Congestive cardiac failure

Published on 02/04/2015 by admin

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Last modified 22/04/2025

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16 Congestive cardiac failure

Instruction

Examine this patient’s cardiovascular system.

Salient features

History

• Dyspnoea on exertion

• Past history of hypertension, ischaemic heart disease or cardiomyopathy

Examination

• Signs of fluid retention: raised JVP, lung crepitations, pitting leg oedema, tender hepatomegaly

• Signs of impaired perfusion: cold clammy skin, low BP

• Signs of ventricular dysfunction: displaced left ventricular apex, right ventricular heave, third or fourth heart sound, functional mitral or tricuspid regurgitation, tachycardia

• Look for the aetiology:

• Valvular disease
• Atherosclerotic vascular disease
• Severe hypertension
• Severe anaemia or volume overload, e.g. arteriovenous shunt
• Pathological arrhythmia
• Evidence of generalized myopathy or poisoning.

Diagnosis

This patient has congestive cardiac failure caused by hypertension and is severely limited with NYHA class 4 dyspnoea.

Be prepared to discuss mortality in heart failure depending on the NYHA functional class (see p. 3).

How would you investigate this patient?

• Chest radiography (Fig. 16.1). Presence of pulmonary oedema on chest radiograph suggests that left ventricular end-diastolic pressure is 25 mmHg (normal ~7 mmHg).

• ECG to look for underlying cause, e.g. ischaemia or infarction, left ventricular hypertrophy, arrhythmia, other causes of pathological Q waves. Monitoring with 24-Holter can identify ventricular arrhythmias.

• Echocardiogram detects valvular disease and determines whether LV function is globally impaired (e.g. idiopathic dilated cardiomyopathy) or whether there is segmental wall motion abnormalities (e.g. in ischaemic heart disease). Ejection fraction can be estimated and usually treatment is initiated when ejection fraction is ≤40. Doppler echocardiography allows determination of diastolic dysfunction.

• Exercise testing is useful to identify ischaemic heart disease.

• Cardiopulmonary exercise testing is useful to determine functional capacity before cardiac rehabilitation and to determine eligibility for cardiac transplantation.

• Blood tests can identify associated disease: renal, liver and electrolyte disturbances (common); metabolic causes (e.g. haemochromatosis, hypocalcaemic cardiomyopathy, thyroid heart disease, anaemia, heavy metal poisoning), amyloid (serum electrophoresis, rectal biopsy), sarcoid (serum ACE).

• Coronary angiography is used to identify ischaemic heart disease.

• Ventricular biopsy for specific myocarditis, especially viral, and to exclude infiltrative diseases such as cardiac sarcoidosis and amyloidosis.

• Radionuclide ventriculography or echocardiography to quantitate severity of systolic dysfunction (ejection fraction).

image

Fig. 16.1 Radiograph of person with heart failure before (left) and after treatment (right).

(With permission from Krum 2009.)

What is the pharmacologic treatment of left ventricular systolic dysfunction?

• Diuretics for symptomatic patients to maintain appropriate fluid balance

• For patients with systolic dysfunction (ejection fraction <40%) who have no contraindications:

• ACE inhibitors for all patients
• Beta-blockers for all patients except those who are haemodynamically unstable or who are intolerant
• Spironolactone for patients with rest dyspnoea or with a history of rest dypnoea
• Digoxin both for patients who remain symptomatic despite diuretics, ACE inhibitors and beta-blockers and for patients with rest dyspnoea or who have a history of rest dyspnoea.

Advanced-level questions

What drugs should be avoided in heart failure?

• Antiarrhythmic drugs

• Non-dihydropyridine calcium antagonists, e.g. verapamil, diltiazem in patients with systolic chronic heart failure

• Tricyclic antidepressants

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Cyclo-oxygenase 2 inhibitors

• Corticosteroids

• Doxorubicin and trastuzamab

• Thiazolidinediones.

What is diastolic dysfunction?

It is excessive stiffness of the heart resulting in an inability of the heart to fill properly (Eur Heart J 1998;19:990–1003). This is in contrast to systolic dysfunction, where contractility is impaired. Patients have clinical features of left heart failure but normal systolic function by echocardiography or radionuclide ventriculography. It is a feature of hypertrophic cardiomyopathy, severe left ventricular hypertrophy (e.g. aortic stenosis or hypertension) and restrictive cardiomyopathy (e.g. amyloidosis). Treatment is directed towards the underlying cause.

What is the role of devices in heart failure?

Three types of device have been found to effective in treatment of systolic heart failure:

• Atrial-synchronized biventricular pacing (also called cardiac resynchronization therapy); ventricular dyssynchrony is currently defined as a QRS duration of at least 120 ms on the 12 lead ECG.

• Implantable cardioverter defibrillators: a 23–31% reduction in all-cause mortality is attributable to diminished risk for sudden cardiac death in patients randomly allocated an implantable cardioverter defibrillator and best medical treatment versus those assigned best medical care alone.

• Left ventricular assist devices may be considered in three situations:

• For individuals listed for transplantation but who need support before a suitable donor heart becomes available
• As a bridge to recovery in people with potentially reversible forms of heart failure, such as myocarditis or postpartum cardiomyopathy
• As ‘destination therapy’ for patients not judged candidates for transplantation.

What are the indications for heart transplantation?

When patients are refractory to treatment, both medical and surgical (such as valve replacement), and are in NYHA class IV, then they are unlikely to survive for 1 year and should be considered for heart transplantation. The survival rate is about 69% at 5 years, although most patients have one episode of rejection and 25% have multiple episodes. They are also prone to accelerated coronary atherosclerosis.

In 1967 Christiaan Barnard, a South African surgeon, was the first to perform cardiac transplantation in humans.

Sir Magdi Yacoub, contemporary professor of cardiology at University of London and Royal Brompton Hospital and Harefield Hospital is Egyptian-born surgeon who performed several pioneering cardiac surgeries.

Professor Shoumo Bhattacharya is Professor of Cardiovascular Medicine at Oxford. He is Fellow of Green Templeton College and his research interest includes cardiac development, congenital heart disease and myocardial homeostasis. His clinical interest is chemotherapy induced cardiomyopathy.

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