HFpEF is naturally a harder diagnosis to make and is often undiagnosed as a result. 

Differentials: 

• Acutely: Pneumonia , Pulmonary Embolus , Acute coronary artery event (MI)

• Chronic pulmonary disease can present similarly with sob/ reduced exercise tolerance, e.g. COPD, Pulmonary Hypertension or ILD (Interstitial Lung Disease) 

Acute Management (decompensated CHF) 

1. Optimising medical ward management

• Furosemide IV 20mg - 40mg

• Fluid balance: consider urine catheter

• Investigations: CXR, FBC/ EUC/ LFT, BNP +- troponin, ECHO

• Daily EUCs and fluid review

2. CCU/ HDU Care

   • BiPAP: reduces LV afterload

   • GTN infusion

   • Furosemide infusion

Chronic Management

HFrEF

1. ACE inhibitor, statin, betablocker, furosemide

ARB if ACEi not tolerated

2. Spirolactone if K+ < 4.5

Eplerenone if gynecomastia

3. Sacubitril/ valsartan (stop monotherapy ACEi/ARB)

4. Other interventions

   • Ivabradine: max dose of betablocker & HR > 75

   • Hydralazine + nitrate

   • SGLT-2 inhibitors

5. Cardio re-synchronisation therapy

6. End of Life Care: morphine

HFpEF

1. Furosemide

2. Empagliflozin

Cardio Reg Notes

Explaining ejection fraction and HFpEF

The function of the heart to pump blood around the body, blood in volume. 

Ejection fraction measures the percentage of blood filling into the heart as being pumped out. In HFpEF, the heart doesn't fill properly therefore it only pumps out a small amount of blood, however the volume of blood pumped out / total blood filled (ejection fraction) is preserved. 

Therefore the ejection fraction is not always a great metric of cardiac function. 

Indications for Cardio Resynchronisation Therapy (CRT)

Need 3/3

1. QRS > 120, 

2. Class II NYHA CHF 

3. LBBB

? Bifasicular block (e.g. RBBB + left axis deviation)

In patients with LBBB & QRS 100-120m ICD preferred.

Furosemide conversions

Furosemide 40mg PO = 

• Furosemide 20mg IV

• Bumetanide 1mg 

Furosemide 80mg PO TDS = furosemide 24hr infusion: 10mg/hr

Inpatient Management

• Daily fluid review

• Daily Na+ and K+

• Discharge planning

  • IV furosemide to PO

  • Cardiology follow up

  • Heart failure nurse specialist follow up

  • Education on fluid and salt restrictions

Long Term Management

Ivabradine can cause new AF and should be stopped if this occurs. 

References and Resources

Page written in 2024.