Tuesday, 28 July 2015

Left Heart Failure

The left side of the heart fails, for many reasons:
- Restrictive (haemochromatosis, pericardial disease)
- Ischaemic (MI)
- Congestive (volume overload of teventricle from valvular insufficiencies)
- Hypertrophic (longstanding HTN)

This reduces the stroke volume, and hence the cardiac output. 
Cardiac output = stroke volume x heart rate
SV affected by preload, afterload and myocardial contractility. The Frank-Starling Curve has an effect here.

Exertional dyspnoea
Vague "not feeling right"

Clinical Findings

- Increased sympathetic activity to attempt to maintain cardiac output = sweating, tachypnoea, tachycardia
- Loud P2, presence of S3 and S4
- Raised diastolic pressure --> narrowed pulse pressure
- Ascites
- Ankle oedema

<100 microgram /mL - unlikely CHF
100 - 500 = may be CHF
500 - most consistent with CHF


Upper lobe diversion
Peri-bronchial cuffing
Kerley B lines
White interlobular fissures
Pleural effusion
Air bronchogram
Airspace opacification
Cardiomegaly - cardiac ratio > 0.5 on PA film

Look for evidence of ischaemia and poor contractility

Management Options
Decrease Pre-load: Salt and water restriction
                    Reduce caffeine, alcohol and smoking
                    Diuretics - get euvolemia, then titrate to lowest possible dose.

Improve contractility: Inotropes

Reduce afterload: Vasodilators

Improve Mortality: 
- ACE inhibitors eg. ramipril - NNT 26. Titrate up
- Angiotensin receptor blockers if ACE intolerant.
- Beta blockers eg. metoprolol
- Consider aldosterone agonists like spironolactone NNT 10 or eplerenone NNT 34

End of Life
There is no cure - consider end of life options early. Involve palliative care if needed.

Class I 
No limitations, ordinary physical activity does not cause undue fatigue, dyspnoea or palpitations (asymptomatic LV dysfunction). 5% 1 year mortality.

Class II 
Slight limitation of physical activity, ordinary physical activity results in fatigue, palpitation, dyspnoea, or angina (Mild CHF). 10% 1 year mortality.

Class III
Marked limitation of physical activity. Less than ordinary physical activity causes symptoms (moderate CHF). 20% 1 year mortality.

Class IV
Unable to carry on any physical activity without discomfort. Symptoms of CHF present at rest (severe CHF). 50% 1 year mortality.


1 comment:

  1. I had my TL a little more than a year ago when my third child was born via c-section. I was not told ANYTHING about the possible side effects of having this procedure. Since then I have experienced heavy bleeding lasting sometimes 3 weeks out of the month, weight gain, severe mood swings. Severe cramping, changes to my libido, severe depression accompanied by suicidal thoughts, headaches, migraines, many new symptoms & older issues are now exacerbated. The father of two of my children doesn't want me anymore. I've become too much of a pain in the ass I guess. We don't talk. We don't sleep in the same bed. I think he might really think I am crazy... & maybe I am. I feel crazy a lot of the time.
    I'm unpredictable. I feel so angry about the whole thing & now what was once a mild fear of doctors has exploded into full on white coat syndrome that causes me to have a panic attack/hypertensive emergency (severe increase in blood pressure) whenever I have to deal with them. I'm not sure what to do... I fear the next time I have to see a doctor I'll have a stroke or a heart attack from the stress & anxiety of it... what do I do? I take my time and keep searching on internet looking for natural healing that how I came across Dr Itua herbal center website and I was so excited when Dr Itua told me to calm down that he will help me with his natural remedy I put my hope on him so I purchase his herbal medicines which was shipped to my address I used it as prescribed guess what? I'm totally healed my cramp pain is gone completely I also used his Anti Bacteria herbal medicines it's works for me very well I want anyone with health problem to contact Dr Itua herbal center for any kind diseases remedies such as Parkinson, Herpes, ALS, MS, Diabetes, Hepatitis, Hiv/Aids,Cancers, Men & Women Infertility, I got his email address  drituaherbalcenter@gmail.com he has any kind of herbal remedies for women & men also for our babes. I really miss my Hunni...he's a fantastic father & a good man. He doesn't deserve this. I feel like an empty shell of who I used to be.