Heart Failure

#Heart Failure S: Subjective Symptoms: (-) Dyspnoea on exertion (-) Dyspnoea at rest (-) Paroxysmal nocturnal dyspnoea* (-) Orthopnoea* (-) Ischaemic chest pain (-) Fatigue (-) Nocturnal cough (-) Abdominal bloating (-) Anorexia (-) Palpitation (-) Syncope (-) Weight gain (>2 kg/week) *Highly specific for heart failure NYHA Functional Classification: (-) Class I - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath. (-) Class II - Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain. (-) Class III - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain. (-) Class IV - Symptoms of heart failure at rest. Any physical activity causes further discomfort. Medications Potentially Contributing to HF: (-) NSAIDs (-) Corticosteroids (-) CCBs O: Objective Examination Findings: HR (bpm): BP (sitting): BP (standing): Weight (kg): (-) Elevated JVP -> (-) Hepato-jugular reflux (-) 3rd heart sound (-) Heart murmur -> (-) Tachycardia -> (-) Laterally displaced apex beat (-) Tachypnoea (-) Pulmonary crackles (-) Pleural effusion (-) Peripheral oedema (ankles, sacrum) (-) Ascites (-) Other -> Investigation Results: 12-lead ECG: A: Assessment Diagnosis: (-) HFrEF (-) Congested (-) Euvolaemic (-) HFmrEF (-) HFpEF P: Plan Investigations: (+) ordered; (-) not ordered. (-) CXR (-) Echocardiogram Pathology: (-) Electrolytes, urea, creatinine, glucose, LFTs (-) FBC (-) Fe studies, CRP (-) Urine ACR (-) NT-proBNP Treatment: (-) ARNI / ACEi -> (-) SGLT2i -> (-) MRA -> (-) Beta-blocker^ -> (-) ICD (LVEF 35% or less after 3 months treatment) (-) Cardiac resynchronisation therapy (QRS 130+ ms) (-) Iron infusion (ferritin <100 or ferritin 100-299 and transferrin saturation <20%) ^Carvedilol, bisoprolol, metoprolol succinate, nebivolol. Referrals: Patient Education / Home Care Advice: Review:

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Notes

• Heart failure is a clinical syndrome characterised by abnormalities of ventricular function and neurohormonal regulation, which are accompanied by effort intolerance and fluid retention.
• Left ventricular failure is a clinical syndrome characterised by abnormalities of left ventricular function resulting in pulmonary congestion, pulmonary oedema, and fluid retention.
• Right ventricular failure is heart failure associated with right ventricular dysfunction manifest by raised JVP, enlargement of the liver, and dependent oedema.

Source: ICD-11 – Heart Failure.

DDx / Mechanisms

• Left ventricular dysfunction
  • HFrEF - Heart failure with reduced ejection fraction (LVEF ≤40%)
    • cardiomyopathy
      • Ischaemic
      • Dilated
  • HFmrEF - Heart failure with mildly reduced ejection fraction (LVEF 41-49%)
    • cardiomyopathy
      • Ischaemic
      • Dilated
  • HFpEF - Heart failure with preserved ejection fraction (LVEF ≥50%)
    • cardiomyopathy
      • Hypertrophic (familial or non-familial [hypertension])
      • Restrictive (familial or non-familial)
      • Non-compaction
• Valvular heart disease
  • Valvular stenosis
  • Valvular regurgitation
• Pericardial disease
  • Cardiac tamponade
  • Constrictive pericarditis
  • Combined effusion and constriction
• Obstructions
  • Atrial myxoma
  • Pulmonary vein stenosis
• Right ventricular dysfunction
  • Pulmonary hypertension
  • Right ventricular infarction
  • Right ventricular cardiomyopathy (including RV arrhythmia and conduction defects)
• High output heart failure
  • Anaemia
  • Hyperthyroidism
  • AV shunts
  • Pregnancy - 3rd trimester
  • Paget disease

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