Heart Failure

Investigation And Management

By: Ismah Haron

Diagnosis

• Framingham criteria• Simultaneous presence of at least 2

major criteria or 1 major criterion plus 2 minor criteria.

Framingham criteria

PND Acute pulmonary edema JVP Hepatojugular reflux S3 gallop Crackles in lung fields Cardiomegaly on CXR CVP (>160 cmH2O at RA) Weight loss >4.5 kg in 5

days in response to Rx of HF

Major Nocturnal cough Dyspnea on ordinary

exertion Bilateral ankle edema Tachycardia (HR >120/min) Hepatomegaly Pleural effusion Decrease in vital capacity

by 1/3rd

Minor

Quiz

• For Framingham criteria: simultaneous presence of at least ……. or …… plus ……..

ECG

• No specific changes• AF • Tachy / bradyarrhythmias• Previous MI • Cardiac ischemia • Ventricular hypertrophy

Plasma BNP

• Secreted by ventricular myocardium• Closely related to LV pressure • Reflect myocyte stretch • Highest in decompensated heart failure • Diagnosis of HF if BNP >100ng/L

CXR

Alveolar oedema (Bat’s

wing)

Kerley B line

Pleural Effusion

Dilated prominent upper

lobe vessel

Cardiomegaly

Echocardiogram

• Resting LV size and function• Absence/presence of LV dysfunction• To detect valvular disease, pericardial

or myocardial disease

Acute managementSit the patient

uprightO2 100%

IV access and monitor ECG.

Treat any arrhythmias

Ix whilst continuing treatment

Diarmorphine 2.5 to 5mg IV

slowly.

Furosemide 40-80mg IV

slowly

GTN spray 2 puffs SL or 2 X 0.3mg tablets

SL

Necessary ix, examination and history

If BP ≥100mmHg, start nitrate

infusion If SBP

<100mmHg treat as

cardiogenic shock

Management outline • Confirm diagnosis• Ascertain the severity of symptoms and

presenting features• Determine the etiology of HF• Identify the exacerbating factors and any

concomitant illness• Estimate prognosis• Anticipate complications• Counsel patient and relatives• Choose appropriate management• Monitor progress and manage accordingly

Chronic management

• Change in lifestyle: smoking. Salty foods. Weight and nutrition.

• Treat the cause• Treat exacerbating factors• Avoid exacerbating factors• Drugs

QuizFollowing is/are true regarding heart failure:

A. Framingham criteria can be used to diagnose HF

B. Hepatomegaly is the major point in Framingham criteria

C. CXR in HF will shows dilated prominent lower lobe vessels

D. The higher the BNP, the lower the cardiovascular mortality

E. Usage of Digoxin is absolutely contraindicated in heart failure

References

• Oxford Handbook of Clinical Medicine• Oxford American Handbook of

Cardiology

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