Heart failure Classification & Management
Definition inability of cardiac output to meet
physiological demands of the body Investigations
Bloods FBC, U&Es, BNP, TFT,
Pathophysiology
lipids, glucose
1. Reduced CO initially compensation
Starling effect dilates heart to increase CXR
contractility Alveolar shadowing
Remodelling hypertrophy kerley B lines
RAS + ANP/BNP release Cardiomegaly
Sympathetic activation
2. Progressive reduction in CO Dilated upper lobe vessels
decompensation Effusions
Progressive dilatation impaired Fluid in fissures
contractility + functional valve regurgitation ECG ischaemia, hypertrophy, AF
Hypertrophy relative myocardial
ischaemia ECHO (gold standard)
RAS activation Na + and fluid retention Previous MI? Yes within 2
oedema weeks
Sympathetic activation increased Previous MI? No Measure
afterload reduced CO
Signs cold peripheries + cyanosis, often in AF,
BNP
cardiomegaly, S3 + tachycardia = gallop, wheeze, BNP high within 2 weeks
bibasal creps BNP raised within 6 weeks
BNP levels
Classification
High >400
1. Left ventricular failure (LVF) symptoms: PND,
wheeze, nocturnal cough, pink sputum Raised 100-400
(pulmonary oedema) Normal <100
2. Right ventricular failure (RVF) symptoms:
Peripheral oedema, ascites, raised JVP,
smooth hepatomegaly
3. Low output pump failure (systolic, diastolic,
arrhythmias), excessive pre-load + afterload
4. High output anaemia, AVM, thyrotoxicosis,
thiamine deficiency, pregnancy, Paget’s
Management
New York Heart Association (NYHA) 1. Conservative: Rx risk
classification
i) No limitation of physical activity
factors
ii) Slight limitation of physical activity 2. Medical
iii) Marked limitation of physical activity ACEi
iv) Inability to carry out physical activity
Beta-blockers
(Bisoprolol/Carvediol)
Candesartan
Digoxin
Diuretic
Framingham criteria Spironolactone
2 major criteria/1 major + 2 minor
Major criteria PAINS Minor criteria PAIN 1 : ACEi + beta-blocker
st
2nd: Spironolactone,
Paroxysmal nocturnal Pleural effusion
dyspnoea ARB/Hydralazine w/ nitrates
Acute pulmonary oedema Ankle oedema 3rd: Digoxin/CRT/Ivabradine
(bilateral)
Increased heart size/ Increased HR > 120 (already on suitable Rx, HR >
Increased CVP bpm 75, LVF < 35%)
Neck vein distension Nocturnal cough
S3 gallop
Definition inability of cardiac output to meet
physiological demands of the body Investigations
Bloods FBC, U&Es, BNP, TFT,
Pathophysiology
lipids, glucose
1. Reduced CO initially compensation
Starling effect dilates heart to increase CXR
contractility Alveolar shadowing
Remodelling hypertrophy kerley B lines
RAS + ANP/BNP release Cardiomegaly
Sympathetic activation
2. Progressive reduction in CO Dilated upper lobe vessels
decompensation Effusions
Progressive dilatation impaired Fluid in fissures
contractility + functional valve regurgitation ECG ischaemia, hypertrophy, AF
Hypertrophy relative myocardial
ischaemia ECHO (gold standard)
RAS activation Na + and fluid retention Previous MI? Yes within 2
oedema weeks
Sympathetic activation increased Previous MI? No Measure
afterload reduced CO
Signs cold peripheries + cyanosis, often in AF,
BNP
cardiomegaly, S3 + tachycardia = gallop, wheeze, BNP high within 2 weeks
bibasal creps BNP raised within 6 weeks
BNP levels
Classification
High >400
1. Left ventricular failure (LVF) symptoms: PND,
wheeze, nocturnal cough, pink sputum Raised 100-400
(pulmonary oedema) Normal <100
2. Right ventricular failure (RVF) symptoms:
Peripheral oedema, ascites, raised JVP,
smooth hepatomegaly
3. Low output pump failure (systolic, diastolic,
arrhythmias), excessive pre-load + afterload
4. High output anaemia, AVM, thyrotoxicosis,
thiamine deficiency, pregnancy, Paget’s
Management
New York Heart Association (NYHA) 1. Conservative: Rx risk
classification
i) No limitation of physical activity
factors
ii) Slight limitation of physical activity 2. Medical
iii) Marked limitation of physical activity ACEi
iv) Inability to carry out physical activity
Beta-blockers
(Bisoprolol/Carvediol)
Candesartan
Digoxin
Diuretic
Framingham criteria Spironolactone
2 major criteria/1 major + 2 minor
Major criteria PAINS Minor criteria PAIN 1 : ACEi + beta-blocker
st
2nd: Spironolactone,
Paroxysmal nocturnal Pleural effusion
dyspnoea ARB/Hydralazine w/ nitrates
Acute pulmonary oedema Ankle oedema 3rd: Digoxin/CRT/Ivabradine
(bilateral)
Increased heart size/ Increased HR > 120 (already on suitable Rx, HR >
Increased CVP bpm 75, LVF < 35%)
Neck vein distension Nocturnal cough
S3 gallop
