Right Sided Heart Failure

It's often difficult to differentiate right sided heart failure from left sided - because left goes on to cause right!

Pathophysiology

http://calgaryguide.ucalgary.ca/right-heart-failure/

Caused by respiratory problems, and by progression of left sided heart failure. 

Signs

High JVP

Pitting oedema

RUQ pain - hepatomegaly 

Loud P2, and heave 

Investigations

ECG: If the ECG is normal, heart failure is unlikely

  Reduced ECG amplitude (more air between heart and leads)

  Prominent P waves

  Right axis deviation

  RBBB (Broad QRS > 120 ms, RSR’ pattern in V1-3 (‘M-shaped’ QRS complex), Wide, slurred S wave in the lateral leads (I, aVL, V5-6))

  Sagging of ST segment below baseline 

http://lifeinthefastlane.com/ecg-library/basics/p-wave/

P Waves: 

P mitrale (bifid P waves), seen with left atrial enlargement.

P pulmonale (peaked P waves), seen with right atrial enlargement.

P wave inversion, seen with ectopic atrial and junctional rhythms.

Variable P wave morphology, seen in multifocal atrial rhythms.

--> if P waves are inverted check lead placement

Management

Reduce hypoxia and hypercarbia

Ventilation and PEEP

Inotropes and vasopressors

RV assist device may be useful 

http://lifeinthefastlane.com/ecg-library/copd/

http://lifeinthefastlane.com/ecg-library/basics/p-wave/

http://lifeinthefastlane.com/ccc/right-ventricular-failure/
http://www.rcemlearning.co.uk/references/pulmonary-hypertension-and-right-heart-failure/

http://www.rcemfoamed.co.uk/portfolio/rcem-belfast-day-3/ 

Left Heart Failure

Pathophysiology
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)

http://calgaryguide.ucalgary.ca/left-heart-failure-pathogenesis/

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.

Symptoms
Exertional dyspnoea
Fatigue
PND
Orthopnoea
Vague "not feeling right"

http://calgaryguide.ucalgary.ca/left-heart-failure-findings-on-history/

Clinical Findings

http://calgaryguide.ucalgary.ca/left-heart-failure-physical-exam-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


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

CXR

http://calgaryguide.ucalgary.ca/left-heart-failure-findings-on-chest-x-ray/

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

Echo
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.

Grading
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.

References
http://www.cemfoamed.co.uk/portfolio/agm-conference/
http://learning.bmj.com/learning/module-intro/chronic-heart-failure.html?moduleId=10051928&searchTerm=%E2%80%9Cheart%20failure%E2%80%9D&page=1&locale=en_GB
http://lifeinthefastlane.com/frank-starling-curve-physiology-bscc/
http://calgaryguide.ucalgary.ca/left-heart-failure-pathogenesis/
http://foam4gp.com/2014/10/23/chronic-heart-failure/