HEART FAILURE- DIAGNOSIS AND MANAGEMENT

Aug 26, 2023

HEART FAILURE- DIAGNOSIS AND MANAGEMENT

Rapid Review for PLAB channel is created to help doctors preparing for PLAB or similar examinations. It is also useful as a revision tool for junior doctors.

I am working as an Emergency Physician in the United Kingdom for many years and teaching medical students and junior doctors is my passion.

I have used mind maps for this purpose as they are fantastic tools for summary and recall.

In this video I have discussed diagnosis and management of heart failure

In the next videos we will learn about diagnosis and management of hypertension

Content

6.319 -> hi everyone i am dr rahil here welcome

9.2 -> to another cardiology topic

11.599 -> today we will discuss diagnosis and

14.4 -> management of heart failure

16.48 -> let's first start with the case scenario

18.88 -> a 79 years old lady was brought to

21.119 -> emergency department by ambulance who

23.439 -> woke up from sleep with severe shortness

25.76 -> of breath and cough productive of

28 -> pinkish frothy sputum she was otherwise

31.039 -> well before going to bed her significant

33.84 -> past medical history included

35.84 -> hypertension and type 2 diabetes

39.2 -> on examination she was technique and was

41.92 -> unable to speak in full sentences other

44.559 -> significant findings on physical

46.16 -> examination included tachycardia with

49.12 -> heart rate of 120 beats per minute blood

52.48 -> pressure of 178 to 190 millimeter of

55.44 -> mercury on lung auscultation there were

59.12 -> generalized reputations bilaterally

61.76 -> with decreased oxygen saturation of 88

64.64 -> percent on romeo

66.24 -> she was a fibroid

68 -> her ecg revealed sinus tachycardia there

70.64 -> were no significant std changes her

73.84 -> chest x-ray showed bilateral alveolar

76.96 -> shadowing and the findings were

78.64 -> consistent of pulmonary edema

81.68 -> now coming to the question

83.36 -> what is the most appropriate initial

85.92 -> treatment in this situation

88.32 -> please pause the video to go through the

89.92 -> options and answer the question

92.32 -> the correct answer is option 3

95.36 -> which is intravenous furosemide

98.079 -> and this take us to the discussion of

99.84 -> heart failure in detail

101.759 -> i will revisit the scenario later to

103.92 -> discuss about various options in

105.92 -> management of heart failure

107.84 -> this presentation is mostly based on

110.399 -> nice guidelines on acute heart failure

112.88 -> which was last updated in november 2021.

116.399 -> i've also consulted heart failure

118.079 -> management guidelines from european

120.32 -> society of cardiology as well as other

123.119 -> great resources such as uptodate.com and

126.079 -> bmj best evidence website

128.72 -> without further ado let's start with the

131.2 -> definition

132.48 -> simple definition of heart failure is it

134.64 -> is a condition in which the heart does

137.12 -> not pump enough blood to meet all the

139.84 -> needs of the body

141.52 -> acute heart failure can present as

144.4 -> nuanced heart failure in people without

146.72 -> known cardiac dysfunction

149.04 -> or as acute decompensation of chronic

152.08 -> heart failure it can result from an

154.72 -> abnormality of cardiac structure or its

156.959 -> function

158.08 -> most important causes of acute heart

160 -> failure are number one acute coronary

163.04 -> syndrome

164.08 -> number two hypertensive emergency

167.12 -> and number three take arrhythmias or

169.519 -> severe bradycardia or conduction

171.2 -> disturbance

172.8 -> other causes include

174.64 -> acute mechanical cause like ruptured

177.239 -> interventicular septum or acute mitral

179.92 -> regurgitation as a complication of acute

182.239 -> coronary syndrome acute pulmonary

184.48 -> embolism

185.599 -> infections including myocarditis and

188.08 -> cardiac tamponade

190 -> clinical features

191.599 -> the onset and severity of symptoms of

193.92 -> acute heart failure vary and depend on

196 -> the nature of the underlying cardiac

197.76 -> cause and the rate at which the syndrome

200.319 -> develops

201.44 -> patients typically present with sudden

203.84 -> onset of shortness of breath and

205.68 -> overwhelming sensation of suffocation

207.76 -> and air hunger

209.28 -> the other symptoms are cough

211.36 -> expectoration of pink for the sputum

214.08 -> sensation of drowning and extreme

216.319 -> anxiety

217.599 -> the physical examination findings are

219.92 -> tachypnea patients will be sitting

222 -> upright using accessory muscles of

223.76 -> respiration and unable to speak in full

225.92 -> sentences

227.44 -> tachycardia

228.799 -> the pulse rate is most often elevated

231.599 -> secondary to an increased adrenergic

234.319 -> drive

235.68 -> blood pressure is

237.28 -> markedly elevated if you acute heart

239.439 -> failure is secondary to

241.439 -> hypertension emergency it may be low in

244 -> presence of acute coronary syndrome and

246.4 -> cardiac arrhythmias

248.4 -> the oxygen saturation is usually less

250.879 -> than 90 on roomy air before treatment

253.76 -> auscultation of the lungs reveal

256.239 -> coarse gravitations with ways that are

258.479 -> detected first at the lung bases

261.04 -> but then extend upward to the apises as

264.479 -> the pulmonary edema versus

266.96 -> cardic auscultation may be difficult in

268.72 -> the acute situation but third and fourth

271.919 -> hearthstones may be present

274.24 -> now let's discuss the investigations

277.04 -> ecg

278.16 -> every patient presenting with symptoms

279.919 -> of heart failure should have ecg

281.6 -> performed as soon as possible it may

284.08 -> reveal the evidence of ischemia or

285.84 -> infection arrhythmias or

288.639 -> evidence of left ventricular hypertrophy

290.96 -> usually seen in patients with diastolic

293.12 -> heart failure

294.88 -> chest x-ray

296.479 -> common findings on chest x-ray include

299.04 -> increased alveolar markings due to

301.6 -> accumulation of fluid in the alveoli

304.24 -> fluid in the horizontal fissure and

306.639 -> blending of costophrenic angles

309.199 -> other findings may be presence of

311.36 -> cardiovascularly and upper lobe

313.199 -> diversion which are basically prominent

315.52 -> upper low pulmonary vessels

317.919 -> chest x-ray is also useful to roll out

320.4 -> alternate diagnosis like pneumonia

323.84 -> natural uretric peptide

326.56 -> nice guidelines suggest to perform a

328.4 -> single measurement of serum nitric

330.88 -> uretric peptide like bnp or nt pro bnp

335.84 -> in people presenting with new suspected

338.639 -> acute heart failure

340.56 -> diagnosis of heart failure

342.639 -> is ruled out if bnp is less than 100

346.639 -> nanogram per liter or anti pro bnp

351.12 -> is less than 300 nanogram per liter

354.479 -> however elevated levels of nitrouetic

357.68 -> peptide do not automatically concern the

360.319 -> diagnosis of heart acute heart failure

362.4 -> as

363.28 -> they may be associated with wide variety

365.68 -> of cardiac and non-cardiac causes

369.199 -> routine blood tests

370.96 -> including urinary electrolytes troponin

373.6 -> especially if there is evidence of

375.039 -> ischemia or infection on ecg

377.6 -> and d damage if suspicion of pulmonary

380.319 -> embolism

382.039 -> echocardiography

383.84 -> echocardiography is used to assess

386.16 -> myocardial systolic and diastolic

388.639 -> function of both left and right

390.88 -> ventricles

392.08 -> follicular function and measurement of

394.72 -> left ventricular ejection fraction

397.44 -> any patient with suspected

399.6 -> heart failure who is hemodynamically

401.84 -> unstable

403.12 -> or in respiratory failure should have

405.68 -> immediate bedside echocardiography

408.88 -> if a patient is stable

410.52 -> echocardiography should be performed

412.96 -> within 48 hours

415.28 -> coming to management

417.199 -> oxygen therapy should be titrated to

419.28 -> achieve oxygen saturation of 94 to 98

422.72 -> percent

423.919 -> nitrates

425.12 -> nitrates in the form of sublingual gtn

428.24 -> or intravenous form as isosobide

431.68 -> dinitrate used to be part of initial

434 -> therapy

435.12 -> but current nice guidelines suggest not

437.759 -> to use nitrates routinely and to

440.319 -> consider only in specific circumstances

442.96 -> with close monitoring of blood pressure

445.44 -> for people with concomitant myocardial

447.919 -> ischemia

449.039 -> severe hypertension

450.56 -> or aortic or mitral valve regurgitation

454.72 -> diuretics

456.479 -> diuretics are the ministry of treatment

459.28 -> loop diuretics like furosemide is the

461.84 -> first choice

463.12 -> it can be given as intravenous bonus or

465.599 -> as infusion

467.199 -> nice guidelines does not give a specific

469.84 -> recommendation about dosage but 40

472.24 -> milligram intravenous bonus is the

474.08 -> optimum initial therapy

476.4 -> adjust the dose according to the

478 -> patient's response and clinical status

481.12 -> if a patient is already taking a

483.599 -> diuretic we should consider a higher

485.68 -> dose and some experts

488 -> recommend to use twice the equivalent of

490.479 -> oral dose unless there is evidence of

493.12 -> patients non-compliance with the therapy

496.4 -> ionotropes and vasopressor

499.84 -> patients with acute heart failure with

501.68 -> potentially reversible cardiogenic shock

504.72 -> should be treated with ionotropes and

506.4 -> vasopressors and should be admitted in a

508.56 -> coronary care unit or ito

511.199 -> discussion of individual drugs in this

513.039 -> situation is beyond the scope of this

514.959 -> presentation

517.279 -> ventilation

519.039 -> a person with cardiogenic pulmonary

521.279 -> edema with severe dyspnea acidemia

523.36 -> should be considered for

525.279 -> non-invasive ventilation such as cpap or

528.08 -> bipap without delay

530.56 -> considering ventilation in people with

532.32 -> acute heart failure that despite

534.08 -> treatment is

535.519 -> leading to or is complicated by

538 -> respective failure or reduced

539.92 -> consciousness or physical exhaustion

542.959 -> and the last but not the least is the

545.279 -> management of underlying cause of

547.12 -> cardiac failure simultaneously with the

549.44 -> other management strategies we have

551.44 -> discussed just now

554.08 -> let's do the submariner heart failure is

556.56 -> defined as inability of the heart to

558.72 -> pump the blood to meet all the needs of

560.8 -> the body although there are many causes

563.12 -> of heart failure the most important

564.72 -> causes are acute coronary syndrome high

567.76 -> potential emergencies and erythema's

571.279 -> clinical features of acute heart failure

573.2 -> include certain onset of severe

575.519 -> shortness of breath associated with

578.08 -> decreased oxygen saturation and presence

580.72 -> of reputations on lung auscultation

584.48 -> most important initial investigation is

586.48 -> ecg which may reveal underlying cause of

588.88 -> heart failure such as acs or cardiac

591.519 -> arrhythmias

593.04 -> chest x-ray helps to confirm the

594.8 -> diagnosis of heart failure and rule out

596.959 -> alternate diagnosis such as pneumonia

599.2 -> etc

600.88 -> a limited level of bnp is seen in many

603.76 -> cardiac and non-cardiac causes but

606.24 -> normal levels in the setting of acute

608.399 -> presentation of shortness of breath

610.64 -> rules out the possibility of heart

612.72 -> failure and nice guidelines recommend to

615.92 -> perform single measurement

618.24 -> at baseline

620 -> apart from routine blood tests other

621.76 -> investigations include troponin if

624.079 -> suspicion of ischemia or infection

626.48 -> in fact european society of cardiology

628.959 -> guidelines suggests to perform troponin

631.2 -> in every patient with acute heart

632.959 -> failure as elevated troponin level is a

636.079 -> poor prognostic marker

638.959 -> echocardiography helps to evaluate the

641.36 -> structure of heart valvular disease

644.32 -> and injection fraction

647.04 -> treatment of underlying cause of heart

648.64 -> failure is an important aspect of

650.8 -> management and should continue

653.04 -> simultaneously to other treatment

655.04 -> options

656.72 -> ministry of management of acute heart

658.72 -> failure is diuretic therapy the first

661.36 -> choice being ferroysmite

663.839 -> nitrates should only be used in specific

666.399 -> situations such as management of severe

668.56 -> hypertension with close blood pressure

671.36 -> monitoring

672.88 -> ventilation such as cpap or bipap is

675.839 -> indicated in presence of acute heart

677.92 -> failure with acidemia

680.48 -> mechanical ventilation is indicated in

682.56 -> patients with reduced level of

684.32 -> consciousness of physical exhaustion

686.88 -> in presence of reversible underlying

689.279 -> factors

691.12 -> inotropes and vasopressors are indicated

694 -> in presence of cardiogenic shock

696.88 -> this is the end of this presentation

699.44 -> thank you for watching the next topic is

701.92 -> on hypertension

703.6 -> till then take care and good bye

Source: https://www.youtube.com/watch?v=ebuKpl55GSI