Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive...

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Cardiac Failure Cardiac Failure Richard Price Richard Price Consultant, Intensive Consultant, Intensive Care, RAH. Care, RAH.

Transcript of Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive...

Page 1: Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive Care, RAH.

Cardiac FailureCardiac Failure

Richard PriceRichard PriceConsultant, Intensive Consultant, Intensive

Care, RAH.Care, RAH.

Page 2: Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive Care, RAH.

ObjectivesObjectives• Overview of terminologyOverview of terminology

• Pathophysiology of cardiac failurePathophysiology of cardiac failure

• Clinical features, x-rays and Clinical features, x-rays and echosechos

• Outline of acute and chronic Outline of acute and chronic treatmentstreatments

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Cardiac failureCardiac failure

•A clinical syndrome with signs and A clinical syndrome with signs and symptoms of congestion and symptoms of congestion and circulatory failurecirculatory failure

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EpidemiologyEpidemiology

• Prevalence Prevalence 10%10% in >65 years in >65 years

• 2% of general medical admissions 2% of general medical admissions

• In US is the most common cause of In US is the most common cause of hospitalisation in > 65 years hospitalisation in > 65 years

• Mortality Mortality 60%60% at 5 yrs post diagnosis at 5 yrs post diagnosis

• Is as ‘malignant’ as the most Is as ‘malignant’ as the most common causes of cancercommon causes of cancer

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TerminologyTerminology• Acute heart failureAcute heart failure

• Chronic Heart FailureChronic Heart Failure

• Decompensated CHFDecompensated CHF

• (Right heart failure and high (Right heart failure and high output failure)output failure)

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TerminologyTerminology• LV dysfunctionLV dysfunction

• Systolic dysfunction Systolic dysfunction

• (abnormal contraction)(abnormal contraction)

• Diastolic dysfunction Diastolic dysfunction

• (abnormal relaxation)(abnormal relaxation)

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AetiologyAetiology• Coronary artery diseaseCoronary artery disease

• HypertensionHypertension

• Valvular heart diseaseValvular heart disease

• Cardiomyopathies eg viral, Cardiomyopathies eg viral, alcoholic, septicalcoholic, septic

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Preload

Performance

Sympathetics

Normal

Failing

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Preload

Performance

P1 P2

Higher pressure needed for the same performance

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Afterload

Performance

Sympathetics

Normal

Failing

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Afterload

Performance

Less able to cope with afterload

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CO

SNS R-A-A

Na+

Vasoconstriction

Afterload Preload

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OedemaOedema

• Downstream pressureDownstream pressure

• Colloid osmotic pressureColloid osmotic pressure

• Lymphatic drainageLymphatic drainage

• Capillary LeakCapillary Leak

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Clinical presentationClinical presentation• Short of breath Short of breath

• HypoxaemiaHypoxaemia

• TachycardiaTachycardia

•Bilateral lung crepitationsBilateral lung crepitations

•Peripheral Oedema - takes timePeripheral Oedema - takes time

• Hypotension, Hypotension, ⇓⇓ peripheral peripheral perfusion perfusion

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InvestigationsInvestigations

•ECGECG

•CXRCXR

•Basic bloodsBasic bloods

•EchocardiographyEchocardiography

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Large Heart

Perihilar congestion

Fluid in the fissure

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ManagementManagement• AcuteAcute

• OO22

• IV opiatesIV opiates

• IV diureticsIV diuretics

• IV nitratesIV nitrates

• CPAPCPAP

• Cardiogenic shockCardiogenic shock• InotropesInotropes• Balloon pumpingBalloon pumping• VentilationVentilation

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CPAPCPAP First described in: Lancet 1936; II: 981First described in: Lancet 1936; II: 981

Meta-analysis: Lancet 2006; 357: 1155Meta-analysis: Lancet 2006; 357: 1155

3CPO study - NEJM 2008; 359: 142 3CPO study - NEJM 2008; 359: 142

no mortality difference at 7 days vs no mortality difference at 7 days vs standard carestandard care

Hypoxic despite medical therapy - CPAPHypoxic despite medical therapy - CPAP

NIV - probably no benefit over CPAPNIV - probably no benefit over CPAP

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Peribronchiolar cuffing

ECG Monitoring

CVP Line

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Pleural effusion

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Chronic ManagementChronic Management

•DiureticsDiuretics

•ACE Inhibitors ACE Inhibitors

•ββ-blockers-blockers

•SpironolactonSpironolactone e

•Digoxin Digoxin

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Chronic ManagementChronic Management

• DiureticsDiuretics

• ACE Inhibitors ACE Inhibitors

• ββ-blockers-blockers

• Spironolactone Spironolactone

• Digoxin Digoxin

Reduce symptomsReduce symptoms

Decrease mortality, Decrease mortality, improve ejection improve ejection fraction, improve fraction, improve symptomssymptoms

Decrease mortality with Decrease mortality with severe diseasesevere disease

May reduce May reduce hospitalisationhospitalisation

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Cardiac resynchronisationCardiac resynchronisation

Defibrillators (ICD)Defibrillators (ICD)

Assist Devices (LVAD)Assist Devices (LVAD)

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Severe ARDS

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Summary Summary

A clinical syndrome due to variable pathologyA clinical syndrome due to variable pathology

Physiological response leads to further Physiological response leads to further deteriorationdeterioration

Investigations aimed at diagnosis and Investigations aimed at diagnosis and aetiologyaetiology

Treatment aims to reverse the cause and Treatment aims to reverse the cause and reduce preload and afterloadreduce preload and afterload

Common, serious and often progressiveCommon, serious and often progressive

Page 29: Cardiac Failure Richard Price Richard Price Consultant, Intensive Care, RAH. Consultant, Intensive Care, RAH.

Further reading

McMurray JJV. Systolic heart failure. New England Journal of Medicine 2010; 362: 228.